Latest / Straumann® ProTalk / Clinical edition: How hydrophilic surfaces redefined Implant secondary stability with Prof. Shakeel Shahdad

Transcript

Clinical edition: How hydrophilic surfaces redefined Implant secondary stability with Prof. Shakeel Shahdad · Straumann® ProTalk

• 0:00
  The debate is about the interaction between the blood cells, the bone
• 0:05
  cells, and the implant surface.
• 0:07
  So you already have this bone that has been already traumatized
• 0:11
  by the drilling process.
• 0:12
  There's trauma, no question.
• 0:14
  There we'll need a turnover and remodeling.
• 0:16
  Just by that fact.
• 0:18
  And then you squeeze that cork in.
• 0:21
  Yeah, because people get hung up on insertion torque.
• 0:24
  I wanted 80 Ncm insertion torque.
• 0:26
  It's counterproductive.
• 0:28
  It's counterproductive.
• 0:29
  This year marks a very special milestone for Straumann, the
• 0:32
  20th anniversary of SLActive®.
• 0:35
  A Surface that has truly redefined the way we think about implant
• 0:38
  osseointegration and long-term outcome.
• 0:40
  I had the privilege of speaking with Professor Shakeel Shahdad, one of the
• 0:44
  leading experts in implant surface who shared his clinical and research journey
• 0:49
  and why you two should trust your patients with a SLActive® surface implants.
• 0:53
  Don't miss this conversation.
• 0:54
  I'm Dr. Christian Jarry, and this is Straumann ProTalk Clinical.
• 1:12
  Professor Shahdad, what an honor to have you with us.
• 1:16
  Christian.
• 1:16
  Thank you very much.
• 1:17
  Very flattering introduction.
• 1:19
  It is a absolute pleasure for me to be here with you and
• 1:23
  spend the morning sharing some experiences and thoughts with you.
• 1:26
  Oh, I can't wait to see where this conversation will go.
• 1:29
  Now, what's incidental is you just mentioned 20 years of SLActive®.
• 1:33
  Incidentally, my journey through Strauamnn and Al is also 20 years this year.
• 1:40
  So in a way, I feel we have grown together.
• 1:43
  I have grown with, matured with Al over the last 20 years, and during
• 1:48
  that journey have gained immense experience with, in terms of what.
• 1:54
  An implant surface can do for us and our patients.
• 1:58
  So I'll be delighted to share, share my thoughts and experiences and
• 2:03
  knowledge with you guys in terms of what we've done, what I've learned
• 2:06
  over the years, and also the experience of our recent research studies.
• 2:11
  And we deeply appreciate you coming.
• 2:12
  And by the way, happy anniversary then.
• 2:15
  Thank you.
• 2:15
  Yes, indeed.
• 2:18
  So we set the pace here.
• 2:20
  We still hear often people couldn't care less.
• 2:24
  They just want an implant to be placed it, but, and sometimes people take for
• 2:30
  granted the importance of an implant surface for all the colleagues are
• 2:35
  there that still take for granted?
• 2:37
  How do you define, let's set the basis right?
• 2:40
  Yeah.
• 2:40
  The fundamentals.
• 2:40
  How do you define the infant treatment process and why does it matter?
• 2:46
  This is it.
• 2:46
  This is something that I really need to.
• 2:49
  First things first.
• 2:50
  I think we need to once we appreciate that we're actually placing a
• 2:53
  foreign body in a patient's mouth.
• 2:55
  Yeah.
• 2:55
  Yeah.
• 2:56
  And the in my opinion, implant surface does matter.
• 3:00
  It has, we've always known in terms of if you look at casting back
• 3:04
  and seeing the implant surface is how they've evolved over time.
• 3:07
  The various alloys, it didn't work as well as, commercially pure titanium.
• 3:12
  And the debate doesn't necessarily need to be between the, it's not
• 3:16
  just about between the rough and the smooth and not between how
• 3:21
  is an implant surface made rough.
• 3:23
  The debate is much wider than that.
• 3:25
  The debate is about the interaction between the blood cells, the bone
• 3:30
  cells, and the implant surface.
• 3:33
  What triggers a process of osseointegration and
• 3:37
  whether we can modify that.
• 3:40
  In our favor.
• 3:41
  When I say our favor, I'm talking about both me as a clinician and my patient
• 3:45
  as a recipient of that device, shall we say, so therefore the implant surfaces
• 3:51
  are absolutely essential because.
• 3:54
  What we did with implants 20, 30 years ago is very different to what we do
• 3:58
  with implants today because we have, over the years gained so much confidence
• 4:04
  with what we can do with our implants, and then we're pushing the boundaries.
• 4:08
  And if we're pushing the boundaries, whether it's immediacy or whether it
• 4:13
  is surgical sites with significantly deficient bone, or, having to push
• 4:18
  those boundaries means we need the tools to be able to support that as well.
• 4:23
  And that goes in implant surfaces, that goes in implant designs,
• 4:27
  biomaterials that we choose.
• 4:29
  So as clinician I believe we have a huge responsibility in terms of making sure.
• 4:35
  That we make the right decisions for our patients because
• 4:39
  patients don't come asking us.
• 4:40
  To place a specific implant, a design, a surface length, diameter.
• 4:46
  They just want a tooth.
• 4:48
  Yeah.
• 4:48
  Yeah.
• 4:48
  We make those decisions.
• 4:50
  They couldn't care less about
• 4:51
  a beautiful suture.
• 4:52
  Exactly.
• 4:53
  Nobody, I've never had a patient come to say, Hey, I want a
• 4:56
  Strauamnn and electio bone level or tissue level, eight millimeters.
• 4:59
  No.
• 5:00
  I say I've got a problem.
• 5:01
  Please
• 5:02
  solve it for me.
• 5:04
  I like this very much, how you contextualize and how the surfaces
• 5:08
  play a big role because honestly, the problems won't change.
• 5:13
  Yeah.
• 5:14
  Better tools will make a difference and you have to be better equipped for this.
• 5:18
  Yeah.
• 5:19
  And speaking of, you wanna say something?
• 5:21
  No.
• 5:21
  Speaking of anniversary, why 20 years in your opinion?
• 5:25
  The cases you have seen, why do you think the introduction of a
• 5:29
  selected 20 years ago was such a turning point in Implantology?
• 5:34
  The, it goes back to the basic science, when you place an implant
• 5:38
  what, we talk a lot about primary stability and implant dentistry,
• 5:43
  and it's always been the, primary stability is underpinned the overall
• 5:48
  basics and basis of implant dentistry.
• 5:51
  And then that was particularly true when we were.
• 5:53
  Placing machined run mark implants at the time.
• 5:57
  And as stren has always been rough surface implants, but of course there
• 6:00
  are rough surfaces evolved over time.
• 6:03
  The the, secondary stability or the bonet implant contact is the
• 6:08
  most critical thing for long term.
• 6:10
  Now I say long term which is great, but you also have to question
• 6:15
  what do we want in the short term?
• 6:16
  I'm talking about the first few weeks after placing the implant.
• 6:20
  That early interaction between the host and the implant surface, and
• 6:25
  that early interaction is so critical because you have a, the moment you
• 6:29
  place an implant, there is a race.
• 6:33
  There's a race between bone and there's a race between fibrous encapsulation.
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  In other words, there's a race between osseointegration
• 6:41
  and fibrous and copulation.
• 6:42
  One osseointegration means success.
• 6:45
  Fibrous and encapsulation is failure.
• 6:48
  So anything that we as clinicians can choose that can trigger or fast track that
• 6:55
  early interaction between the blood clot.
• 6:58
  And as a result of that, the blood cells, the early angiogenesis, early
• 7:02
  bone cell proliferation which can trigger that process and speed up our
• 7:07
  osseointegration is gonna be of course, beneficial for us because then we are
• 7:11
  not really relying on primary stability.
• 7:14
  Primary stability gives that initial confidence, but that's not enough
• 7:17
  because implants fail if they don't achieve secondary stability.
• 7:21
  In other words, if they don't, osseointegrate, okay.
• 7:23
  And those early few early weeks are very critical, particularly in
• 7:28
  cases which are aggressive, shall you say cases which include your
• 7:33
  extraction sockets, which include your pretty big bone defects, right?
• 7:37
  We have gained so much confidence over the years in terms of what we do with
• 7:41
  bone regeneration around implants.
• 7:43
  The days when every case would get a block graft and people would have to
• 7:47
  have their hip sacrifice for putting implants in the mouth those days have
• 7:52
  changed and that's only come because of the confidence that we have with
• 7:55
  guided bone regeneration, for example.
• 7:57
  And talking about guided bone regeneration, right?
• 8:01
  The implant surface, like an SLActive®® surface we know from
• 8:05
  evidence is a, what do you call, an osteo promoting implant surface.
• 8:09
  So it not only is helping you achieve quicker osseointegration
• 8:14
  with the whole bone, it's also.
• 8:17
  At the same time helping promote the newborn formation
• 8:21
  through the GBR proceed process.
• 8:22
  So it's an, we also know, I'm talking a lot about SLActive®® at the moment,
• 8:26
  but we also know that other implant surfaces, rough implant surfaces if
• 8:30
  you give them enough time to heal, they will reach the same level of.
• 8:34
  Stability and secondary stability over time.
• 8:37
  Over time.
• 8:37
  Yeah.
• 8:38
  It's that initial race.
• 8:39
  I often when in my lectures I often talk about this is like an a
• 8:43
  hundred meter sprinter or sand bolt versus a marathon runner mo far.
• 8:49
  They both will win a gold, but one is a lot quicker than the other one.
• 8:55
  Shaq?
• 8:55
  I would say I already dropped the professor.
• 8:57
  You're already Shaq.
• 8:58
  Thank you for making you know, the professor
• 9:00
  title makes me feel a lot older than I actually probably am.
• 9:04
  You just hit the nail in the head because we often talk to clinicians
• 9:09
  and there's a bit of a skepticism.
• 9:12
  They say oh yeah.
• 9:13
  How would a surface help many immediate solutions?
• 9:16
  How would that help my primary stability?
• 9:19
  You are right.
• 9:19
  You won't.
• 9:20
  Yeah, but you took so much care, engaging your implant in the right position,
• 9:25
  respecting three dimensional positioning.
• 9:28
  You took so much care creating that beautiful emergence profile.
• 9:33
  For that patient to go home and now it's not under your care.
• 9:37
  There's so much a patient can do when it's released back home.
• 9:41
  Yeah.
• 9:41
  Whatever that is, that the behavior or that could trigger a potential
• 9:45
  or could jeopardize all the precious therapy you just applied that you
• 9:50
  want your secondary stability to come as quickly as possible to kick in.
• 9:56
  And that's a turning point.
• 9:58
  So when I. When I reflect about the role of SLActive®, how is, how do you
• 10:04
  see this affecting the decision making process in such an indications that we
• 10:10
  were not so familiar with in the past?
• 10:12
  Now we are.
• 10:13
  And how such a tool in your toolbox changing the decision making process,
• 10:18
  for example, as we just said, immediate solution is one that will be compromised.
• 10:23
  Patients that we may touch on that one, but sometimes we don't even
• 10:26
  know the patient is compromised.
• 10:28
  Absolutely.
• 10:29
  How you see the surface as an added adjunct value in this therapy?
• 10:32
  Yeah.
• 10:33
  Let's
• 10:33
  pick up immediate.
• 10:34
  Yeah.
• 10:34
  Implants in an extraction socket, a simple, that's
• 10:37
  actually a wrong word to use.
• 10:38
  Simple.
• 10:38
  Let's call it a, people consider central incisor an easy, from an
• 10:42
  immediate point of view, feel it's easy.
• 10:44
  It's far from that.
• 10:45
  But let's pick that for as an example now.
• 10:48
  The reality is if you're gonna get your implant in the correct place for
• 10:52
  a central incisor as an immediate most of your implant on the facial aspect.
• 10:57
  Is not in contact with the bone, should not be in contact.
• 11:00
  It's naked.
• 11:01
  Yep.
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  It's the apical few threads.
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  Whatever you have, whatever space you have or height you have available
• 11:06
  above the apex of the implant is what gives you that primary stability.
• 11:10
  And often we forget that most of that implant has no contact
• 11:16
  with the bone is not engaging, the threads are not engaging.
• 11:19
  So therefore, whilst we have primary stability, that primary
• 11:22
  stability is provided by the few apical millimeters of that implant.
• 11:26
  Not the whole length of the implant.
• 11:28
  And we often forget that.
• 11:29
  What that means is if you, from a surface area point of view, if you say, okay,
• 11:34
  now if you look at surface area point of view a vast surface area of that
• 11:38
  implant is not in contact with the bone and we place some bone graft in between.
• 11:42
  So therefore.
• 11:45
  As the primary stability drops, which we know it drops over a period of first
• 11:49
  few weeks and the secondary stability starts to kick in, we need to shift that
• 11:53
  graft to the left so that the secondary stability kicks in as quickly as possible.
• 11:59
  Now, that is where the benefit of a. Active surface, like a
• 12:03
  SLActive® surface comes in because you're getting the confidence that
• 12:07
  your implant is say, I tell my patients, look, this is like baking.
• 12:12
  Yeah.
• 12:12
  You take, you prepare a dish, you have to put it in an oven, and then the
• 12:15
  question is, how long do you place it in an oven before it's cooked?
• 12:19
  The difference is your elect cooks much quicker because your oven is a lot more
• 12:23
  efficient than a non SLActive® surface where it takes longer to bake that dish
• 12:29
  or make 'em out undercooked, and patients understand that language easily,
• 12:34
  right?
• 12:34
  You gotta make it less scientific for patients, right?
• 12:37
  Or can mean by healing times why they need to wait for certain things and stuff.
• 12:41
  We'll try to break it into a language that a patient with easy.
• 12:44
  Relate.
• 12:45
  Oh, of course.
• 12:46
  Baking is not a bad thing.
• 12:47
  Is it?
• 12:47
  Not a bad thing.
• 12:47
  It's such a good thing.
• 12:50
  You just don't want anything undercooked.
• 12:52
  You don't want anything undercooked.
• 12:54
  Yes.
• 12:55
  Yes.
• 12:55
  Because it'll end up in the bin.
• 12:57
  Exactly.
• 12:58
  What a great analogy.
• 13:01
  Any compromise situation.
• 13:02
  We said primary to secondary stability.
• 13:05
  And added to the fact that I was just reflecting, as you were saying, the
• 13:10
  implant alone is partially in a bone.
• 13:12
  And also, especially in aesthetic zone, patients will
• 13:14
  like to go home smiling, huh?
• 13:17
  Then you place an abutment and you increase the arm force, then you increase
• 13:21
  a, put a prosthetic provisional crown.
• 13:23
  You make the arm lever longer, quiet, longer, quite discrepancy.
• 13:28
  I agree with you completely that we should make use of every possible resource.
• 13:33
  To improve the baking.
• 13:36
  So what has happened over the last 20 years, at least in my practice and in my
• 13:41
  unit, is a vast majority of patients that we treat are patients who have hypodontia
• 13:48
  patients who are born without teeth.
• 13:50
  And we know that in such cases, because there has never been that the,
• 13:55
  a permanent tooth hasn't developed.
• 13:56
  So the alveolus is completely underdeveloped.
• 14:00
  So we end up with patients with pretty severe bone defects.
• 14:03
  I'm talking about 2, 3, 4 millimeter ridges that we place in per in.
• 14:07
  Now, in the past, these patients needed quite a significant
• 14:12
  amount of reconstruction.
• 14:14
  We are talking about young teenagers having had no teeth, and then a
• 14:19
  few years of orthodontic treatment
• 14:23
  and.
• 14:24
  The last thing they want when they hit age of 18 to now put them through
• 14:30
  lots and lots of invasive, aggressive surgeries bone reconstruction
• 14:35
  for soft tissue reconstruction, and then putting implants in.
• 14:38
  It's a long journey.
• 14:39
  Yes.
• 14:40
  What we have over the years the confidence that we've gained with the implant surface
• 14:46
  that we've used is we have developed our philosophy around the motto minimizing
• 14:52
  morbidity without compromising outcomes.
• 14:56
  What do we mean by that?
• 14:57
  There is evidence base.
• 14:59
  And I like to use evidence-based as a benchmark.
• 15:02
  Yeah.
• 15:03
  And when we quote evidence to our patients it is a benchmark because
• 15:08
  you can't always say, because this is the evidence, we will achieve it.
• 15:11
  You have to, we're clinicians.
• 15:14
  And dentistry, implant dentistry, anything.
• 15:16
  A dentistry is dependent on the clinician who's delivering that treatment.
• 15:21
  So therefore we need to know our own success rates to be able to quote it
• 15:25
  to the patients and tell them in my hands in evidence is a. But in our hands
• 15:30
  or in my unit, this is our evidence.
• 15:32
  So therefore, it's important that we tell the patients what they're
• 15:35
  expecting from me as a clinician rather than what is written in a journal.
• 15:40
  But it's, it is important that we benchmark ourselves against gold standard.
• 15:43
  And gold standard has to be evidence-based.
• 15:46
  So when I say minimizing morbidity put yourself as a patient.
• 15:51
  Yeah.
• 15:52
  Let's say you need a surgery.
• 15:54
  Let's leave dentistry out.
• 15:55
  You need, let's, God forbid you need a cardiac surgery.
• 15:57
  What would you want?
• 15:58
  You want, right?
• 15:59
  You want the surgeon to be confident enough to give you an outcome,
• 16:03
  in least number of surgeries.
• 16:05
  Or you want the surgeon to say, oh, I need to do six surgeries for
• 16:07
  you before I'm gonna get you there.
• 16:09
  Of course everybody wants least number of surgeries.
• 16:12
  And it's the same thing.
• 16:13
  Our philosophy literally revolves around the same belief that we want
• 16:19
  to achieve outcomes for our patients.
• 16:21
  Yeah, with the least number of surgeries.
• 16:24
  When I say least number of surgeries, I'm talking about one surgery, and often
• 16:29
  our patients require replace an implant.
• 16:32
  There is bone missing buccally.
• 16:35
  There is bone missing palatally, and we do a bone graft, GBR palatally.
• 16:39
  We do a GBR buccally and we reconstruct site in one one visit.
• 16:44
  So I call it a sandwich, GBR because we are sandwiching an implant
• 16:48
  between the buckle and the plate.
• 16:50
  GBR.
• 16:52
  Now to be able to push the envelope of GBR to that extent where you are really
• 16:59
  going against all the grains here, you need the confidence of the tools that you.
• 17:04
  Choosing for your patients.
• 17:05
  And you cannot afford failures because you know it's gonna get you a bad name.
• 17:10
  Your unit is gonna get a bad name, you're gonna get a bad
• 17:12
  name amongst your colleagues.
• 17:14
  And as they say often, the most successful practice is one
• 17:17
  which moves every five years
• 17:21
  because you don't see your long term outcomes and
• 17:23
  no accountability.
• 17:24
  Exactly.
• 17:25
  So we don't want that.
• 17:26
  So therefore we have to, be mindful of I, I want to choose things which
• 17:32
  have evidence-based, but also at the same time, I want to be confident
• 17:35
  because I want to, in our own clinical experience, be able to demonstrate that
• 17:40
  we can push the boundaries here for our, for the benefit of our patients.
• 17:44
  Yeah.
• 17:45
  And if we feel.
• 17:47
  We'll probably come to set some point about the primary stability and its
• 17:52
  significance in my opinion, has always been overcooked in implant industry.
• 17:57
  But then to be able to place implants with compromised primary stability, I'll take
• 18:05
  it to an extent with no primary stability.
• 18:08
  Yeah.
• 18:08
  You need to.
• 18:10
  Have some belief that there is for example, SLActive®® is, if it wasn't
• 18:14
  for SLActive®®, I probably, we, I probably wouldn't be practicing the
• 18:17
  type of implant dentistry I do today.
• 18:20
  I will really summarize it that much.
• 18:23
  I see that over the last 20 years with every case that we do, the more and
• 18:27
  more confidence that we gain, we are, I'm truly relying on an implant surface
• 18:34
  to deliver results for us and in a way.
• 18:39
  To make me feel good, make me look good, shall we say, because we're
• 18:43
  doing something which is really aggressive in terms of treatment, but
• 18:47
  still not compromising our outcomes.
• 18:50
  And also to feel good.
• 18:51
  Come on.
• 18:52
  We don't choose the industry because it's just some random Oh, we choose
• 18:57
  because we have a passion for it.
• 18:58
  We like to.
• 19:00
  Deal with people.
• 19:01
  We like to do good to people and we like to know that what we are doing,
• 19:07
  it's an assertive decision supported by partners like industry partners.
• 19:12
  That is, we are so privileged.
• 19:14
  I would say that those words you're saying it really resonates that all
• 19:19
  the efforts that an immense amount of input into from Straumann into
• 19:25
  research into development comes to.
• 19:29
  A final outcome that you are feeling satisfied because you're
• 19:32
  providing to your patients.
• 19:34
  Yeah.
• 19:34
  Something that it makes you and them feel happy about it?
• 19:38
  Absolutely.
• 19:39
  Absolutely.
• 19:39
  And that you cannot, in, in dentistry and particularly implant
• 19:44
  dentistry, you can't, you cannot underestimate that collaboration
• 19:48
  between industry and clinicians.
• 19:51
  It is a key essential, and the industry, but the industry has to be responsive
• 19:56
  to the needs of the clinician and to the feedback from clinicians.
• 20:02
  That's important.
• 20:02
  It's, and they have to work in collaboration because there's only so
• 20:06
  much experimentation industry can do in their corporate offices and stuff.
• 20:09
  Yeah.
• 20:10
  Ultimately the feedback and what works, what doesn't work
• 20:14
  has to come from clinicians.
• 20:16
  And that's why this collaboration is so important.
• 20:18
  And we have moved long ways away from all the implants.
• 20:22
  The, so be perio as you were describing in the beginning.
• 20:25
  Some experimental alloys.
• 20:28
  Implant dentistry is very well fundamental.
• 20:30
  That's what I like so much about, Chuck.
• 20:33
  We have one session in a podcast called, it's Not What We Think, it's what we
• 20:38
  know, and I ask our guest to highlight one article that you think the dental
• 20:45
  community should know because it either opened your eyes to something new or.
• 20:51
  Shifted your eyes to something that you were not doing, and now you
• 20:54
  started doing and you nicely shared with me the paper from French Schwarz.
• 21:00
  That is quite the standard in research up to this day, how we promote
• 21:05
  research in implant dentistry.
• 21:07
  That is it's an article from 2008 seven
• 21:10
  2007. Two eight was a series of articles published.
• 21:13
  Yeah, this one's published in 2008.
• 21:16
  Bone regeneration in dehiscence type defects at non-submerged and
• 21:21
  submerged, clinically modified surface and conventional.
• 21:26
  Ally titanium implants and immunohisto- an immunohistochemical study.
• 21:33
  Such a tongue twisting, it's a tongue twister, right?
• 21:36
  My god.
• 21:37
  Yeah.
• 21:38
  It feels like those German words, they attach to everything together
• 21:42
  and immunohistochemical study talk.
• 21:46
  Shak, why is this so meaningful to you that you thought you should
• 21:49
  share with the dental community?
• 21:52
  This study.
• 21:54
  Really was a big game changer for me in terms of thinking about how an implant
• 22:02
  surface on its own can be osteo promoting.
• 22:05
  It was the first time, when you say not, it's about this is where the evidence
• 22:09
  base really plays a big important role in our, this clinical decision making.
• 22:14
  This was a study where.
• 22:16
  The the SLA and SSL active implants were placed in dogs with big
• 22:20
  four by three millimeter days since defects that Frank created
• 22:25
  and didn't put any bone graft in, didn't put a membrane in.
• 22:28
  We just closed the plant.
• 22:30
  Just defect.
• 22:30
  Yeah.
• 22:30
  Some of them were submerged, some of them were not submerged.
• 22:33
  And you compare the hydrophobic to a hydrophilic implant surface.
• 22:36
  Remember at that time there was only one hydrophilic implant surface and that
• 22:40
  was the new cell active implant surface.
• 22:42
  This concept didn't exist at that time.
• 22:44
  And what was remarkable was the absolute stark difference between.
• 22:51
  The spontaneous, we're talking about spontaneous bone
• 22:54
  regeneration in an SLActive® defect compared to an SLA defect.
• 22:59
  And in Sal, after eight weeks, nearly 80% of that defect had filled with new bone.
• 23:06
  Yeah.
• 23:08
  Now what does that tell us?
• 23:09
  That tells us that the that, that tells us how powerful the human biology.
• 23:16
  In conjunction with a a, an attractive surface to cell attachment to clot
• 23:24
  attachment can be at two weeks.
• 23:26
  There was a significant difference between and Sal Act two and eight weeks.
• 23:30
  There was, you, when you first see those slides, the histo histology slides,
• 23:35
  you can't believe your eyes that you can see so much bone fill in a defect.
• 23:40
  Yeah, there we go.
• 23:41
  Yeah you look at that.
• 23:43
  It's a lot.
• 23:44
  It's significant and it's hard to believe.
• 23:48
  And when you compare to the SLA, and that is exactly what you would
• 23:51
  expect, no bone felt because you haven't put a graft in or forget the
• 23:54
  graft, you haven't put a barrier in.
• 23:56
  You needed the barrier.
• 23:57
  More importantly, you need a barrier membrane for as scaffold
• 24:00
  as allow the clot to stabilize.
• 24:03
  So what that showed, and then he went on to show in the series of articles as
• 24:07
  well in terms of the how the blood clot stabilizes around the sim implant surface.
• 24:13
  Which allows for the absorption of the proteins, allows the absorption
• 24:16
  of the cell attachment, the bone cell attachment, happening within the
• 24:20
  first few days of implant placement.
• 24:24
  And that's takes me back to my sain bolt and mo farra analogy and stuff.
• 24:28
  But here, mo Farra couldn't because here the hydrophobic implant surface didn't
• 24:32
  regenerate any bone after eight weeks.
• 24:34
  Because the, by the time the cells would've needed to
• 24:37
  attach the implant surface.
• 24:39
  The soft tissue had already attached, taken over.
• 24:42
  That race was won by the soft tissue.
• 24:43
  Yeah.
• 24:44
  Much faster.
• 24:45
  So that really changed my thought process in thinking, whoa, there's something
• 24:51
  truly here because up to that point.
• 24:54
  As I said, I started placing SLActive® when I started
• 24:57
  placing STR implants in 2005.
• 25:00
  I immediately started with SLActive® because just SLActive®
• 25:03
  was on a limited market release.
• 25:05
  And interestingly or should we say subjectively I had noticed.
• 25:10
  That the healing around those tissue level implants was a lot nicer than I
• 25:15
  would've seen after one vehicle placement.
• 25:17
  But that was a very subjective shall we say, observation.
• 25:20
  Until these sort of studies started to come out and started saying,
• 25:23
  okay, this starts to make some sense.
• 25:25
  Yeah, to connect the dots.
• 25:27
  But you still skeptical.
• 25:28
  As a clinician, you think okay, this isn't dogs.
• 25:31
  Maybe dogs behave very differently.
• 25:32
  And they do to some extent.
• 25:34
  We know they do behave differently, and to translate that into humans
• 25:39
  is sometimes quite difficult.
• 25:41
  And you ask questions, will this really happen in humans as well?
• 25:44
  But in other words, what I do, same what Frank did in dogs, in humans, and
• 25:50
  no, I would not just leave an exposed implant surface and not place a graft.
• 25:56
  But at least what this study gave me at that time was a confidence to
• 25:59
  say, okay, if this can happen without a graft, that means that if I place
• 26:03
  a graft and place a good bone graft material in the membrane I can speed
• 26:07
  up the process of bone regeneration.
• 26:10
  I'm giving my implant and my bone graft the best chance to have a good outcome.
• 26:16
  And that paper really then literally changed the direction of travel for me.
• 26:22
  And then subsequently my colleagues who worked with me as you say, you
• 26:26
  sometimes, you have to demonstrate success for others to believe in you.
• 26:30
  And to believe in what you do.
• 26:32
  And that takes time.
• 26:34
  And you have to, lead with example, as I say.
• 26:37
  So in my unit today we have no hesitation in placing implants
• 26:42
  without primary stability.
• 26:44
  We have no hesitation in placing implants, which need very aggressive bone graft.
• 26:48
  Because over the last 20 years me and my colleagues have realized
• 26:52
  that we can push the boundaries.
• 26:54
  That paper, I think I would say has been one which has really been
• 26:58
  always at the forefront of my mind.
• 27:01
  And interestingly because in the last four or five years we've done more
• 27:05
  recent work, because if it was, there wasn't much in the hydrophilic implant
• 27:09
  surface right then you wouldn't see what we are seeing today in the market.
• 27:16
  Yeah, we're seeing a lot of other implant surfaces being marketed,
• 27:21
  which are hydrophilic as well.
• 27:24
  And I was, it's the, because of the curiosity from this and over the time
• 27:30
  I was the sort of cases we've been doing, I was quite curious to say okay.
• 27:36
  Are all hydrophilic surfaces the same then?
• 27:38
  Yeah.
• 27:38
  Yeah.
• 27:40
  That's a million dollar question, right?
• 27:41
  A million question.
• 27:41
  See?
• 27:43
  Must be, because if you're hydrophilic, and hydrophilic by definition is only
• 27:49
  you, zero degree contact angle, when you dip it in liquid of fluid, no tension.
• 27:55
  Yeah.
• 27:55
  No surface.
• 27:55
  Yeah.
• 27:56
  High surface energy, no tension.
• 27:58
  Is that it is that just the hydrophilicity zero degree you
• 28:02
  prove with zero degrees, that is it.
• 28:04
  And the series of studies that we have conducted and published in the recent
• 28:08
  years actually demonstrate otherwise.
• 28:12
  So it isn't just that surface energy, which seems to be
• 28:17
  the be all and end all of it.
• 28:21
  Which is interesting because if you also see the amount of research that
• 28:25
  has been done on SLActive® in the last 20 years, we have more than 300 odd
• 28:29
  articles published, research papers published on it has also demonstrated
• 28:34
  over multiple in vitro studies, clinical studies, and animal studies, particularly
• 28:40
  in vitro studies, have shed a bit more light on the implant surface.
• 28:46
  That it isn't just, it is hydrophilic.
• 28:48
  Even if you compare the s Strauamnn as Roxolid solid, shall we
• 28:51
  say, if you compare the Roxolid solid SLA to Sal two, right?
• 28:55
  We now know there is a bit of nano topography on Sal.
• 29:00
  So there is a lot of other things happening in this SLActive® surface,
• 29:04
  which isn't just about hydrophilicity, which isn't just about dip it in the
• 29:09
  blood and it seeps up the surface.
• 29:12
  There is nano topography, which is allowing a very different kind of an
• 29:17
  interaction between the protein cells and the blood clot at the very early stages.
• 29:22
  We know that the, the SLActive® implant surface is, has got anti-inflammatory
• 29:28
  properties or we at the moment conducting some in vitro studies comparing some
• 29:35
  of the hydrophilic implant surfaces.
• 29:37
  And surprisingly.
• 29:40
  We can see a cascade of anti-inflammatory cytokines in a active surface, whereas
• 29:46
  we see a cascade of pro-inflammatory cells attaching to the other
• 29:51
  hydrophilic implant surfaces.
• 29:54
  So ain't just the zero degree contact angle.
• 29:57
  So there's more to it.
• 29:58
  And it's fascinating because the animal studies that we did, and interestingly
• 30:02
  Frank's study is on the dogs.
• 30:04
  Yeah.
• 30:05
  And the study that we did, it was on mini pigs.
• 30:08
  And if I show you the histological specimens of our electio surface,
• 30:14
  you would think I have copied and pasted them from Frank's study.
• 30:17
  I was, honestly, I was, it was such a when you're doing research thinking.
• 30:21
  I wonder what theological specimen I'm going to get because, he
• 30:25
  is published 20 years ago.
• 30:27
  And honestly, it looks like copy and paste,
• 30:29
  copy paste
• 30:30
  exactly the same behavior where we left dehiscence defects of hydrophilic,
• 30:35
  hydrophobic, and a one of the other competitor implant surface.
• 30:40
  And the SLActive® surface had the same behavior.
• 30:45
  Then we repeated the study with bone graft particulate bone
• 30:49
  graft and a membrane on top.
• 30:50
  And the successful bone regeneration was fascinating.
• 30:55
  Bone implant contact in eight weeks in a mini pig fascinating.
• 30:59
  Whereas the one of the other implant surfaces we were testing, which was, which
• 31:03
  is supposed to be hydrophilic, beautiful bone regeneration for the GBR, but no
• 31:09
  bone implant contact with the surface.
• 31:12
  So what happened as a result?
• 31:15
  Of those studies, it raised more questions than the answers we had.
• 31:20
  'cause now we're getting confused thinking what is going on here?
• 31:23
  Because, so we've gone back to doing some in vitro tests.
• 31:28
  Yeah.
• 31:29
  To look at cytokines to look at how immune, what sort of immune response
• 31:33
  you're getting around those surfaces.
• 31:35
  And there's some work done by Rene in university of British Columbia.
• 31:41
  And we have gone back to more or less recycle what he's done, where he had shown
• 31:48
  the behavior of the anti-inflammatory behavior of SLActive® computer sla.
• 31:54
  So we're now comparing different implant surfaces, right?
• 31:56
  And that's where we noticing that there is the SLActive® surface
• 32:00
  is very anti-inflammatory.
• 32:02
  Which is what you need.
• 32:04
  Whereas the other implant surface phases including the SLA from Strauamnn has got
• 32:09
  a bit more of pro-inflammatory response.
• 32:11
  Correct.
• 32:12
  And I think that's where.
• 32:13
  Probably the difference lies not probably, I'm getting more and
• 32:17
  more convinced now that we got those basic science experiments,
• 32:20
  that is where the difference is.
• 32:23
  It's not just hydro Felicity, it is not just roughness.
• 32:27
  There is a surface.
• 32:28
  Chemistry is such that you are getting a an anti-inflammatory response early
• 32:34
  on within the first few days and that.
• 32:38
  Is gonna be the trigger for that fast track osseointegration.
• 32:45
  We're extending that.
• 32:47
  Am I talking too much?
• 32:48
  No.
• 32:50
  Interestingly, what we're doing at the moment, we have a clinical trial running
• 32:54
  and we're extending that experimentation to not doing those in vitro tests.
• 33:00
  Just on the, the plasma and stuff that you can buy in the market.
• 33:05
  We're using the blood and plasma from each individual patient
• 33:09
  who's having that implant.
• 33:10
  So patient specific immune testing.
• 33:14
  Yeah,
• 33:15
  and we don't have the results yet.
• 33:17
  But I'm really curious to see whether individual patients
• 33:21
  will respond differently to individual implant services.
• 33:24
  Wow.
• 33:26
  That would be great.
• 33:26
  That would be great.
• 33:27
  Yeah.
• 33:27
  I think that will also set the stage for when we look what's next.
• 33:33
  Exactly.
• 33:35
  Exactly.
• 33:36
  Because the tissue engineering science is getting more and
• 33:40
  more advanced if host factor
• 33:43
  is a factor.
• 33:44
  How about we tackle that one too?
• 33:45
  Mission specific.
• 33:46
  I love it.
• 33:47
  Yes.
• 33:48
  That's, I love the angle you brought to this because I asked you what
• 33:51
  an article that was meaningful.
• 33:53
  Either open your eyes to something or made you change the
• 33:56
  way you'd see or do something.
• 33:59
  And I like how you spend it this in a way that it was, it
• 34:03
  started with a observational.
• 34:07
  Elements that we all have in the office, something that we can just not explain.
• 34:11
  Something that we say but I cannot just tell people it works in my
• 34:15
  hands because that's not, yeah.
• 34:18
  They will say, oh yeah, tell me something else.
• 34:20
  Yeah.
• 34:20
  Whatever.
• 34:20
  But how you brought this how the evidence.
• 34:24
  Helped you reassure that what you were seeing, you were not alone?
• 34:30
  No.
• 34:30
  Yeah.
• 34:31
  It started to make sense why I'm observing what I'm observing.
• 34:34
  Excellent.
• 34:35
  I'll give you another example.
• 34:36
  Yeah.
• 34:37
  This is 2009.
• 34:39
  I had a patient flying for treatment for from Nigeria, and I
• 34:45
  was extracting an upper canine and placing an implant in the same visits.
• 34:53
  I extracted the canine.
• 34:55
  The length of the root of that canine was longer and bigger than
• 34:59
  the longest implant that I had.
• 35:03
  Yeah.
• 35:04
  So to extracted the tooth and I take this implant and it is,
• 35:08
  it's really just dangling in that extraction socket, and I'm left with.
• 35:17
  Three choices essentially.
• 35:19
  One is just abort and do nothing.
• 35:22
  Two is don't place the implant, but place a graft in the socket, do the
• 35:26
  outreach, preservation and come back.
• 35:29
  And three is place the implant and take a punt int Yeah.
• 35:36
  But a calculated punt based on what I have noticed with SLActive®.
• 35:40
  So I in conversation with the patient, I said, Hey, listen,
• 35:43
  this is the problem we have.
• 35:45
  Now I said, I've already opened my implant.
• 35:47
  It's gonna be a waste.
• 35:49
  I'm gonna put in a bin.
• 35:49
  Anyway, these are our options.
• 35:54
  What do you think, because you've got involved patients in
• 35:57
  decision making sometimes, right?
• 35:58
  Yeah.
• 35:59
  It's a teamwork.
• 35:59
  And she goes what do you think you got involved with the doctor back?
• 36:04
  I said, I would personally say, we place it.
• 36:09
  And I'm going to, I'm a, I, for me for our unit, for me, the prosthetically
• 36:14
  driven implant placement is a sacrosanct.
• 36:17
  It's about anything in implant dentistry will never compromise the position
• 36:21
  of the implant for the sake of where the bone is or where the bone is in
• 36:24
  the, where the implant needs to go.
• 36:25
  Prosthetically driven placement is absolute must for us because
• 36:28
  there's one problem you cannot fix.
• 36:30
  Is when you get an implanter is mild positioned.
• 36:33
  So I am now left with the this problem of this big socket.
• 36:39
  And having to place an implant in prosthetically driven position,
• 36:42
  which can be anything I said.
• 36:44
  I'm going scraped a lot of bone using professor Buser's technique.
• 36:47
  That's what I use for my GBR and have used it for more than two decades as taking
• 36:52
  the bone, a lot of bone scraping, and I used the bone to position my implant
• 36:56
  in that socket in the ideal position.
• 36:59
  Yeah, but it's literally dangling.
• 37:01
  Yeah.
• 37:02
  And then there was a bone defect on the buckle wall as well, which
• 37:05
  we regenerated like we normally do.
• 37:07
  And I subed it and the patient went back to Nigeria and she came back after three
• 37:12
  months for the second stage surgery and.
• 37:18
  I was pretty convinced this implant has to come out.
• 37:21
  You were ready to take out.
• 37:23
  I was ready to take it out.
• 37:24
  I took a radiograph before she, when she came and I radiograph looked good.
• 37:28
  But you can't judge osseointegration truly on a radiograph.
• 37:31
  And I, it probably was the only time when I was nervous doing a
• 37:36
  second stage surgery knowing that I'm gonna pick this implant out.
• 37:40
  Yeah, and then I had to create up the clean the mess that I've created
• 37:43
  in there, and I go in there and start all over and start all over.
• 37:48
  And I open the flap and tap.
• 37:50
  Tap.
• 37:51
  Absolutely brilliant.
• 37:52
  And that for me was another watershed moment in terms of questioning
• 37:58
  how important is primary stability in cases where we can protect
• 38:04
  the implant from macro motion.
• 38:06
  Yeah, that's important.
• 38:07
  Of course, immediacy, you need.
• 38:09
  You need good primary stability, you submerged it.
• 38:12
  It was completely submerged.
• 38:13
  Yeah.
• 38:13
  Yeah.
• 38:14
  So as long as you with a implant surface like Asel Act two I know I'm all I need is
• 38:20
  about, two weeks to start to get the bone to stick created the secondary stability.
• 38:25
  Yeah.
• 38:26
  So because the process is much quicker, I'm giving the best
• 38:30
  chance for this implant to integrate and that since that day.
• 38:35
  We, primary stability has never been a stopper for us for not placing implants.
• 38:42
  But what has happened now with the, of course, it was always more difficult
• 38:46
  to achieve primary stability with with tissue level implants because
• 38:50
  they're passive design implants.
• 38:52
  And you probably, quite well that I am a big tissue level user.
• 38:57
  Bone level is very rarely comes into our clinical indication.
• 39:01
  With the new generation four.
• 39:05
  Tissue level designs of TLC and TLX the big issue about, we can now, I can
• 39:14
  achieve now enough primary stability with a millimeter of engagement of
• 39:18
  the apical part of the implants.
• 39:20
  So you can get the best of both words.
• 39:22
  I am a happy man.
• 39:24
  The TLC design that, the tissue level taper design.
• 39:28
  Yeah, it is.
• 39:29
  I personally, I feel it's been a big change for us because now with very little
• 39:35
  couple of millimeters of engagement, one millimeter of engagement of the
• 39:38
  apex, we've got enough stability con.
• 39:41
  Nobody wants to place implants without primary stability.
• 39:44
  No, you don't choose to place implants without primary.
• 39:47
  That's not an option.
• 39:47
  Yeah.
• 39:48
  It's the, it's circumstantial as they say.
• 39:51
  Yeah.
• 39:51
  The only choice is either you are bought and don't do it, or you have
• 39:54
  the confidence of the tools, you have the implants, you have the
• 39:58
  surfaces you have, and you do that.
• 40:01
  So it's a big kind of leap of faith, shall we say, to, when we talk about,
• 40:08
  because the first, first when somebody goes to study implant dentistry.
• 40:14
  The first topic they teach you is primary stability.
• 40:16
  Yeah.
• 40:17
  Yeah.
• 40:17
  After they do the surface and the history and stuff, the first thing
• 40:20
  they teach you is primary stability.
• 40:21
  And it is such a big, underpins everything.
• 40:25
  And then when we demonstrate cases and stuff that we have done.
• 40:29
  Successfully without primary stability.
• 40:31
  Yeah.
• 40:31
  It takes a leap of faith.
• 40:33
  It does.
• 40:33
  Now, I really, honestly, Christian, I couldn't tell you I couldn't answer one.
• 40:37
  If you asked me a question, what would you expect?
• 40:39
  The same results from other implant surfaces?
• 40:42
  I can't answer that question.
• 40:43
  Yeah.
• 40:44
  'cause I've never tested it.
• 40:47
  So I really like this example you cited because the literature is quite fast.
• 40:52
  Correlating also lower primary stability with implant failures.
• 40:57
  But it's not quite.
• 40:59
  There's not quite a consensus whether higher torque values will
• 41:03
  have an impact on failures as well.
• 41:06
  We have common sense.
• 41:07
  There will be less vascularization and initial period depending on the region.
• 41:12
  Less less vascularization for example, in the lower anterior zone.
• 41:16
  Harder bone, higher turnover.
• 41:18
  You don't wanna compromise the limited vascularization you already have.
• 41:21
  So you have to be more cautious.
• 41:23
  Common sense should be predominant, however,
• 41:27
  right?
• 41:27
  So we published a systematic review last year on the same
• 41:31
  subject of primary stability.
• 41:33
  Now what is interesting to note is we looked at two things.
• 41:38
  We looked at insertion, torque of about 35, and we look at
• 41:42
  the IQ value of about 50.
• 41:45
  There is no correlation.
• 41:47
  Between the higher the insertion torque, the more successful the implant.
• 41:51
  On the contrary, like exactly what you said, the more, the higher the torque
• 41:55
  value in an avascular bone, the more those implants fail because of the, you get
• 42:02
  the pressure necrosis and stuff, right?
• 42:03
  That is.
• 42:04
  Absolutely certain.
• 42:05
  Yeah.
• 42:06
  So therefore all of those studies that you look at from the implant outcomes
• 42:10
  and the studies that have supported their data with insertion, torque, or I sq
• 42:15
  values, there is absolutely no correlation between the lower values of insertion,
• 42:22
  torque or ISQ to higher failure.
• 42:25
  So I asked the question, where is all this?
• 42:29
  Where is all we talk about evidence base?
• 42:31
  Yeah.
• 42:31
  There is no evidence to say if you have low primary stability,
• 42:34
  your implant will fail.
• 42:36
  I, again, repeat myself.
• 42:38
  It's very important that those implants will lower primary stability
• 42:41
  are protected from macro motion.
• 42:44
  That's the critical thing.
• 42:45
  Yeah.
• 42:47
  We published recently an animal study.
• 42:49
  Yeah.
• 42:50
  We did a mini pig study comparing SLActive® and SA.
• 42:55
  Implants were placed with normal preparation of osteotomy.
• 42:58
  So you get normal preparation, good primary stability, high
• 43:02
  insertion, torque implants.
• 43:04
  Sites were over prepared and the implant was breast fit.
• 43:08
  They were literally dangling in the osteotomy site.
• 43:11
  So we have normal preparation and over preparation, SLActive® and SLA
• 43:17
  results were fascinating.
• 43:19
  We, when we look at the slac, so none of the over preparation.
• 43:24
  Implants failed.
• 43:25
  So everything integrated.
• 43:27
  This is in a mini paper where you can't control, you can't tell
• 43:30
  them, Hey, don't show on that side.
• 43:31
  Yeah, soft diet, you can't control that.
• 43:35
  But what was really interesting is, I would urge people to look at that paper
• 43:39
  and see, because it will help it'll help them rethink their osteotomy preparation.
• 43:46
  For the benefit of the patients between SLActive® and SLA, if you look
• 43:50
  at two weeks, you'll see a lot more cellular activity in elect between
• 43:55
  the implant and the the clot and the bone surface compared to SLA.
• 44:00
  Number one, so that com, that confirms everything we know about
• 44:04
  SLActive® in terms of the speed of early engagement between the host
• 44:09
  and the implant surface, number one.
• 44:11
  Number two is the top two millimeters of the implant, the coronal part of
• 44:15
  the implant, which I would consider the most critical part of the influence.
• 44:21
  Yeah.
• 44:21
  In terms of aesthetics, in terms of long-term stability, in terms of where
• 44:26
  all the evil stuff around the implant starts is the implant abutment junction,
• 44:30
  all the ones that were normal preparation implants had coronal buckle bone loss.
• 44:39
  Yeah.
• 44:41
  And in over preparation sites, there was a thick buckle plate in those implants.
• 44:48
  Now, what does that tell us?
• 44:49
  At the coronal?
• 44:50
  At the coronal two mil, top two millimeters, the implant.
• 44:53
  That tells us that compressing an implant in particularly in the
• 44:58
  coronal two millimeters, because the buckle bone is usually thin.
• 45:02
  Yeah.
• 45:02
  It's cortical that, squeezing that implant into our osteotomy site at the
• 45:07
  top, which compresses the cortical plate.
• 45:10
  Leads to bone loss.
• 45:11
  Yeah.
• 45:12
  And therefore the, when there is no compression on the bone.
• 45:17
  They really respond.
• 45:19
  They breathe a lot more favorably.
• 45:21
  Yes.
• 45:22
  They go.
• 45:23
  Whereas if you crush someone Yeah.
• 45:25
  Something they don't behave normally.
• 45:29
  Yeah.
• 45:30
  So what that, what does that mean?
• 45:32
  In clinical translation, it means you aim to achieve your high primary stability
• 45:37
  from the apical part of the implant and the middle part of the implant.
• 45:40
  But please slightly flare your coronal preparation.
• 45:45
  Even if your implant is not in full contact with the bone, it's
• 45:49
  better than crushing the implant in,
• 45:52
  I love this.
• 45:53
  You hit the nail in the head because if you look at all the sites, not immediate
• 45:56
  of course, but take a tooth out.
• 45:59
  The start soft tissue starts to protect, and then over time,
• 46:04
  that site is not painful anymore.
• 46:06
  Patient starts chewing on it.
• 46:07
  You have the buccal bone poorly, vascularized starts collapsing,
• 46:11
  or, and you have normally this teardrop healing pattern.
• 46:15
  I honestly could never understand.
• 46:19
  Implant designs, they start in such a way and they -. Flare, flare up.
• 46:23
  Yeah.
• 46:23
  But from the middle of the implant where the most critical converging
• 46:27
  area of the bone is coming together and the implant is pushing, so you already
• 46:32
  have this bone that has been already traumatized by the drilling process.
• 46:36
  That's trauma.
• 46:37
  No question.
• 46:38
  They will need a turnover in remodeling just by that fact.
• 46:42
  And then you squeeze that cork in.
• 46:45
  Yeah, because people get hung up on insertion torque.
• 46:48
  I want an 80 Ncm insertion torque.
• 46:50
  It's counterproductive.
• 46:52
  It's counterproductive.
• 46:53
  It's counterproductive because you are getting a lot more osteoclastic
• 46:56
  activity because you're crushing the hell out of those bone cells.
• 47:00
  You need to be gentle.
• 47:01
  So in the mandible for my standard parallel implants, I would
• 47:05
  always tap the implant side.
• 47:07
  I want my implant to go in easy rather than really having
• 47:10
  to crush it and force it.
• 47:12
  I see.
• 47:12
  Now, if you look at some of the implant designs, I'm not a big bone level user.
• 47:16
  I very rarely use a bone level implant, but the BLX implant, and I think
• 47:20
  there are some of the other implant systems that taper at the top, which
• 47:24
  is actually probably one of the best implant designs you can have at the top
• 47:27
  one millimeter, they become narrower.
• 47:29
  So there's no pressure on that buckle plate.
• 47:31
  And I would certainly say you may not have every design like that, but
• 47:35
  you can modify your osteotomy, right?
• 47:37
  To just flare the Corona one millimeter, two millimeters, so
• 47:41
  you're not crushing that bone.
• 47:43
  And again, at the last ITI conference the there was the, one of the systematic
• 47:49
  reviews and the consensus statements, I was part of that group as well in
• 47:53
  the consensus statement where the need.
• 47:56
  To increase the thickness, what was expected until that point was we need
• 48:01
  one millimeter of bone on an implant, and on that consensus conference it was
• 48:05
  in increased to 1.5, 1.8 millimeters.
• 48:08
  I see.
• 48:09
  Because we need that thickness of bone.
• 48:12
  More cortical.
• 48:12
  The bone, it's hard.
• 48:15
  Wood
• 48:15
  doesn't respond as well.
• 48:18
  Chuck.
• 48:20
  I regret to inform, but our time is up.
• 48:22
  I could spend all day here discussing with you.
• 48:25
  It's a delightful conversation because it's not only about the surface,
• 48:28
  it's everything that en enables.
• 48:31
  For us, peace of mind workflow, and also as an end result to patients.
• 48:37
  You brought to the table, the evidence, your personal choices, how this has
• 48:42
  impacted in certain ways, even in challenging situations where you have
• 48:45
  a floater there you're a zero torque.
• 48:48
  According to, you're a zero Tor implant.
• 48:51
  You're a canine floater.
• 48:52
  Yeah.
• 48:53
  I love this very much.
• 48:54
  Thank you for participating in Straumann Pro Talk Clinical.
• 48:58
  It was a delightful conversation.
• 49:00
  Thank you very much, Christian.
• 49:02
  Thank you for the time.
• 49:03
  Really enjoyed it.
• 49:04
  Thank you and to all of you interested to learn more about a SLActive® surface.
• 49:11
  Stay tuned for Professor Shaky Shahdad Lectures, publications.
• 49:16
  It's worth your time.
• 49:17
  Of course, all the articles we mentioned here, we'll leave it
• 49:20
  in the description below in this video, the first one we asked and
• 49:23
  the other ones that we highlighted.
• 49:25
  We'll leave it all ready for you to just have a delightful reading.
• 49:30
  We thank you very much.
• 49:32
  Celebrate with us the 20th anniversary of a SLActive® surface, a surface that has
• 49:37
  redefined the way we do implantology and think how osseointegration should move.
• 49:42
  Until the next episode.
• 49:44
  See you then.