ENG) 2026 Minimalism Consensus _ where are bright Implants truly Indicated?

Added: 2026-05-23

[00:00:05]Good afternoon. I am Sumhan from Korea.

[00:00:08]I'd like to thank you for tenting company and also appreciate professor her to moderate this session. Uh I know what is what what time is it now? About 2:30 p.m. I know this time is probably the hardest time for you to stay awake.

[00:00:28]uh but I promise to make this session worth your time today. I'd like to introduce bright tissue level implants in briefly. Uh probably many of you many of you are still unfamiliar with this product. So I'm going to explore the clinical indications where they can be particularly useful. I will spend the first half of the session covering the theoretical background and then I'll present related clinical cases in the later half. uh bright tissue level implant cases uh introduced earlier session so I'll make it brief conceptually bright tissue lab implant can be understood as a structurally solid implanted body without an internal hardos chamber combined with external hex connection at the coronal portion by relocating the connection upward and eliminating the internal cavity overall fractural resistance is greatly improved.

[00:01:30]It looks like a one body implant featuring an external hex connection structure at the top.

[00:01:37]The greatest strength of the brightish level implant is simple, narrow but strong. This product was uh this product is was developed to enable even a 3.5 mm diameter implants to function effectively when it is placed in the posterior reason.

[00:01:56]This product have a unique design.

[00:01:58]Conventional internal communical connection system such as super line has a typically uh tapered design with a thicker coronal portion. In contrast, bright tissue level implant has a slight different configuration.

[00:02:13]Rather than being thickest at the top, it mid body portion is relatively reinforced.

[00:02:20]This structural difference leads to different pattern of primary stability during implant placement. With superline conical connection systems, the highest insertion torque is usually achieved at the implant platform level.

[00:02:36]Uh this means the maximum primary stability is obtained at the crest level. On the other hand with bright tissue level implant primary stability is mainly achieved in the mid body portion within the cancerous form.

[00:02:51]Clinically this difference becomes significant especially in narrow ridges when primary stability is concentrated at the crest turbone as in a tapered conical system stress may be generated at the crest level.

[00:03:08]In contrast, when primary stability is achieved more centrally within the cancerous bone, the stress at the crest bone can be reduced. This may contribute to better bone preservation, especially in thin niche conditions.

[00:03:24]Furthermore, thanks to the concave transmucal part design, better sub tissue response is commonly found.

[00:03:34]Where are bright tissue level implants truly indicated?

[00:03:38]Before moving forward, let me begin by introducing two important concept.

[00:03:43]Critical carbon dimension and individual alvola phenotype.

[00:03:48]Critical carbon dimension refers to the minimum amount of bone thickness required to maintain long-term implant health and stability. This concept is especially relevant to the buckar bone.

[00:04:01]This concept is known to have been first introduced by Dr. Spray in the year 2000.

[00:04:07]As is well recognized, it has been suggested that at least 1.8 mm of buckarbone thickness is required around the implant. However, this conclusion was based on the observation that when 1.8 mm of buckarbone was present at the time of implant placement, no implant thread exposure was noted at the time of uncovering second stage surgery. It was not derived from long-term functional outcomes after years of implant loading.

[00:04:40]In recent years, the concept of critical carbon dimension has been more systematarally investigated and refined.

[00:04:48]Dr. Monet from Spain proposed 1.5 mm as the threshold for critical carbon dimension. This proposal was based on animal studies demonstrating that when barbon thickness at the time of implant placement was 1.5 mm or less barbon resion occurred.

[00:05:09]This was interpreted as a physiologic bone modeling associated with a vascular necrosis.

[00:05:16]In contrast when the barbon thickness exceeded 1.5 mm for carbon resorption was minimized. Furthermore, even after liature induced parimplantitis was initiated, pathology bonus was significantly reduced. Based on these findings, he defined the critical carbon dimension as 1.5 mm. The concept of critical carbon dimension is now widely accepted and having been endorsed at the seventh ITI consensus conference.

[00:05:49]However, in clinical situations, implants are often found to survive we even when vocal bone is partially or completely absent. For example, in a long-term randomized control trial comparing early and late and delayed implant placement protocol, Dr. Sh evaluate the fate of vocal bone using CT scans after 10 years. The barbon level was found to be located on average every 2.1 mm apical to the implanted shoulder.

[00:06:23]This indicates that implants were functioning with exposed thread on the vocal aspect in the long term.

[00:06:32]Accordingly, some systematic reviews have suggested that critical bone dimension is not necessarily a determining factor for inflated survival.

[00:06:42]So which perspective do you agree with?

[00:06:45]Is it better to have a carbon or is it acceptable even in its absence?

[00:06:52]In this regard, I would like to introduce an interesting study.

[00:06:57]This is a human study conducted from a university of jurik in Switzerland. In cases where small tiens defect, one group received no additional treatment and was allowed to heal spontaneously while the other group underwent GBR surgery to regenerate the lost vocal bone. The in patients was subsequently followed and multiple clinical parameters were assessed.

[00:07:24]The initial outcome after 18 months demonstrate that even in clinical situation where the high sense of pen stress was left untreated there was not a higher layer of infl failure in comparison to defect treated with GVR.

[00:07:40]Other clinical parameters in the spontaneous healing group were within acceptable limits. However, more favorable bone conditions were found in the GVR group.

[00:07:52]In the subsequent long-term followup at 7 and a half years, the results were similar. The influence survival rate was 100% no biological and the severe biological complications observed and the clinical parameters remained within acceptable limits.

[00:08:11]Nevertheless, bone related parameters were clearly more favorable and remained superior in the GBI group throughout the observation period.

[00:08:22]Okay. While seven and a half year followup is not negligible, it may still be insufficient considering that parimplantitis is typically a late on set complication. In fact, in the previous study, uh Dr. Jung published this study in cases where small TI sense defects were left untreated for the vocarbon loss occurred in 42% of cases compared to 20% in the GB group almost double the rate. This finding indicate that exposure of implant thread may represent a risk factor for the development of perimplantitis.

[00:09:04]The conclusion of the consensus report from osteology foundation was clear. It does not seem reasonable to leave exposed thread without further treatment. Moreover, performing lateral bone augmentation aside with exposed implant threat appears to contribute to the maintenance of implant health.

[00:09:26]For example, Dr. Vzi reported that perimplantitis developed in 13.4% 4% of cases where bone augmentation was performed at exposed implant surface whereas the instance increased to 24.8% when no treatment was provided almost double the rate. Uh therefore the presence of bone may not be critical for implant survival but may it may critical for long-term biological stability.

[00:09:58]So if you the patient receiving implant treatment, what would you prefer? If your implant thread was exposed, would you feel comfortable leaving them untreated?

[00:10:09]So if you agree that maintaining the critical bone dimension is important, bone augmentation becomes necessary.

[00:10:17]Now the next question is to what extent can we augment?

[00:10:24]Consensus reports generally agreed that that horizontal bone gain of approximately 3 to 4 mm can be achieved predictably.

[00:10:33]However, I believe that rather than focusing on absolute numbers, we should consider this from a relative perspective.

[00:10:41]And this is where the concept of individual are relevant phenotype becomes highly relevant.

[00:10:47]This concept itself is not new. It appears that the the term was formerly introduced by Dr. Kirin in 2023.

[00:10:56]In simple terms, each individual possesses a unique bone dimension and it is biologically difficult to augment beyond these inherent anatomical boundaries.

[00:11:10]I have been interested in this concept quite a long time ago. As early as 21 years ago, Dr. Y published the findings related to this issue.

[00:11:21]He performed the blockbone grafting in the maxillary anteriorism and followed the biometric changes over five five years. Interestingly, regardless of the degree of aug over augmentmentation, the augmented bone volume eventually reduced to a level comparable to the patient's original bone envelope.

[00:11:46]More recently, Professor Song from Korea reported similar findings. He performed lateral bone augmentation using GVR procedure in chronic defect model of dog.

[00:11:58]Although over grafted space beyond the original bone envelope or radioarly maintained uh these areas did not contain newly formed bone instead they consisted mainly of residual car membrane and bone graft material. He concluded that uh the bone defects tend to be restored to the original le control by newborn tissue. Nowadays similar studies can be easily found and from these studies we can see bone augmentation tends to remodel toward the patient's inherent arvola phenotype.

[00:12:36]Now we have discussed both the concept of critical carbon dimension and our individual arable phenotype. Let us integrate these two ideas around implant a certain sicknesses of bone is always required.

[00:12:53]However, when a defect is present the amount of bone we can regenerate is limited to patients inherent biological envelope.

[00:13:04]Therefore, if a defect occurs in patients having thick ara phenotype, placing an implant with simultaneous GBR may still allow us to achieve sufficient critical bone dimension even uh a wide diameter implant was used.

[00:13:22]What happens when a patient has a thin alvola phenotype? In such a cases, no matter how much bone augmentation is performed, it is difficult to maintain an optimal critical bone dimension around an implant. Right?

[00:13:38]In such a cases, a bright tissue level implant could represent a biologically favorable alternative.

[00:13:47]By using a bright tissue level implant, we can limit the amount of augmentation to the extent permitted by the patient's inherent phenotype while still maintaining the critical bond dimension.

[00:14:02]Okay, having discussed the biological principles, let us now examine how these concepts uh apply in actual clinical cases. This case involves the need for influence in the right central and lateral insert size sites due to the failure bridge restoration failure. The CT scan shows that the bone width of this patient is inherently narrow. As you can see from the centralized side CT image uh this is taken before tooth traction. The patient native bone thickness is not substantial in the lateral insert site. The leachch has already become significantly reduced. In cases like this, even with GVR combined with placement of standard diamel, the potential for increasing the horizontal bone techniques is biologically limited. Consequently, securing a sufficient critical bone dimension may be difficult.

[00:15:03]Furthermore, in this case, central incizite has a significant apical reason as well as the bone undercut making immediate placement some risky.

[00:15:15]So 2.5 mm diameter of right tissue level implant was placed in the narrow bone of retro in site and ARP procedure without placing an implant in the central insert site was performed.

[00:15:31]uh in this case uh collagenated bone and collagen matrix was used.

[00:15:38]Open healing was intended as in a standard ARP procedure and provisional restoration was provided uh using a remaining natural dentition.

[00:15:49]Although there was a minor flat sloping healing progressed well without any noticeable complications as is often the case resorption was observed despite ARP procedure based only on the three month CT outcome. Some boom formation was observed suggesting that implant placement may be feasible. There is still insufficient vocarbon around the implant placed in the lateral incite.

[00:16:20]However, clinically a completely different situation was found. There was no confirmation at all. I'm not sure of the exact reason, but this may suggest that ARP procedure per se may have limited effectiveness. Anyway, I had intended to take a simple approach via ARP, but the unexpected outcome complicated the whole situation. So, definite solution is required to resolve this problem.

[00:16:50]Considering the patient's inherently thin arbor phenotype 3 mm diameter of right tissue level implant was selected instead of standard dimer implant.

[00:17:02]Nearly whole thread was exposed. It was protruded out of bony envelope. So meticulous GBR surgery should be followed.

[00:17:12]Bongra material a mixture of small amount of bone and oian xeno and aloate material was applied and then this bonget material was applied up to the lateral insert site with a thimoc carbon and membrane was placed like this slide. This is collision membrane 2. Collision membrane 2 was fixed at the apical portion using fixation pin and stretched to the paral side and placed around the transmucosal part of this bright tissue level implant and lenant piece of collagen membrane to was placed to cover the lateral inside and undo stability was achieved in this way and primary flex closure was achieved.

[00:17:58]This is healing. Healing was only bent four and second stage surgery was performed after four months you without raising up lab at the crest area only small body incision was made to remove the fixation pin.

[00:18:14]Finally provation at both implants were connected and proval restoration was modified several times to accommodate patients preferences and this is final outcome.

[00:18:27]Take a close look at the CT image compared with the previous CT image taken after three months uh just after ARP procedure uh uh three months after procedure. Sorry, the difference is obvious.

[00:18:44]It clearly appears that bone has formed.

[00:18:49]Please note that the regenerated bone seems to extend only up to the patient's inherent biological boundary. The key point here is by placing 3 mm diameter of rightish level implant I was able to maintain the critical bone dimension. If a standard diameter implant had been placed instead this would likely not have been possible and this is one year follow critical bond dimension is still there.

[00:19:20]In this case, lateral incision missing side show severe bon atrophy.

[00:19:26]A super line 3.6 mm narrow diameter implant was barely placed in this site but bone deisens occurred. Nearly all the threads were exposed.

[00:19:38]So as lutin a simultaneous GB surgery was performed meticulously. Membrane was stabilized with both membrane fixation technique and membrane holding suture technique.

[00:19:52]uh healing was uneventful without any complication during healing period. Four months later when I opened the fle I was disappoint I was disappointed uh at the uh result of this surgery. uh although substantial bone formation was found at the mid area and at the apical site bone gain at the implanted platform level was somewhat deficient despite meticulous GBR.

[00:20:22]The CT outcome after five years shows that the barbon thickness may still be insufficient to be considered as optimal critical carbon dimension.

[00:20:34]Achieving photo horizontal bone augmentation in this inherent thin phenotype would have been difficult. If a bright tissue level implant with a smaller diameter such as 2.5 or 3 mm had been selected, a greater critical carbon dimension might have been uh secured.

[00:20:55]Let us consider another clinical cases in this mandibular posterior site.

[00:21:00]Advanced legion has already taken place leading to a marketkedly reduced bone width. By evaluating the intact first primola region on the right slide, lower right slide, we can appreciate that the patient's native arola bone thickness is relatively thin.

[00:21:21]This slide shows the surgical procedures. And if I had planned to place wide diameter implant in the molarism and the standard diameter implanted in preolarism, a staged approach surgery would likely have you know more appropriate treatment option.

[00:21:39]However, in this case by placing four 4 mm bright tissue level implant in the molar le and 3.5 mm diameter of bright tissue level implant in the primar le I was able to perform simultaneous GBR and implant placement for GBR surgery tenting screw was used and membrane was fixed using the screw because the mandivular bone has so rigid and so hard A mixture of bongra material compos bong graft material consisting of oen xenoc and autotogenous bone was applied.

[00:22:21]Healing was uneventful. I intentionally buried these two tissue level implants to promote better wound healing. I believe that submerged healing with primary closure result in more favorable bone regenerative outcomes than open healing especially in compromised cases and reentry surgery was performed at performance. Previously exposed thread was covered by bubon tissue completely and horizontal bone technique increased uh increased much but the level of adjacent bone site.

[00:22:56]Anyway uh final uh juna process were delivered and this is the CT outcome. Uh I was able to perform simultaneous approach. I was able to keep the critical carbon dimension in this case.

[00:23:13]In clinical practice we encounter indications for relatively narrow right tissue level implants more often than you might expect. This is another case of rigid failure. When I reviewed the initial radioraphs, I also felt that this would not be an easy case.

[00:23:31]Moreover, patients strongly requested implant placement in all four anterior sides. On the penal radioraph, you can confirm large size of incisive conal between the central incures. The size of corner further limited the available bone in this area.

[00:23:52]Therefore I explained to the patient for bridge restorations for uni bridge restoration and using two implant placement in both lateral incides uh might be peaceful option the central insider side could be a more challenging but patient still wanted to have full influence.

[00:24:15]So I first proceeded with bone augmentation surgery using GBR approach.

[00:24:20]A titan plate was placed using three screw. Titan plate was placed like a fence. Uh it looks like a shell technique and some space was created between the placed titan plate and native bone. In that created space a mixture composite bone graft was applied. Composite bone rect also consist of small amount of trogenous bone and alo rat and osteogen particulated bone and collagen membrane was placed like this. This is collagen membrane too. This membrane has a stretched stretcher. So memory was fixed at the apical site using just one screw and stretched to the polar site and stabilized photo using suture material and another collision membrane one was placed uh for photo protection wound stability was achieved in like this slice and fl was closed and healing was uneventful during the nine months of healing period.

[00:25:25]Although the C team suggested adequate overall bone thickness, insufficient bone is still observed around the insect canal.

[00:25:37]The real situation was as follows.

[00:25:40]Proper positioning of standard diameter implant might be inevitably limited by the location of inside canal.

[00:25:49]Shifting the implant for the vocally or distally was not an option because that would compromise aesthetic outcome at the moment. A bright tissue level bright tissue level implants was a viable option to me. So 2.5 mm brightish level implant were placed without encroaching upon the inside canal while maintaining the proper alignment with medival dentition and keeping the adequate balon thickening.

[00:26:22]Ult ultimately 3.6 6 mm diameter super line two implants were placed in both lateral inc site while 2.5 mm bright tissue level implants were placed in two central incite the lower slide shows the situation at the time of second stage surgery and healing connection surgery and stable bformation can still be observed around the implant probation was delivered uh through the probe Progenation period final processes was delivered reflecting patients wish all the prosthetic procedures proceeded with digital process as shown in the earlier session.

[00:27:08]And this is final CT outcome. I know this is not ideal but fully acceptable to the patient. It will be interesting to observe these cases that I presented today in the long term by comparing the bone response of uh bone level implant and tissue level implant.

[00:27:30]Okay, I'm going to have to skip the rest of the lecture and here is my conclusion.

[00:27:38]Imprinted design have steadily evolved toward improved performance. Moving forward, they must continue to evolve in a direction that resolve the limitation of existing implants. Preferably, it should encompass not only improving strength but also reducing surgical burden and more improvement preserving biology.

[00:28:03]The bright tissue level concept reflects this direction. While long-term data will further validate its performance, a bright tissue level implant provides the biomeical biomechanical solution for cases where strength and reduce surgical invasiveness must coexist. Keeping the critical bone dimension and reducing the mechanical complication both can be achieved with brightish level implant.

[00:28:29]Thanks for your listening my lecture.