LIVE Webinar : CORTICO-BASAL Implants: A Tectonic shift in Implantology

0:04 Good morning ladies and gentlemen. Team dentist channel.online welcomes you to the live webinar. It's a pleasure to have you all today as our esteemed participants for this live webinar. I want each and every one of you to type out your full names and the city you belong to. Come on. I want each and every one of you to type out your names and the city you belong to. Let's have a quick introductory session. Once again, good morning participants. I request you to kindly type out your names and the city you belong to. Hello Dr. Nati, welcome. Dr. Ankur, welcome.

0:52 Dr. Roy, welcome. Thank you. Thank you everyone. Thank you for being so such a lovely audience. Thank you. All right, that tells me that we are good to start. Well, today is indeed going to be a powerp packed Sunday. I say that because of our dynamic speaker for today, Dr. Rahul Wed. For the ones who know him are aware about his expertise, his skills and his passion in dentistry. For those who don't know him, I would like to take this opportunity to welcome and introduce our speaker for today, Dr. Rahul W. He graduated from the first batch of

1:38 Bharati Vidyapit Dental College and Hospital and Pune University in the year 1994. He currently runs a successful private practice at merit. He's done his post-graduation in aesthetic dentistry from the New York University, United States of America. He also holds a PJ diploma in cosmetic dentistry from Singapore. He's a fellow of the International Congress of Oral Implantes. He's done his MS in implants from UCLA, United States. He's received his master's clinician certificate in immediate loading implantology from Munich, Germany. He's also a certified teacher of the

2:24 International Implant Foundation, Munich, Germany for immediate loading implant lodge. Dr. Rahul is this one personality that you would never want to miss him. Thank you for joining us, Dr. Rahul. It's indeed a pleasure to have you on our platform on the continuing live dental webinar series organized by dentist channel.online. We also have with us Dr. Kapil Kalra who is also a master and an implant foundation teacher for immediate loading implantology. Thank you Dr. Kapil for joining us as well. Dr. Capell would love to answer to all your questions along with Dr. Dr. Rahul Wed at the end of the seminar. Without much further ado, I now welcome

3:10 Dr. Rahul Wed to begin with the live webinar on the topic cortico basal implants, a tectonic shift in implantology. Over to you Dr. Rahul. Morning ladies gentlemen. Am I audible to everybody? Yes. Yes sir. You're audible. Good morning ladies and gentlemen. Dear doctors, uh it is indeed a pleasure

3:57 and an honor to be in front of you to be presenting this uh webinar on a Monday on a Sunday morning. Greetings to all over the participants from all over the world. Uh I would like to initially to start off with my thanks to the entire dentist channel online team to Mr. Dick and to Mr. Lobo for having given me this opportunity to share the screen on a Sunday morning. Uh ladies and gentlemen, it is very kind of you. Uh Mr. Lobo has spoken very high word about me. It is so nice of you. I'll try and live up to your expectations. Dear doctors, I am talking on a very very pertinent very very important and

4:43 uh in the in the postcoid era uh the talk of the town that is a tectonic shift in implant dentistry psychic implants which give us a solution to practically every situation ladies and gentlemen uh just to add on to this to what Mr. logo has said I am uh a journal dental surgeon doing practicing general dentistry. Sorry to interrupt you Dr. Rahul could you please be a little more audible. Thank you very much. Okay ladies and gentlemen I'll just uh even though I've been introduced but uh I just want to apprise the entire audience that I am a journal dental surgeon doing journal dentistry

5:30 uh right from 19. I in my general practice we do everything right from restorations to root canal which are our bread and butters to uh implants and uh I was implants came across to me in 2003 and uh that's the time I was introduced to implants I went ahead to do uh my MS uh or a master clinician course from UCLA which gave me an insight to a different world altogether I had the likes of Dr. Henry Takai I had the opportunity to interact with uh Dr. Sasha Javanovic to Dr. Stavan Orban Dr. Egon. Mind you, ladies and gentlemen, their works were

6:15 masterpieces. Uh and uh after having interacted with them, uh I went ahead to do whatever I was taught and trying to uh do the best that those duras had taught us. But uh thereafter I reached crossroads where the patient expectations came in heavier and went had to do basel program which I was introduced in 2009. So uh I'll just be sharing my experiences with you in the last uh journey that I have been through this cautica plans and how they have made a difference to me and in my career. Having said that, I always say one thing. It's not the gun, but the man

7:01 behind it which makes a difference. I'm just sharing my experience. I'm sure there are many other people with many other better modalities of treatments. This is just one modality and which has worked fantastically for me and I think it should make wonders for most of us uh who are in this webinar. My my gratitude my obstinence to our gurus without whom uh this journey would never have been possible and uh you need a coach for everything in life. It is the coach it is your guru who gets you from darkness to the enlightenment. Uh my first guru will be my my respects to Dr. uh SM Jooshi the gentleman on the right. uh he has been my principal, my

7:47 dean, my guiding light, my first guru. He is the one who actually held my hand and is holding my hand ever since. God bless him with a very long healthy life. Uh thereafter Dr. Stfan Hide who doesn't know him, he is the Jagat Guru the gentleman who introduced caution and implantology in the way that it is it. So uh and of course my younger brother my mentor Dr. Vive God he is the one who introduced me to implants and uh mentoring not only me but lot of people worldwide. So my gratitude to these three gentlemen in my life. Ladies and gentlemen uh whenever you learning is an endless uh process. We

8:35 need to constantly keep upgrading ourselves and we need to have an open mind. Start my presentation with uh the quote from the father of our nation. Two kinds of people who never change their views. One, the insane and the dead. Because we're all here with an open mind. I request you to have an open mind and interact with me. See what I have done and how I have managed to uh how cortical implantology has made a world of difference to me and in my practice. uh in my agenda I will be going through the entire presentation. Uh I will to the corticobel implantology a bit. I will be uh dwelling upon the concepts

9:20 the rationale of corticel implantologology where they are located how we do them various types of implants. I'll be very briefly just touching upon these areas because unless I go into them uh showing you cases will not make much of a difference to anybody. Dr. Rahul I'm very sorry to disturb you once again. Uh I believe we are having a slight issue with the voice with your audio. Could we try without the earphones if possible? Okay. Is it now clear? That's perfectly clear, sir. Yeah. Am I now clear? Audible? Yeah, you're you're audible now, sir. Okay. So, I'll be without the headphones. Yes, please, sir. Thank you very much. Please do continue. Thank you. Thank you. So, I'll just start off with the agenda once again. uh I would like to introduce you

10:06 to the cortical basel implantology the concept the rationale behind it where they are found in the human jaws the types of cortico basil implants that we have and one question which I want you to ponder right from the word and this is something which makes your should start your mind tickling that why alter the bone or the tissue instead change the implant according to the bone. This is the main crux of this entire presentation. Then I will be talking about uh the 72-hour loading. Is it a gimmick? Is it a publicity stunt? And I will be telling you about the science behind it. Why 72 hours loading

10:52 needs to be done? And uh how the bone sets the clock. I thereafter have some case presentations include some full mouths, some segments, some anterior aesthetic zones, some or other no bone cases, section case and thereafter I would like to dwell upon five main points or some main points that have contributed to my successful and I'm sure those those points or takeaway home messages uh will work and have worked for all my participants and my friends uh in a in a major way. Now talking of tectonic shift, it is the tectonic shift that resulted in subcontinent which was purged up in the

11:39 icy Antarctica and this tectonic shift resulted in total change of process, change of geography, change of thought process and made it today in the present Asiatic and making it. So this is the kind of tectonic shift that happened in me and my practice which I'm going to be talking about in my presentation. Now there are few points I like you to ponder and I'm sure we all agree on that patients do not come to us for implants. The doctors patients come to us for fixed teeth. Implant is just a treatment modality. Sure you all agree agree on that.

12:27 So also we would all want implant procedures to be very very simple. Why complicate things? Why make your and patients life difficult? Root canals are a bread and butter. So all of us would want implant procedures to be simpler than doing a root canal treatment. I'm sure we all want that. We all want the procedures to be minimally invasive and keyhole surgeries. In fact in our case maybe pinhole surgeries. We do not want post-operative discomfort to our patients. And the icing on this is that we want the implants to finish off fast and with good and predictable results and good prognosis. And especially in the co era wherein we would not want too much of an interaction of the patient doing the

13:14 best to the patient in a minimum amount of time. But this is our outlook. lot of our patients would say a no to a dental treatment. Why? Well, I'm sure this is one question which could be asked by all the patients and the reasons could be multiple implant surgeries. You need to call the patient multiple number of times which in the postcoid era we need to think about it. We have post-operative discomfort. Even if you're giving a local anesthetic, it is going to cause a bit of a discomfort to the patient. He will require maybe an analesia for a couple of hours he'll be slightly numb. So why have all those things? Then we have shortness of time. No, who's got the

14:01 time to wait for a few months, week times under a year? And of course we as doctors could be rejecting a few cases. We could have cases where could there could be no alvular bone. We could have cases where the patient is medically compromised and doing your implant surgery could be contraindicated. There could be cases where the patient has got habits vices. He could be a smoker and in the Indian context he could be a ponuer. So naturally that results in poor treatment outcome you generally would start rejecting the case and of course budget money will make a difference. So these are just a few points that a patient would say a no to dental impla treatment. Now how do you

14:51 as I did my programs in various uh implantology uh courses classes including UCLA generally I was very happy I enjoyed the surgical of the implants. I was very happily doing multiple incisions, doing multiple surgeries. I looking at likes of our our teachers doing graphs, the CTS, the ponchos, the pedicles, the bone wraps. Wonderful. They are they are beautiful modalities of treatment. No doubt about that. But you need to have more aramentarium. You need to have a proper skill and you need to have a proper patient who would be cooperative to undergo all those procedures. Sinus lift was a new kick that gave us

15:39 but that incre improved and increased our aramentarium and in spite of all this when there was no alvol bone we were left in a lurch and invariably when I began had a CBC in my area only had ops to to to bank on and invariably I would open up the case to do a full mouth and would end up after a couple of hours maybe three hours suching it back and saying a no because uh the OPG did not reveal what was clinically visible. So having said that that's the time when this tectonic shift or I was at the crossroads wherein I had was finding it to answer all my patients and give them the results that they had come here for.

16:27 I came across this treatment modality wherein the treatments were practically flapless, practically incisionless, had relatively no contraindications. I was my inventory came down drastically because there were no grafting materials. There were no other thing which I required to outsource from outside and I was very happily doing bypasses and the aramentarium decreased dramatically. There's only one kit that you require and the icing on the cake. The best part is that you had when bone was less it was an opportunity for you. When a few months back, a few years back, I would outrightly say put a question mark

17:14 to my treatment protocol, I was saying a huge yes, a welcome yes. So that was a huge wow factor. So for me I was at the crossroads and then two river roads diverge in the woods. This is Robert Frost famous lines and I took the line I took the road less traveled by and that has made all the difference to me and in my practice patients just don't want to rely on slow work. We want super fast cars, buses, trains, planes, super fast computers. In endodontics dentistry we are happily giving very very good results and satisfactory results with single sitting root canalans. So ladies and gentlemen when life is so

17:59 simple why complicate things for us. So strategic implantology or cortico basal implantology was a boon for my patients as well as for all of us we doctors. Now what is static implantology? It is a science which involves unique crystal and basil implants. Uh I'm emphasizing on the word unique crystal and basil implants because they are unique in a way. I will explain them in my due course. They are with advanced designs in a strategic manner to facilitate the remediate functional loading prosthesis within a matter of 72 hours. So I will speak about the uniqueness. I will speak about the advanced designs

18:45 and how we can immediately load and why we load them in 72 hours. Now conceptually this concept was taken this actually is an amalgamation of an orthopedic dromatology with our conventional implantology. Our orthopedic friends, our orthopedicians for the last couple of centuries have been using polished screws, stainless steel or titanium in material and they were constantly and regularly bone plating, putting rods and different procedures doing putting implants right from the last almost couple of centuries now. And this concept is again an orthopedic and a conventional uh implant uh amalgamation. Most of these procedures are carried out employing flapless techniques without any kind of

19:32 augmentation procedures, grafting, lip splits, sinus clips etc etc. We have various implant systems to various to various types of bones. We have a classification broadly three in fact now we have a fourth one also but in my presentation I'll restrict my presentation to only these three classifications. We have the crystal implants. Uh these implants are the Kos and the Kos micro series. These are are regular crystal conventional implants like them but they are just monoblock. They have a polished collar, a polished neck and a polish abutment as well. It's only these kind of implant systems can be used anywhere in good bone cases or

20:17 where the sightes have healed and the bone is adequately present. Thereafter we have basil or transocious implants. Now this the first implant that you see here is the BCS or the biccortical screw as it is called. Now this is a gold standard for basil implants. This is primarily used in very low or no bone cases because it engages the orates into the basil bone or the cortical bone which generally is one of the hardest bones present in the body. Least susceptible to infection highly mineralized and low vascular. So in even if there is pathogenesis it heals fast after taking care of that. These two are the transautious implants. They are the

21:03 famous VOIs series of late. They have been not even used that much because they involved a lot more uh invasiveness compared to the other current procedures which are a lot more conservative in their approach. But having said that these implants have worked beautifully and have been documented also. Then lastly we have a combination of implants. Now these implants are used. The first one is called as a BC XES or uh in the European countries it's called as a TPG UNO. Now these implants are fully this implant is a fully polished implant and it is indicated in all areas and especially where we have a post extraction case has a longish neck

21:48 almost a 4 mm long neck to take care of the bending zone as well. So that is prosthetically more viable. This incidentally happens to be my favorite and I I've been using it very very uh liberally in my practice. Second combination this also would condense the bone. This and even the implants they are known to condense the bone and there they are there thereby cause osteo integration faster. Mind you all these implants that are there are there of titanium and uh you' all agree that over a period of time any titanium will integrate with the bone these initially implants tend to osopixate and thereafter also integrate with passage of time. Now coming on to our last implant. This is a combination

22:34 of polished which has got polished fluids in it. It's got a rough surface in its in in the center. This implant uh engages gives you best of both the worlds. best of the cortical engagement and the best of canalis bone engagement as well. Mind you, all these implants are bendable and these implants can be used the rough surface especially can also be used in uh anterior segments where you don't you want anti-rotational properties as well. Now just to give you a very very brief very very primitive insight uh of uh how particular bezel and a conventional implant would differ. Now I want you to imagine a wall a brick wall normal brick

23:19 wall in your homes wherever wherein you have a cortex which is equated to a plaster on one side on both the sides of the wall we have plaster the cement plaster that we have and in between we have a lot of brick work. Now the plaster work can be compared to or can be simulated to a cortex of a bone and the inside the brick work can be compared to a cancerous bone. Uh this is a very primitive example uh just to give you a kind of a layman insight as to this is how what I show my patients also that things become easier for them to understand. So a crystal implant or a conventional implant rough surface unlike this one the screw will go from the crest and go all the way down till the cortex till the

24:06 cancellous area into the bone into the alvolus wherein a corticobasil implant will go from the cortical bone into the basil bone which is the lower part and if there is plaster here also it will engage this also. So these implants are relatively longer. They are polished and they engage a different part of the bone. That part of the bone which is least susceptible to infection, least susceptible to resorption. Why put our money in an area which will resolve which will do rather have things which are safer. So this is a kind of an investment that we do into our patients bones into the cortical areas which are least susceptible to resorption and they can

24:52 fight the pathogens better because of the low vascularity and the high mineral content and heal also faster. Having said that, a crystal implant will lie in relatively less denser bone reserve a BCS implant which will lie from the crest and go down from the denser to the densest part of the bone. I hope I'm making things slightly understandable and clear. Now where they are found? Well, they are found in areas uh I will not be wrong if I say they are found in or we we locate them in areas which are non dental bones. We are dental surgeons don't use them very regularly in our practice. So they are

25:38 the bones areas like the teriggoids rather we utilize the tuberosity as a portal of entry and engage them into the teroid. So they are called as a tubot tergoid implants or the teroid areas or the term maxillary butresses. We go into the nasal floor. We go into the nasom maxillary buttresses. We go into the anterior nasal spine area and we also to some extent utilize the floor and the walls of maxillary sinus. Now these are the areas which are least susceptible to resorption. We all know that the maxilla and the mandible resolve. The alvulus will resolve. So why put our implants in areas which

26:25 are susceptible to resorption. Instead why not write from the word go utilize areas or use areas which don't resolve or have minimal resorption. In the lower jaws they found in the intra foromin space. We have criss-crossing of trajectories in the anterior anterior zone between the two maxillary mental for mental forominas is a good cautical bone. Then for most procedists I'm sure you'll all agree that we utilize the the myoid the distal lingual sulcus. So we utilize the myoid ridge area the myoid portion in the distal lingual area of the mandible. Of course the entire length of the mandible on the base

27:10 these are the areas which where where we engage our cortical basil implants and utilize these areas. So it's very important for all of us to be at the right place that is the strategic position into the basil or the cortical bone or the maxilla and the mandible. We also have the zygomatic areas. I think I did I missed that? Yes, the the zygomatic processes they are again areas which are least susceptible to to resorption. Now coming on to the rationale we I have spoken about this earlier but I'm again going to reiterate that the it is an amalgamation or we have taken this concept from the orthopedic. The basil principles are similar to the

27:56 ones of the orthopedic segments wherein those gentlemen would be doing cortical engagement. They would be putting their screws through the bone plates to go onto the other part of the cortex so as to give them extra stability and create loadbearing areas which would distance from the portal areas of infection in the oral cavity. The cortical bone would get easily repaired after injuries and was less susceptible to infection. The idea of orthopedic surgery is that they also orthopedicians also use smooth surfaces. They prefer or they going for biocortical anchorage. They go in for nonp parallel screws so as to have micro retention in their plates that increases stability against the

28:43 lateral forces. and bone plates can simulate it to our bridges or rigid metal bridges which cause splinting resulting in immediate splinting and immediate loading of implants. So this concept has been taken or amalgamated with the orthopedics and the dental implantology segment and it is a marriage of these two principles. I've spoken about this that we have the infection free bone and the basil bone. We have very very thin mucosal penetrations. I will show you in my cases below and because of they being polished there's virtually no par implantitis and preferably our abutments are single piece we do have multi-unit abutments uh to cater for people wherein we want where retrievability is uh is

29:29 required and of course in our impl implants we have bending zones as well. So today we are in a position to offer dental implants based on orthopedic principles. So we could also term this particular science as orthopedic dental implantology wherein we are able to fix teeth to our patients within a matter of 72 hours. Now spoken having spoken of 72 hours why the 72 hours I'm sure this is one question which must have been in everybody's minds all our colleagues even our patients ask that why do you do it in 72 hours or how do you do in 72 hours I'm sure it possibly is a pos is a publicity gimmick well ladies and gentlemen it is not we are just going by

30:16 the way the nature wants us to go we are bound by the nature and as long as We are in coniance with the nature things will go our way. So this question as to why 72 hours is because it is the bone which sets the clock. It is not my choice or our choice. It is the bone which demands so we do it in that particular stipulated period of 72 hours. Now why this happens? Now this graph is from a SK book skeletal tissue mechanics by Bur and Martin Tak and Fry. Now this is supposed to be a gold standard textbook for orthopedicians and for people who want to go in for oal uh

31:03 study. Now here we can see there is there is a a vertical line which depicts the quality of the bone with 100% being the normal and the horizontal bar shows us the days. So this is a comparison between the quality of bone and the days subject when the bone is subjected to any stimulus any insult be it could be extraction it could be fracture it could be implant placements anything and this is not pertaining to a dental bone this pertains to any bone in the body. Now this graph as you can see moment there is trauma or any stimulus the first 3 to 5 days there is a lull there is no oal activity there are

31:50 inflammatory process which are going on I'm not denying that there is robbo or all the inflammatory five uh processes that is that are going on but the healing of bone and the oenal remodeling starts 3 days after any bone surgery or an implant placement. So it is within these three days that the bone is more stable. It is easily available where there is no oal activity or it is in good shape. This is the reason why we equip the implants within this short period of time and load them, splint them and load them and leave it in place minimum for 6 to 9 months maybe longer. These days we don't need to touch our processes once again. So in the first three days

32:38 there's an activation. I will give you a small little illustration of a with with a very very primitive kind of a uh an animation which will show as to how we go ahead and how things are done. So this is a normal BMU or a normal bone cell. Moment there is a stimulus. Stimulus could be a trauma, it could be an extraction, it could be an uh implant placement any any insult any stimulus. The first phase is called as the activation.

33:24 uation means that the first cells that is the osteoclasts that is the bone scavengers the cells which take away the bone they are the first cells to reach the site of stimulus or trauma or extraction. So they will take around 3 days for them to start activated activation and to reach the particular site 3 to 5 days. Now these are moving at a very very slow but at a very steady pace of 40 micrometers day. So first 3 to 5 days there is total lull. There is noity. That's the time when we load it. Thereafter there is a phase of resorption when just the bone has been taken away.

34:10 Then for the next days there is a lull in the there is no activity at all. The osteoplast have moved forward and the osteoblasts are kind of forming. 30 days it takes for this thing to happen. Then the phase of refilling. Now the osteoblasts start coming on and they start filling in the space gradually. So by the time the osteoblasts have started off their journey to lay down the bone and the prime mineralization starts it is if you see this again it takes 3 days for activation it take 30 days for this uh reversal or the lag phase 100 days of refilling it almost would take around

34:55 150 days before the primary mineralization ends now this was the time that Dr. Pranamak the father of crystal implantology wanted to do second surgery that is why the 12 weeks and thereafter process began possibly but having said that why go till that this particular period of time bone is worse than Swiss cheese why not load and equip your implants or your bone to the needful in the first 3 to 5 days in fact the earlier the better. So this is the right time for us is situated 72 hours. The earlier better.

35:44 Now where do we find or how do we engage these corticles? So or what are the third or second corticles. Now if you see this last implant here the first cortex is the crest proity that this implant has perforated. Thereafter once it exits the magilla or the posterior part of the magilla or the tuberosity that is the second cortex that it perforates. So we have two cortex which have been perforated and the third cortex is once it's engag engages the the tergoids. So we have a tririccortical anchorage in this particular implant. We have a bicarticle here. Here we've done a bypass of this particular tooth and engaged the the the nasium maxillary butress area

36:29 which is again very stable bone. So here we have a tririccortical anchorage and here we have up to a bicartical anchorage. Now as these implants are minimally invasive there are minimal surgical complications because you you're not raising a flap. uh I'm sure studies have proven and I'm sure you all would be aware that moment you raise a flap you end up losing 5 mm of bone thereafter. So once we are already in in an area where we don't want to lose bone bone for us is gold we don't want to lose that bone. So why do a procedure that results in even.5 mm or more of resorption right from the word go. So we

37:17 rather going incisionless. The photos if as you can see in this photographs here the implants are almost keyhole. These are this is an immediate posttop pick immediately after the procedure. There's practically no blood. In fact uh they're very relatively very very clean. Plus another question that most of people ask is that why do you have to do an extraction immediately? Why can't we wait? We do an extraction on one side, right side of the lower jaw, then the left side of the lower jaw, then the upper jaw and so on and so forth and thereafter planned surgeries thereafter. Well, studies have shown one of them uh Dr. Atkinson was one gentleman who in 1977 happened to have worked extensively on pig jaws and he

38:04 proved beyond doubt that whenever there is a trauma or an insult it is the entire hollow bone which underosal remodeling rather than the particular site. Now uh to explain it further if I have a injury on my skin say if I if I have a cut on my skin it is just that particular skin around that area that will take some time to heal. But for our bones any kind of an insult any time it will take as I showed in the previous graph will take up to a year's time before things come back to normal. So if you're doing an extraction say in the first 10 days and you're putting an implant say after a couple of weeks months you have made the bone which is sound and stable into very very soft

38:50 bone. So you are actually trading into murky waters making things complicated for yourself. So it is best action do the proper toilet of the cavity ensure that to the best possible way you have cured the area you've made it infection free and then you are inserting and loading the implants. So these implants are often flapless. They are keyhole involving minimum bone cutting. These implants tend to be self tight and they condense the bone around the implant during insertion and being minimally invasive. They are also associated with minimum posttop edema and the healing at the procedure sites are rapid and often often uneventful. Additional surgical risks and complications are eliminated in addition to cost savings. So this actually is a

39:38 boom to all of us. Now how do we avoid bone grafting etc procedures because we are not utilizing those areas. I have bypassed in the upper maxilla I have bypassed the sinuses and my implants or we can even go trans sinus because our implants are very very polished and the diameter the osttomy is 2 mm. You just require a 2 mm drill to go through it. And as we all aware that this nidarian membrane can tolerate up to 5 mm of an insult or a tear and it will heal. So our implants this particular implant is 3.6 3.7 mm in diameter. The shaft is 2 mm only and they are mono block. So we tend to bypass these sinuses or go trans sinus

40:23 also easily engaging those areas which are less susceptible to infection. engaging areas where where the bone will not resolve and which is stable bone and will remain stable throughout. Even if the alvolus resorbs or the crest resorbs the area which is there in the where they are primarily anchored our implants are osteoxiated which tend to osgate with period of time. For the lower jaws we utilize the bone around the distal mandible what we call as the bypass. we tend to go near the next to the bone. This is a buckle bypass. This is the buckle area and this is the lingual area. So here we've done the buckle bypass and because these implants are bendable so they can be

41:09 bended to suit our prosthetic demands. Here we've utilized the distal distingual area. So ladies and gentlemen, why alter existing structures? It could be hot, hard or soft when we have implants designed to suit our needs. So I hope I'm making a point there. So also another rationale is that these implants tend to display 60% less amount of bone compared to any other conventional implants. These are studies which have been done. The bone integrity and profusion are barely affected. As a result, the posttop swelling or complications are minimal and they have a faster recovery. The rational is that they reduce the

41:54 risk of fibrous formation. They minimize woven bone and promote laminal bone. And laminal bone is something which we are all looking for. So they these implants inherently promote bone laminar bone formation. So also it has been shown and studies have proved that the bone implant contact that is the BIC was greater in immediately loaded implants. So when we have all these advantages I'm not saying uh uh option B is better than the option one. No but I'm just trying to prove what made me scient as a as a doctor as a thinker think on these lines and start utilizing and incorporating this particular science into my my practice. Plus basil implants work very very fine

42:41 and with gum diseases because you're not utilizing the alvol bone you're utilizing the cortisis. So and we can immediately after a proper toilet after a proper cleaning of the lesion after liberal usage of antibacterials we can easily uh go in for placing these implants. Basil implants have always spoken about this that there are regions are highly resistant to resorption and have high repairing capacities and of course uh various studies the study as recent as a John Spear study as recent as December 2019 in the procontics conference uh mentioned that perimplantitis is one major cause of

43:26 implant failures of conventional implant failures. So this happens. There could be many reasons but one of the main reasons is because they are rough surface. They being rough surface. So they intend to harbor more pathogens compared to a smooth surface. And so the judicious use of monoblock smooth polish surface basil implants eliminates the chances of harboring of the microorganisms. There thereby the per implantage possibility is reduced dramatically to almost 98%. And we can easily use them with practically very very limited contra indications. We can use them in control in smokers. Even though a smoker I would want him to leave the smoking but and

44:12 especially for the first maybe uh one week 10 days while the the the soft tissue is still healing maybe a month they should ideally leave but they can be easily done in smokers. uh in our part of the country where pawn is a major major deterrent major vice so they can easily use in pawns in patients suffering from chronic distractive printitis or in patients who have little or no bone in fact little or no bone is as I mentioned a war factor for us don't require any excessive oral hygiene measures you just require a regular water flosser or a water pick and a dental brush and of course the regular oral hygiene of rinses uh is all that you require And once you're doing all this, money saved, time saved, no additional

45:02 things into your kitty, no graphs, no second stage surgery, patient doctor interaction is minimal. I'm not saying you don't require follow-ups. All procedures, all dental procedures require regular follow-ups. But then the follow-ups could be spaced in a longer time. So and in the postcoid era you would not want the patient visiting you every now and then. So we have the right stuff as I mentioned earlier we have implants suited for each condition. This implant this implant would be there for a post extraction area this implant various areas various areas of various application. It's it's I repeat it's again an operator oriented kind of a thing wherein you feel the best these

45:48 areas could be in a good bone case. So gone are the days when people would say oh basil implants or they are only meant for places where you have no bone. Well I'm afraid uh in my practice I'm utilizing them everywhere. I may be having still having an inventory of conventional implants a fair bit but when it comes to the patient convenience and to my convenience uh I have been using these cortic implants to the best of my uh ability and to my patients comfort and satisfaction. I repeat works in somebody's ex's hands maybe best for him. I'm by no means saying that this is working fantastically in my hands. This is good but this has worked and is working and making wonders for me. The last implant that you see here, I would like to mention that this is MU or a multi-unit abutment implant here. I

46:34 won't be speaking much about these implants, but these just at recently and these are the implants where the retrievability option can also be taken care of. So where you think you have a problem, you need to have a solution. And what is a problem for some is today an opportunity for us. For every problem there is a solution. It's up to us whether we're looking at the problem or we're looking at the solution. So let's make an opportunity out of a problem for people. This is one science which has helped me make that. Now this is one case I'm starting off with now that I have generally it's a very huge topic to speak on cortical visual implants. We have a four or five day course and yet

47:20 we feel we're not able to do justice to our participants. So just summing this up in half an hour is difficult but I have tried to give you a brief insight on the the basic concepts of uh of cortic implantology. I'm now starting off with my uh with my cases. Uh I have tried to cover in my cases most of the cases that areas that would come to us like to the general dental surgeon. This particular case is an HB1 AC8. She is a control diabetic a lady uh in her early 60s. And uh complaint was that her bridges kept falling off and she was finding it difficult to chew onto things. Now you can see there's almost a roller coaster kind of a processes in the occlusion frame in the

48:06 upper jaw. This implant this side she must have had a cany liver here which fractured over a period of time. There's a fracture here as you can see. I'm sorry the image quality is not too good. So uh you need to treat the entire case as a whole. Her problem was that she had missing posteriors. She could not chew from this side because there were cracks developing here and the bridges kept falling off. These are it's radioraphs that come across to us every now and then. So after having done all these paperwork case as a whole given her a a new a fresh pair of uh of fixed teeth on either sides she went in for a zerconium processes once the entire area was taken care of. Only then did we go in for implants. plants are elective

48:51 procedures. They are not emergencies and you need to follow a proper protocol. Need to follow a proper training. This I'm saying from training that I received from my from my former teachers uh from Dr. Shasha and uh Dr. Vive and Dr. Henry Te etc. So you need to treat the entire case as a whole. So once you have she had missing posteriors, we only did work where it was required. We I'm a general dentist and I enjoy saving teeth. So I salvaged all the teeth that I could to the to the best of my ability. Did endos gave her crown and bridge work place implants. Now she this was a good bone case. So I used the Kos micros here. So I happen to have put three

49:37 implants here bloodless. She had a thick gingava bioype. So utilize that to my ability. and to the patient's comfort. So this is a CBCT made in July 2016. As you can see, I happen to have utilized the rough surface implants, test implants, the Kos, done a bit of a bypass here. This is the final processes and this is 3.5 year followup. After 3.5 years, things have gone very very well. She is very happy. She is on insulin these days but still managing to maintain a decent hygiene.

50:23 She does have sight about the material ala in this area. That's understandable and pardonable. A 3.5 year follow of this case. This is a 3.5 year. She happened to have come uh just before the lockdown maybe around I think January or February. This is a fullmouth case. Uh this lady had multiple implants and she was slightly shaky in her confidence. This is a fairly old case and uh she had these teeth. She had uh upper full denture lower RPD which is constantly troubling her and uh she did not have the kind of patience to wait for a long time. So she came to us we made an OPG.

51:08 She had these two teeth which are mobile. We happen to have extracted all of them implants. As you can see in the lower jaw, she only wanted the lower jaws first. She was skeptical because she had heard very high or very much of the coticial implants. So we went in for the lower jaws first. The lower jaws gave her an upper complete denture. Day three. And after 3 months she comes to us back that she's highly satisfied with the lower fixed ones and uh there's no comparison to our removal processes. So after 3 or 4 months she comes to us and gets the upper ones done as well. So we did the upper jaw.

51:56 This is the posttop CBC or the upper posttop CBC immediate after placement and this is 5 years followup of this case of the upper and more than 4.5 this is almost 6 years now as of today as of now that we are in 2020 and she's highly satisfied eating worthy and she's forgotten what discomfort meant as far as the dental aspect went. Uh this is another very very important very difficult case because uh a 70 75 year old lady and uh resort pencil thin rather knife edge ridge and to make matters worse uh this

52:45 lady was with Parkinson's so she had a shaky jaw everything was shaking so we almost ended up doing six-handed dentistry because one of my my associates was holding the lower jaw one assistant holding the head to make it stable and uh with a pencil or a knife edge ridge things became more difficult. You can see and appreciate in this uh this picture very very thin practically no ridge at all. So and the the the gingiva was very very flabby. So I had to raise a flap here. So I put in my implants. I put in eight implants here and more so because there was a constant movement. So I will the proper purchase

53:30 point in the in the bone because of a constant Parkinson's underlying disease. So we place eight implants. I have utilize the uh the anterior region with Kos micros and the posterior ones with the BCS. This is her final processes on day three. So from an edentilist to a dentate in 72 hours literally for somebody who could not chew properly uh it is uh a huge blessing that one gets one starts when she's still got an upper denture on which is which requires a change which hadn't changed subsequently of course but this is an old picture and uh this is a 1.5 year uh posttop

54:16 CBCT things are apparently very good and She herself is very happy because the lower jaws would never stay. The lower dentures would never stay and at least now she will be coming back shortly. She was to come to us for the upper jaw in uh in May but I think uh maybe in due course once lockdown is lifted things could improve and then we could do the surgery for her. There's another case an old case. This gentleman is an athlete a huge 6' 3 6' 4 in gentleman very broadly built he again was was fed up with the lower jaw so we went in for the lower jaws implants first then the upper ones I'll have to rush through because we have quite a few slides still remaining so this is posttop lower posttop OPG after one year

55:04 he comes for the upper ones this is I think done in 2013 or 14 and the upper ones he came to us I think in 14 or 15 forgetting the exact date. So these were the implant surgeries. He's a fairly robustly built gentleman. We happened to put 10 implants earlier in the lower jaw because uh he had a big jaw and eight implants. I've utilized multiple implants. I've utilized the BCS the BCS here. I've utilized the Kos plus series here. Of course the BCS in the posterior and other segments. So it's not necessary that you can just put one set of implants. Whatever works, whatever you feel can give you a good anchorage. Whatever you feel you you feel a particular situation demands, the bone demands. So you can according to

55:50 the bone demand, you can put the implant. Of course, you need to be skilled and experienced for that. You need to be trained to that. These are three-day posttopes, final pictures, posttops. And this is more than five year. I mean this is almost five years when this radioraph was taken. So almost six years plus as as this patient is concerned very happy, very satisfied. Another case uh practically no bone case. This gentleman had practically no bone and his lower denture would impinch as you can see his mental form had almost gone crystal. So each time he would put on the denture and even come into normal occlusion with the upper denture he would be not of agony. So this again was a very tough case

56:37 difficult uh case to do for conventional implantology. So here we went in for a bal bypass. In the previous one we had gone for a lingual bypass as I shown. So we put the anterior regions as the chaos micros and went in for the BCS in the posterior segments doing the buckle bypass. This is the process that we delivered and the smile saves it all. This gentleman, another 70 75 year old uh individual male uh again complaints of uh the lower denture and the upper denture upper bridges falling off and uh the sinus lifts were advised to him elsewhere which he kind of refused uh because that would take almost 9 months he was told. So our initial plan was to just give him

57:23 a bridge in the lower jaw and bridge on the upper left segment right segment and just implants in the posterior's left side and the lower posteriorly. But when we removed the bridge we realized that the because of the constant post and poor a lot of dentist was done the prognosis of this particular segments very very poor. So we decided upon to remove these teeth immediately. We removed them, put implants in the lower jaw. Rest of the teeth, they were these teeth which were salvageable. We salvaged them, gave a bridge. This is where the temporaries uh in the patient's job. And then we happen to have done the bridge work where they were required. So these are posttop clinical pictures. You can again appreciate very clean practically no incision, no blood uh and

58:14 practically asymptomatic areas. This is the bridge that has been given for the bridge here. This is the lower jaw and this is one year after we happen to given him a hybrid process initially which is replaced after one year with the PF processes. So this is a two-year posttop follow-up of the same case. This gentleman is a chronic paler. He's a very well- read person. But pan is something which he can't leave even though he had promised when we began our surgeries that he had left his habit for the last month or so and would not be continuing. But as you all are aware and must be experiencing it every day that these kind of patients will never moment they they feel the comfort level is done and underlying uh is taken care of they get back to their

59:00 old vices. So he had a over denture placed few years back his OPG uh they were all non-salvageable teeth loose terms had gone mobile because there was constant overloading so we put in these implants here these these method that you see ladies and gentlemen they are uh various disciplines that we have in the international implant foundation protocol. So these are images that I take from my various courses. So they are just there just to give you an insight that they have very very discipline there 16 disciplines. Of course this is beyond the preview of this lecture to go in for that but just to give you an insight we utilize the method 5 a here we've utilized the method two. So there are different classifications different disciplines

59:48 the impression level pick this is one year posttop pick. Again the gentleman in spite of my uh or his promises he went back to his punch chewing ways making life difficult but in spite of constant stress this is a three-year posttop followup everything seems to be doing well this is a CBCT all implants are in good place the bone seems to be implants well fixated uh and doing good without pathology in spite of all the overloading that 8 to 10 to 12 hours that he's up that he's in his mouth So in spite of he can take that kind of insult as well. But this gentleman came comes to us gets conventional implants put somewhere uh I don't know what what

1:00:34 the teeth plan was for this particular case. However these implants were ailing and uh he was advised by his dental surgeon that possibly we'll have to go in for removal of these implants. So and he did not have the kind of patients to go back to them again. So we remove those implants and immediately put in these are the BCS ex implants which are uh to be put into extraction sockets. These are polished areas polished implants. I've utilized uh a combination of BCS I've done a double tergoid here a tergoid here and I've engaged the posterior maxul in this portion. So even though he was advised the lower jaw also was quite compromised. He was advised extraction for the lower jaws as well but he insisted that things are not relatively better in the lower jaw. So we gave him a bridge even though it was with questionable prognosis but he's

1:01:20 happy with the lower jaw fixed uh with an FD with a bridge and the upper jaw implant supported processes. This is the posttop surgery fix. This this is uh a posttop surgery. You can see decent healing and the lower jaw is is is doing fairly okay. This case is almost now a year and a half two years old. These are posttopics. I repeat the smile or the the look says it all. He's more than happy. This gentleman is uh uh was referred from rather came from Delhi. He he had lower implant ported processes was very very

1:02:05 unhappy because he had spent almost uh a year and wasn't satisfied with the lower jaw and he didn't have the kind of patio again for that agony. So we removed all his here as you can see we put an array or multiple implant systems everywhere. I hope I'm I'm making uh sense to all of you. So these are posttopics again you can appreciate even though actions have been done things about a system is day that day three the patient is made to eat post cementation and for somebody who's not been eating worthy for the last years for various reasons when he or she and has apprehensions that you got put in screws

1:02:51 in my mouth which are fairly long and you've done so much of juggler you've done surgery in the last a day prior to And you're making me eating worthy. You putting you loaded those implants. You want me to put pressure on them. You want me to eat. Oh my god. A satisfaction is is worth seeing. I mean your day is made once your patient starts eating food and you are responsible directly or indirectly for having made added comfort to his life. So what else are we working for as clinicians? These are again postopics. But this is a special case because this was a a patient from a very very low socioeconomic background. This patient was uh I was told this is a consultation case and uh the surgeon happened to have called me over that you need to come and do it straight away. I had not seen the

1:03:37 patient earlier. This is a patient of mucor micosis who had got a hemaxctomy done and uh uh I was told that we needed to do it uh moment to say it because the patient will find it difficult to go and come back again because of her for various reasons that she had. So I'm not saying this is the right protocol but I'm just trying to tell you the versatility with which we can utilize our implants. Now she had this is her clinical pictures. You can see there is a or nasal or anal communication. No magilla at all. These are her scan views. These are only ones we sent to me. There's practically no bone here. Very thin orital rim. Practically no, no zygoma. And but only thing that was visible was partly you

1:04:23 could see a bit of a teroid hanging. So again another image there's practically nothing here very very thin. So it was a fair amount of a challenge to do this particular case and having not seen the case having not not known of this case I repeat that's not the correct protocol but uh this is how it this case you do come out with with things which are beyond your control when you have problems you need to have solutions and uh we got solutions I happen to have gone in for a flapless zygoma engage zygoma here engage it is here with my implants so on four implants I happen to have extracted one tooth because her four or rather her uh yes two four was grade three mobile and she

1:05:09 had fair amount of attrition and this lady is from a very low social low so economic background uh low in education typical rural India is again uh this is flat plus zygoma engaging the teroid here and in the anterior region because she had nothing here to take support from and she did not want any further extractions. So we gave her a bar on which we put on uh the processes and give her option there. This is 6 months posttop.

1:05:55 She's fairly happy and the implants have taken up well. is 10 month posttop. A regular follow-up of all cases is very very important. Your success in these implants are regular follow-ups and occlusion scheme checkups. I come on to segments. This is a lady who had a a tashan or a raan headed kind of a processes. She had 12 processes put on just four teeth and again the occlusion was a problem. Her lower ants had got severely treated. So we looked into all this case. You need to look treat the entire case as a whole. So all these other prosthetic rehabitations were done. These five

1:06:41 teeth were found to be treatable. So we salvaged them. Did reend where required. Did endose where they were not done. If if it is required gave a bridge in this processes. gave a processes or a lower bridge in the lower area. Uh I repeat I'm a I enjoy saving I've been trained to save teeth. So I saved teeth that was poss that was available or possible I could salvage them. I'm showing this particular radioraph here because it's a fourth fee. This case was done somewhere in fourth February or March 2013. Of course this particular case was with Dr. God case she happened to have placed salvage the teeth that was salvageable given her a

1:07:27 lower bridge down below save the anterior front five teeth and place implants in the posterior maxilla bilaterally where the teeth were missing that needed to be raised the bite to be raised now this is almost a sevenyear follow-up she had come just recently last year now she is a diabetic uh on insulins, osteoporotic and other age age related problem that she's uh tackling or dealing with. Even after 7 years, things appear to be doing well. This is a 7-year posttop CBCT. Apparently all good. This implant does appear to be having fair amount of

1:08:12 absorption because she's an amatic as well but it's still holding on and because other implants are firmly anchored and this being a polish implant this can take the kind of load. So no hassles no problems as far she's concerned. Another segment uh uh compromised patient on the bridge she had a cross arch kind of a a missing structure only the chewing surfaces were the upper and lower anteriors. So she had the upper uh right segment posterior segment and the lower left posterior segment missing. We did the uh part first the teeth as a whole. We needed to rehabilitate this area first. So we the bridge work and then the implants where the teeth

1:08:59 are missing only there. Again I have utilized a combination of BCS EX and BCS. here a BCS, EX and the BCS. These are emitted posttopics. Now this is another case. This case was referred to me from Punjab. This lady had a severely resolved area and we happened to have utilized the intercenosis septage here. This is discipline 80. Just a second. She has been advised that this bridge be replaced but because she's a consultation when she comes from outside a dental surgeon has been advised to take care of this segment immediately after I'm sure by now she would have got these things done long

1:09:45 ago the posttopic other patient these teeth generally he's got lot of dental work done he's got lower anterior spinted he's got bridge works all over things are not very very rosy But he's otherwise comfortable and fine. He only wanted things replaced this side. And after having gone into other occasional considerations, we replaced these two teeth which are non-s salvageable which are mobile and replace them with implants. Implants you can again appreciate they're almost pinhole. Even though these extraction sockets is practically very clean surgery and these being BCS ex we've taken care

1:10:31 of the the jumping distance as well because they have they have a wider uh or or a broader base here. This is a one year posttop CBCT. I'll need to rush through because I'm trying to short on time. There are a lot of cases and my aim is to just show you an array of uh where all we can uh do our implant not just in low bone or poor bone cases but even in regular goodbone implantology cases when you can give things on a platter to a patient in a matter of 3 days why make the patient wait for a longer time. The question answers we'll be taking them after this the session which will which will be ending shortly. This is a 82 83 year old lady. She again had missing three sides missing areas. She

1:11:16 had the fourth quadrant missing posteriors. She had the the second coordinate posterior missing and she had a can bridge which is again fractured and uh there was a right. So I repeat I we the entire case as a whole. We did the other parts the teeth which are salvageable. We crowned and bridged them. Only the ones which were non-s salvageable that is maybe grade two to grade three mobility or which had root pieces or had fractured or where the progresses were found to be poor were removed. Bridge works done here. You see the bridge the temper cement is still on. We yet to remove the cement. Uh the implants in place.

1:12:02 the postimplant postsurgery OPG again I used a combination of BCS ex and BCS this is a 2year posttop CBCT the same lady very happy very satisfied so it is not just in poor bone cases implants can be used anywhere and everywhere that is why the topic itself is a solution for every situation I once again repeat I reiterate that this is this is working fantastically in my hands. So uh something which works in somebody's hands uh by no means I have conventional implantology friends. I have my own conventional implants which I've been doing which I've done from 2004 and still holding on very very

1:12:48 good. I mean they are ones which need to be documented. So almost 15 16 years is a very good time. But this is a new science and has made a world of difference to me and to my patient. So I'm sharing here now this is a patient we have a lot of patients who come to us who only have posterior missings missing posterior six and seven how do you replace them again again in this case if you see the uh there's neatization now we we find it very difficult to put conventional implant here unless we go in for a major sinus lift so here I bypass the bicuspit giving implants three implants doing a a teroid in the posterior posterior most with the VCS ex and utilized this as BCS.

1:13:34 He went in for a recording processes. This is his 2.5 year posttop. This is done in August 2019 the 2.5 years time. So these are his posttop CBCs all doing well. All dug well. Uh now coming on to the antior segment again uh patient comes to us for teeth. They don't come to us for implants. So this gentleman a police officer happened to have suffered a fall breaking two of his teeth. This the fall was around almost 3 to four months before he came to me. The graph revealed fracture of the jaw and the IOP revealed they were root fractures as well. So both these had to be they were non-salvageable and they had to be extracted. They were immediately extracted implants

1:14:19 immediately inserted. I happen to have an immediate acrylic crown because he being so so that socially he's not compromised and this is this immediate processes this is almost like two teeth in about an hour's time less than an hour and this is posttop two years posttop thick another beautiful case this was walked in he wanted replacement of teeth and the OPG revealed a huge cyst which incidentally the cyst was removed and it turned out to be of of inflammatory origin. So we happen to have removed the cyst and done the upper and the lower jaws with bridges which were sal

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