Why I Need the Unmatched Clinical Capabilities of Bicon SHORT® Implants – Prof. Dr. Dr. Rolf Ewers [HD]

So thank you for inviting me here and certainly we would like to thank Professor Trombelli for organizing this everything together with the University of Ferrara. And as we already thank all of us to Vin Morgan for being so brave for so many years just to teach us that shorter is better than longer. And I’m very honored to stay here because actually I feel almost at home in Vienna. We have almost such a beautiful place like this called in Vienna the State Opera. You probably know it from the Opera Ball. And the only difference is in Vienna, I’m also on the stage, but unfortunately not as a singer, just as an extra in Carmen or in Tosca. I’m in Carmen, one of the smugglers, and I have the wonderful situation to be standing behind and really enjoy this. But certainly today I’m enjoying being here on stage to give a lecture. And thank you all of you for still staying here and to listen to me this evening. And actually I can tell you I shouldn’t have to give this lecture anymore because everything was said today. So just let me remind you again, we are very happy that we have had in February this consensus conference. You heard everything about it, so I don’t have to talk anything about this anymore. And certainly, today, I don’t have to talk about the unique Bicon system anymore, about the locking taper, about the sloping shoulder, and about the plateau design. So just to summarize all this morning, I just go through very quickly, and you know the one point five degree locking taper. It’s a conical connection, and it certainly leads to bacterial seal. And you see the beautiful… No, you don’t see it yet. Now you see the beautiful reaction of the soft tissue. Thanking for this bacterial seal. Dibart showed this already in 2005, the consequences of this bacterial seal. And now, just this year, Knoefler published this again, that the connection here with the system, over eighteen years showed the most significantly influence on bone loss symptoms. So I think it’s no question anymore the locking taper certainly is unique in the system. The bacterial seal and the platform switching is very important, and it’s a double platform switching. This case I won’t show at the end because it will be too long, but just see how the reaction is that bone grows. And something must happen, and I will explain a little later to you on this beautiful case on a fibular transplant, and I will show you this later. So the double platform switching I call by now the Bicon bone production chamber. What does it mean, a bone production chamber? And we know this, the Bicon plateau design is having these healing chambers, and they are just 360 degrees around. And these 360 degrees healing chambers, already many people published something about this. And Müftü showed with finite element analysis showed that this little short implant has a special load in between these healing chambers if they have some loads from the lateral side because it turns a little bit. And what does this matter? And Coelho could show in histology that due to this healing chamber, it leads to unique long term lamellar bone. And this is very unique compared to screw like implants. And it’s a Haversian like bone morphology. And now I have, after an implant, a two millimeter well implant broke, after 40 month loading, I even have my own histology, and you see the beautiful histology, and that certainly is lamellar bone over a Haversian canal. This you will not see on a screw like implant. So you see a person who was working for many, many years and was fascinated as a young surgeon to do a lot of augmentation, to design big operations. Certainly, if you see the upper part of the x-ray, and you see this after twelve years of loading, we have done something good. You see this in the lower part about seventeen years of loading. Something good was done to the patient. But you have to ask yourself, these are big operations, and as a young surgeon I was very proud that I was able to do it. But today I ask myself, was it necessary? And so after forty five years of searching for something good for the patient, and certainly everybody asks us what’s the best augmentation method? What is the best augmentation material? And I try to give this as an answer in my first two fifty page chapter in the book of Professor Lambrecht published in the Quintessence company, published company. And as this book was so successful, Professor and I was asked to write a second book, five hundred pages just in English, about our oral implant bone forming and bone activating concepts. And certainly we gave many, many answers, and the red line on this book are these Olympic steps and the bone classification according to the vascularization. And we heard this today many times, and you saw already, and there’s no question. An onlay is going to resorb, as you have seen this several times today. So it’s the least good method ever. And I will just talk about class three. That’s the interposition. Interposition of non vascularized bone, but in between two sides of vascularization compared to the onlay, the poorest method, which is also nonvascularized material, but being put just on one side on vascularized material, and therefore it has not been able so good. Let’s start with the mandible. There we have three different methods. The best method, it’s class two, it’s bone transport or called osteodistraction. Or you have the interposition, and this is class two inlay, as I will show you. And later on, it’s the apposition class three. I just have the question, can I put this on the other side? No? Because I don’t see so much what I should show. Okay, anyhow. So, I have to look at my computer. The vertical distraction, we performed eighty five No, that’s fine. We performed this eighty eighty five times. You will see all my statistics will end October twelve after eighteen years because there I stepped down of the university hospital in Vienna. We had eighty five distraction osteogenesis. We had been very proud that this was been able to give this our patient with good results. Certainly, but unfortunately we had six fractures. Three fractures I produced by myself, three my residents. Fortunately, we had been pretty successful. We had less than three percent of bone loss because we had been able to repair everything. But, and now it’s ours, the next joke, and you hear this, This distraction device always dislocates to the lingual side, but second disadvantage is this device is six months in the mouth of the patient. Certainly everybody said, I wouldn’t do it, even not on my mother-in-law. Anyhow, everybody’s sleeping already by now, and certainly the third disadvantage is the perforation of the soft tissue. And therefore we abandoned this method, and now we do it in one if ever we don’t do it anymore so much. If we have to do it, we do it in a one step operation. We stabilize this later on. Here you see it with a one kilometer long implant today, we would do a short implant. We call this pedicled sandwich plasty. It’s a class three. It means an inlay method. Very successful. I did this together with my team twenty three times over twelve years, and we had fortunately no fractures, and also same good result, something around three percent implant loss because everything has been repairable. Now we come to the real problematic patients with less than eight millimeters of bone. At this time, what did we do? We did an augmentation. This means an onlay having bone out of the iliac crest. As you hear this several times today, it’s a big operation. And you see it’s a monocortical bone block from the iliac crest. We stabilized this with an additional screw because at this time I didn’t use screw like implants. As you see, ninety eight, long time ago. And now the next picture shows you the typical reaction on a patient like this. And I want to have from you, and now everybody has to wake up, You see two features on this lower x-ray, and the persons, attendees who know this lecture already, please don’t spoil this answer. What do you see on this picture compared to this picture? I would say I see two features, very important features. Let’s wait up. Yeah. That’s not Photoshop. An original film. You may check this in my office, just come to Vienna. You see how thin it was at this time? And it gained over seventeen years. Maybe it could gain more, but unfortunately she died in February in April this year, so we will never see more than seventeen years. This is one feature. It tripled. Why did it triple? Due to function, as Wolf showed this already. A year ago, I gave a lecture in and a very young resident came and said, Professor Ewers, you have a misspelling in your lecture on your slide. You wrote 1892. I’m sure it was 1992. No, it was 1892. Postulated this already, 1872, and everybody laughed about him. So he says bone follows function, but this is the good side. The bad side is that we have here thirty percent of bone loss, called resorption, and here we have about fifty percent of bone loss. And you will see this bone loss much more on this clinical picture, and this lady helped me by cleaning every day because otherwise this would have been a real big one hundred percent problem, and it would not be a good successful case. So certainly we always would think as it’s said, Hippocrates, you’re supposed to have said this but it’s not certain. This means do as little harm as possible. So therefore, maybe today I would say the best augmentation method is no augmentation if we’re able to avoid this. So less is more, and I started already with less very early 1995, but certainly compared to and all his colleague, it was pretty, pretty late. This gentleman, I applied six eight millimeter IMZ implants, five integrated, and he lived also, he had Parkinson’s and couldn’t clean it, lived it for six years. So certainly, short may be better. Therefore, after Vin Morgan convinced me about all these new ultra short implants, we discussed this with my team in our hospital, and together with Professor Seemann, we started our studies. First, we started October ten with four x five millimeter ultra short implants and we applied four implants. So is one of our first patients, fifty nine years old, and you see seven millimeters of bone. So actually we would have done an onlay out of iliac crest material, and this seven millimeter, and when I applied these implants and I sent this to Vin Morgan, I said I think we are crazy to do something like this. Probably the mandible is going to break, but certainly nothing will work. And at the same time, we started together with Paolo Perpetuini here in Italy to do the work up, the prosthetic work up. And all prosthesis you will see here, it’s done by Paolo Perpetuini and his lab team. And we started this with TRINIA. You see it from below. And certainly we don’t have I don’t have to get into it. You hear this already today, but you certainly, the pegs in the hole, you’re locating this and then you’re tapping this after you have found the wells and later on you’re cementing. So this certainly is very, very successful. But now comes the x-ray, and we had been surprised because I learned when I was starting studying sixty five, medicine and dentistry, that the ratio between the implant and the crown should be one to one. And just see what happened here. It’s at least more than five to one. And if you see the lateral ceph, you even see it’s a pseudoprogenic situation. And when I saw this, I was surprised after sixteen month loading it was working. And now still after forty five month loading, it still is working, and on the x-ray you actually see no big bone resorption around. And therefore I want to show you my first patient, And I started it in ten, very poor situation also, little bone. And then if you see this X-ray starting to load, and now you see it was the seventeenth of May eleven, if we are very fast counting now, this patient is having already her fiftieth birthday. Here was starting to load, and I was horrified to see this. And Paolo called me and I said, are you crazy? These implants are horrible positioned. And I said, yeah, but that’s the situation, and it’s a pseudoprogenic situation. And he said, well, but I can fix this only with this kind of screw retained abutments and they will be in front of the teeth. And now just see the cantilever. It’s unbelievable. I never thought that this is going to work, and we are very happy. She had her first fifth year birthday. Congratulations to TRINIA, to Paolo and to Bicon with these implants. Everything is working. It was the first TRINIA being used, and this is on the eighteen fifth, and just see the soft tissue situation. Just unbelievable. For me, it’s something like a miracle. I never would have thought this, and I was had many many sleepless nights because I said, I never should have said yes to Bicon that we are going to do this study because all my poor residents, they will think I’m crazy with this cantilever. The first statistics, Seemann already published fourteen. Here we overlook now a long time. The loading started, as you heard already. We have lost in the mandible just one implant and now we have more than five years time overviewing this situation. I think it’s Vin Morgan, so may I may I thank you. Anyhow, so certainly, and the statistic is going on now, we are just working up, and we still, after five years, we still have this one implant lost. The ratio is four point three to one between the implants and the cantilever all the way. So also a big difference than the one to one ratio we learned. And this is the patient with implant loss we had. She came seven with this fracture. On a Sunday, my team fixed her with this wonderful plate, and eleven was, and then twelve I placed these four implants, but from top, and I didn’t see that at removing this screw was located in here, and therefore precisely in this position where I positioned this implant, this implant did not integrate, and short after loading, eight to eleven, she lost this implant. I was horrified, called Vin Morgan, said, well our first implant loss, what shall I do? And we said, well we are going to operate. She said, no, I don’t want an operation anymore, and maybe it will work with three. So now she is forty one months loading on three implants, and Paolo calls this now TRINIA. So just guess what’s our next study, maybe it’s TRINIA or maybe also just on one implant. I don’t know yet, we are discussing this with Professor Kern in Kiel in North Germany. Anyhow, now we come to the maxilla. We had big symposium, Der Schwerege Oberkeefer, the difficult maxilla here in our hospital, and this was 1997, we had a big symposium. So the difficult maxilla is different and sometimes a little bit more difficult because the bone is much more different. But this would be too long to talk about. But we are talking very often about sinus lift. We heard several times today sinus lift, and just want to show you my own statistics. 554 sinus lifts I did in general anesthesia in our hospital. I did everything with Algipore, our material out of algae, without no iliac crest bone, and just think about 1990. The Viennese mafia thought I’m crazy, because at this time everybody used iliac crest bone. I said this should be good enough. Little bit collected bone or mixed with venous blood or then with PRP. And surprisingly, that’s the only interesting thing. Surprisingly, we just also, we did not use gold standard iliac crest bone. We just lost four point four percent of our implants over a time of twelve years. Also, smokers and women are included, women’s over fifty years included, and smokers, and we published this in 2005. And it’s still very successful. But so this method is good, but is it necessary anymore? And you hear this today several times, it’s not necessary anymore. The next step is pedicle sandwich plastic PSP, and I was very proud together with my former chief, Härle, to design the horseshoe Le Fort I osteotomy, designed after the Le Fort I osteotomy of Professor Bell who just died two weeks ago, and we had been very, happy about his method and changed this to the horseshoe like method, and this is an interposition of iliac crest. And having patients like this with little, little bone, and we didn’t ever believe in zygoma implants, but this was designed before this, we advanced the maxilla, we lowered the maxilla, and certainly the result speaks for us, especially if you see it from the lateral side, and certainly the face was completely changed because of the increase of the anterior vertical height. So certainly we had been proud about this result, and the patient loved us and really thought we are great persons. And our statistic speaks for itself. You see, in thirteen years, Yarrow worked this up three times. This is published in triple o. We had an implant loss rate of eight point seven percent. Over this long time, it’s exceptionally good because it’s an inlay. It’s better vascularized than an onlay, as I will show you a little later, and now after twenty three years, we still have not more than fifteen percent loss. You will think, God, that’s pretty much, but just remember, less than one millimeter of bone in the maxilla, and if you compare the onlay group, here after two years, seventy nine percent. Four years, twenty five percent left. Five years, more than twenty five lost. So it’s a big difference. Now twenty three years, we are still with eighty five percent. So it’s an excellent result because it’s an inlay and not an onlay, as the Brånemark group thought this would be good enough. So therefore, we had been brave enough to start this also in the maxilla in March twelve, together with Seemann. You see here typical patients, sixty nine years of age, and we just applied four, and you just saw from David that this is possible. This is now our study design. If not enough bone in the anterior, we are using 3.0 x 8.0mm implant. Here TRINIA again and it’s very easy to apply as we heard this today several times. And after seven months starting to load, and now you see he also been fixed in the mandible, fifteen months stable with an excellent aesthetic result. The prosthodontist knows what I’m talking about. Now we have thirty three month loading and surprisingly, with little little complication, we have an implant loss by now of two implants, observation time twenty four months and until now thirty five months loading time, what we are overlooking. So it’s also very, very successful and certainly we had been discussing today cementing screw abutments and everything. So certainly there’s a lot of discussion going on. Here again, something about TRINIA and you have heard so much about TRINIA today and now also pink TRINIA. And the only interesting thing for you is statistic. What are we doing now in the last five years and we have eighty eight TRINIA, full arch bridges. We had no problems like hairline cracks, chipping and fractures. Since few weeks, I know we have one fracture, and I just talked with Paolo, but this fracture was not because of TRINIA, because on this TRINIA bridge, later on a locator was put in and glued in and this was weakening of the TRINIA. So this would be eighty nine. So with our eighty eight TRINIA, we are still having no fracture and no problems. And for me, to be honest, this was very, very surprising. Dr. Marincola doesn’t like to hear this because he knew it’s going to be working good, but I was very critical and congratulations, it really works very, very nicely. And here you just see one of these cases we did in the beginning with too many implants, I don’t need this anymore. And as Dr. Morgan showed the 360 degree freedom and certainly we’re able to localize this step by step and get this into the valves. And it certainly works because as Dr. Morgan always says, just your little child finds which toy first, certainly the round one. So there is no question, and as I said already, all the prosthetic laboratory work is done by Paolo Perpetuini and his team. And here you see it in the maxilla and in the mandible positioning everything here and you see the final result. We are very happy about this good result, maintenance and everything. And I think it was a good argument today. We also heard from colleague, Kistler, that certainly we may discuss about the maintenance, but most of the patients with this system are very, very satisfied, especially with the free gum. And it’s just an unprofessional movie because I just took my iPhone and said, oh, this works so good, I just want to show this. So you see, it’s just positioned with four into four wells, and now take your cell phone and just see how long it takes. Just take the time. You see, it’s positioned into it. Now, it’s my assistant, Alicia, she starts tapping the prosthesis and tapping over the prosthesis the abutments into the wells. And now I say, Alicia, we see too much of your hand. Just change it to the left hand, so we are losing a little time because we are calculating the time, so she’s taking her left hand now and applying this. And this is interesting that to apply a full arch prosthesis in such a short time now and that’s the most difficult part, Now she’s removing and it was Vaseline put in between and careful she takes it out without moving the abutments. And now she’s going to tap the abutments and we don’t have to wait so long. It’s one minute and fifty seconds. And everything is done and then after this and after cleaning, she’s going to glue it in temporarily, in the beginning temporary later on. So as everything worked like this, we had been brave enough and said, well, let’s start with our tumor patients. And fortunately, we have found partners. One partner is Professor Politis in Leuven, Professor Lauer in Dresden and Dr. Poruban, he is here and we just talked about it’s the third patient and we are going to operate with him. So we are almost up to ten patients by now in these university hospitals and the hospital from Dr. Poruban. And I just will show you our regiment. Big tumor in the mandible, floor of the mouth, resection of the bone, partial resection of bone stabilizing with a metal plate. We love to use jejunum, small bowel transplant, so the soft tissue defect is covered, and later on, after a year stabilization, we are using a fibular transplant. Unfortunately, the fibula is long, up to fourteen centimeters, and it has to get a curve, so we have to cut the bone a little bit without destroying the vessel here you see on the left side, then the reanastomosed vessels. So it’s difficult cases, and we are very happy if we have a panoramic x-ray result like this. And here you see already a little difficult. This implant is not very good positioned, not because I was a beginner with Bicon, and I will show you a little later why, but the picture was pretty good. Good result, and little local free gingiva transplant from the mucosa. Beautiful result, elongating the lip, and you see here fifty six months loading by now. The fibula has four to five millimeter cortical bone, then like a hole cavitation, and then again four, five millimeter cortical bone. Now you see we have put this into sleep. Why? You see the curve was not so perfectly done by my residents and therefore this one implant is out of the curve. Therefore, we said, okay, we put this to sleep and so we have another case with trio TRINIA. But now for you will be so interesting, what is the bone reacting to this? We have fifty six month loading time and today we had a wonderful lecture by Rainier Urdaneta and he’s always publishing the bone gain. So certainly since five years I’m always looking what happens to my patient. Is their bone gain or is this just because of the aspirin and the fish oil Rainier is giving? So let’s see what happens. Start to load, and now you see a little defect around here, a little cavity, and you will be surprised this cavity is gone. Why is this happening? And it’s now almost five years loading and there is some change. If we enlarge this picture, we certainly see this before and this now after fifty six months. How can you explain this? And I would explain this when I see these enlargement pictures with the findings of Wolff, what he wrote about 1872, and the book, this book was published 1892, and he said, form of the bone follows the function. And how can you explain this? Whoever worked about fracture, fracture science knows the work of Frost. He published this in 1960, The Utah Paradigm of Skeletal Physiology, and he talked about the modeling and remodeling thresholds. This means the thresholds between adaptive state, overload and fracture, and we know also in fracture treatment, then this must be something around fifteen hundred strains. But just see how difficult it is to explain because here it’s a cut and it’s fifteen thousand suddenly, so we certainly do not know precise. But we know there is a stadium where something is getting loaded, and just remember this picture from Mufti. If the implant is being balanced, loaded from the lateral part, you have a little motion in the implant, and this motion is giving the bone structures, the impetus to form more bone. And this is what Wolff worked eighteen seventy two to eighteen ninety two that he said, If we have here loading and unloading zones during walking, the collagen fibers get bundled, and these collagen fibers will mineralize and form the cortical bone, and in between will be nothing, just marrow. He got to know Karl Culmann. He lived in Leipzig, he lived in Zurich, and he said, you know, I’m working on cranes, and if I take a crane to your model of the hip bone, my crane is the same structure if we have here loading and unloading, and this structure always has to follow your ideas. And you find this also what I’ve learned how to build this tower. These are the cortical structures and this is the marrow in between. So this, we know that the bone is the lightweight structure ever and if we take now our fibula, we know that our fibula is having these bundled structures along here and due to function, the collagen fibers are getting mineralized and it’s going straightened out, and the implant will show crestal bone gain due to function. For me, it’s fascinating to see this even on a fibular transplant because we had so many difficulties with fibular transplants putting in long implants because they had been in there not functional. And especially if we did it bicortical, then we destroyed the complete possibility of loading and unloading and therefore we have big resorptions around the neck of the implant. That’s the answer to these questions we had. And therefore, I really would say, if somebody finds out that their wind is starting, certainly we can build walls, but it’s much better to build windmills and go with the time, and therefore I will show you what I have learned in these last seventeen, eighteen years treating this patient. You know this patient already. It was successful over sixteen years because she cleaned it so fantastic. This patient I treated in an hour, now we have it already overlooking five years and certainly both ladies are happy, but this lady never got to know her and never got to know her that I treated her so much more elegant with so much less morbidity and every thing else. So for the conclusion, I would say, the functional load has more influence than we thought of. We learned that function is very important to the implants and therefore we should shorten the implants. Biomechanical challenging clinical situations like cantilevers or implant crown ratio lead not to higher implant loss. We saw all the statistics today, I don’t have to talk about this. The use of short implants helps to reduce the costs, treatment time and patient morbidity. So think short will open new, meaningful clinical option for you and certainly for the patients. So, as a clinical concept, please follow: Before you treat your patient with implants, you should ask yourself: Do I achieve with short implants the same advantages as with standard implants to guarantee you and your patient a good result? So, you want to have a simple operation in short time, minicable risk and morbidity, minimal pain and minimal cost, just to guarantee this to your patients and to you. So please think short as you saw this already, and I just want to show this picture from Don Rothenberg. After twenty six years of loading, he changed the abutments. The system stayed the same, the system stayed thirty one year the same because it’s not no possibility to get it better than it was thirty one years ago, and therefore we congratulate Bicon for this fantastic result of the thirty one years. I just want to thank the teachers of mine, well, who taught me. Morgan, Marincola, and Daher. He’s not here. Laura Murcko is here, Dr. Urdaneta. So actually all the big shots except Shadi are here. You see how important this Italian meeting was, thanks to the organization of Mauro and his fantastic team. Boyd, Tom Driskell, took me to a friend of mine, he worked with me together in 1973 in Brooklyn, and he told me, we will meet in Boston. I introduce you to Dr. Morgan and you will start. You will start with your big operation and you will start with short implants what I did and I mentioned already Paolo, thank you for doing all this tremendous work. We have done now eighty eight full arch prosthesis and many many other patients doing the lab technical with us. I would like to thank you. So I think I could show you why I need Bicon implants, the short and the ultra short implants. And with this, I would like to thank you for your attention. Thank you very much. Thanks a lot.