Comprehensive Bicon Sinus Lift Techniques

Introduction. Bicon implants provide unmatched clinical capabilities, including the crestal, vertical, or internal elevation of the Schneiderian membrane with significantly reduced morbidity. While many techniques exist for raising the Schneiderian membrane, this video initially introduces a proven method that has been successfully used for decades to teach these delicate surgical procedures to novices. Additional nuanced and advanced clinical treatments and presentations will follow the initial graphic and animation presentation. The final presentation is an in-depth and didactic lecture on the anatomy of the sinus, the Bicon sinus lift, and the efficacy of SynthoGraft as the premier bone grafting material. This illustration serves as a reference to help viewers easily identify instrument depth indications of six millimeters, eight millimeters, eleven millimeters, and fourteen millimeters. Internal sinus lift. Initial and preoperative evaluation. Assess the anatomy clinically and radiographically, determine the overall health of the sinus, the presence of a septa, and measure residual bone dimensions beneath the maxillary sinus floor. Initiating the osteotomy, use a two millimeter pilot drill at one thousand revolutions per minute to perforate the cortical crestal bone, stopping one millimeter shy of the sinus floor. Sequentially, widen the osteotomy with latch reamers carefully monitoring depth to avoid penetrating into the sinus membrane. Infracturing the sinus floor, after widening the osteotomy to five millimeters, use a three point five millimeter hand reamer with a mallet to infracture the cortical bones circumferentially. Membrane elevation and grafting. Inject a putty like mixture of SynthoGraft and the patient’s blood into the osteotomy forming a dome under the Schneiderian membrane. No instrument should exceed the original bone depth. Insert a five millimeter implant, ensuring the first plateau is positioned just above the aperture of the osteotomy. Final positioning and sealing. Transport either a sinus lift abutment or preferably a thin crestal temporary abutment to the implant. Gently tap the abutment into place to seal the osteotomy. A thin crestal temporary abutment screwdriver is fastened to the abutment. Ensure the abutment does not protrude above the crestal surface, facilitating proper closure and suturing of the mucosal flap. Crestal sinus lift provided by doctor Mauro Marincola. The following presentation demonstrates the simultaneous elevation of the Schneiderian membrane with SynthoGraft and a Bicon short implant through a step by step process supported by clinical images and both preoperative and postoperative radiographs. When the depth of the residual bone is less than three millimeters, a transcrestal sinus elevation technique is performed. Additionally, this technique enables the clinician to simultaneously place two or three implants side by side. The width of the crest should ideally be at least five millimeters in width and may be evaluated intraorally and radiographically. Collect a sample of the patient’s blood for later mixture with SynthoGraft. A rounded bur or a specific piezo tip is used for the crestal antrostomy. Similar to the sinus lift approach, bone is removed until the periphery of the antrostomy appears bluish in color and/or central bleeding occurs. Following the removal of the bone, a four millimeter osteotome is used to microfracture the remaining thin floor. In this case, the patient has one point five millimeters of residual bone height, and the osteotome should not go deeper than two millimeters in order to microfracture the floor without penetrating the sinus cavity. View of the microfracture and the intact Schneiderian membrane. A putty like mixture of the patient’s blood and SynthoGraft with a particle size of fifty to five hundred microns is prepared. A bone graft syringe is used to drive the graft slowly into the preparation without pressing too much on the graft. The syringe should stop at a two millimeter depth. Always ensure that the osteotomy contains graft and or blood clot materials. If a black hole is seen, then a complication has occurred, and the procedure must be interrupted. A four millimeter osteotome is used to push the SynthoGraft mixture carefully through the fractured floor to elevate the Schneiderian membrane. The final diameter of the osteotomy at five millimeters wide can be prepared with sequentially wider latch reamers. The final five millimeter latch reamer prepares the osteotomy for the seating of the five by six millimeter implant. It is critical that the osteotomy has a floor made entirely of the SynthoGraft mixture. The three point zero millimeter inserter retriever is used to insert the implant into the osteotomy. Do not force the implant or tap with a mallet. Verify that the base of the implant’s shoulder is at the crest of the osteotomy’s aperture before removing the inserter retriever from the implant. The six point five by two point five millimeter sinus lift abutment is shown being placed into the three millimeter well of the implant using a two millimeter seating tip. Without tapping on the seating tip, remove it gently. The standard seating tip is shown being used to tap the implant abutment complex until the sinus lift abutment is seated with the widest perimeter at crest level. These images reveal the proper positioning of the sinus lift abutment flush with the alveolar bony crest, which facilitates the closure and suture of the mucosal flap. After suturing, wait a minimum of four months prior to uncovering. The radiograph reveals the elevation of the Schneiderian membrane with the SynthoGraft cupola, the proper positioning of the implant, and the correct placement of the sinus lift abutment at the alveolar bony crest and not above it. The crestal sinus lift technique is demonstrated clearly in this radiograph sequence. Internal sinus lift using SynthoGraft and restoration with a CADCAM extraorally cemented crown provided by doctor Vincent J Morgan. This video demonstrates the simultaneous bone grafting of a large buccal defect and placement of a short Bicon five by six millimeter implant with an internal sinus lift procedure using SynthoGraft and a sinus lift abutment as well as the implant’s restoration of the CADCAM fabricated extra orally cemented crown in only three clinical visits. After clinical and radiographic evaluation of the recent molar site, the treatment begins with the reflection of a full thickness mucoperiosteal flap and the collection of blood from the surgical site. The collected blood will be mixed with SynthoGraft, a beta tricalcium phosphate bone grafting material, which will be used both for the buccal defect and for the internal sinus lift procedure. The mixture of SynthoGraft and blood is transported to the bony defect in a bone syringe. After the complete filling of the bony defect, the implant’s osteotomy is initiated with a two millimeter pilot drill rotating at eleven hundred revolutions per minute. The osteotomy is sequentially widened at half millimeter increments with hand reamers. The hand reamers are not only used to widen the osteotomy but also to gently elevate the sinus floor in conjunction with hand osteotomes. After final widening has been achieved, a gold five millimeter osteotome is used to gently elevate the sinus floor to the desired height, after which additional SynthoGraft material is introduced into the prepared osteotomy prior to the insertion of the five by six millimeter Integra CP implant. After cutting the plastic bags containing the implant in sinus lift abutment, The implant’s black polyethylene healing plug is replaced with a six point five by two point five millimeter sinus lift abutment attached to a purple two millimeter inserter retriever instrument, which is fastened to an offset driver while the implant is still within its plastic bag. The implant attached to the sinus lift abutment is removed from its plastic bag and transported to the osteotomy with the inserter retriever instrument attached to an offset driver. The implant and sinus lift abutment are initially seated with the implant inserter retriever instrument and then definitively tapped into position with a large abutment seating tip attached to an offset driver. Additional SynthoGraft material is placed buccally over the implant prior to the placement of a resorbable Bicon membrane over the sinus lift abutment and buccal bone graft. After closure and suturing of the flap, a postoperative radiograph reveals the subcrestal position of the five by six millimeter implant and the SynthoGraft bone material. Five months after the implant’s placement, a crestal incision is made to reveal the sinus lift abutment, which is removed from the implant’s well with a rongeur. A green three millimeter metal impression post with its acrylic sleeve attached is inserted into the three millimeter well of the implant with only finger pressure for the making of a full arch implant level transfer impression. Upon removal of the impression, the green acrylic sleeve remains within the impression material, and the green metal impression post is removed from the implant’s well with forceps. A white six point five millimeter temporary abutment is inserted into the implant’s well with a gentle tap to facilitate the healing and formation of an appropriate soft tissue sulcus. After the laboratory CADCAM fabrication of the extraorally cemented crown and removal of the white six point five millimeter temporary abutment from the well of the implant, the crown is brought to the mouth and inserted into the well of the implant. Definitive seating of the crown is achieved by having the patient apply occlusal pressure on a cotton applicator. A post insertion radiograph is taken after confirmation of the appropriate interproximal and occlusal contacts. This video has demonstrated how a patient with minimal bone can be successfully treated in only three clinical visits. Insertion of a Bicon short implant into an atrophic ridge provided by Doctor Stefano Carelli. This video demonstrates the insertion of a Bicon short implant into an atrophic ridge with a bone height of two millimeters below the maxillary sinus. The procedure involves a crestal elevation of the Schneiderian membrane along with simultaneous bone grafting and implant placement, thereby reducing the number and complexity of surgical procedures. The treatment begins with the extraction of the second molar and the collection of the patient’s blood from the extraction site. This blood is later mixed with SynthoGraft, a beta tricalcium phosphate bone grafting material. A full thickness mucoperiosteal flap is raised to expose the bone and to remove any granulation tissue using degranulation burs rotating at eight hundred revolutions per minute. This step precedes the actual lifting of the Schneiderian membrane. Successively, wider semicircular chisels mounted on a straight handle are used to remove sufficient bone from the sinus floor, enabling the elevation of the Schneiderian membrane. A thin putty like mixture of SynthoGraft and the patient’s blood is then applied. The grafting material is inserted slowly and gently to fill the space created by the removal of bone from the sinus floor. This process elevates the membrane by two to five millimeters. A hand reamer is subsequently used to prepare the site for the placement of a five by six millimeter short implant. The implant and abutment are transported to the site using a conometric connection into the abutment head. The head of the sinus lift abutment is ovoid shaped. Its shorter side fits perfectly into the five millimeter osteotomy, while the longer side at six point five millimeters prevents the abutment from entering the osteotomy. The sinus lift abutment is gently tapped until it is flush with the alveolar ridge, enabling the clinician to easily close and suture the flap. A postoperative radiograph confirms that the implant is stabilized in the residual bone and that the graft material has successfully elevated the Schneiderian membrane. Transcrestal sinus lift using a six by five millimeter Bicon short implant and SynthoGraft presented by doctor Shadi Daher. On the radiograph, you will see a translucency of a six millimeter wide, five point seven millimeter long implant. We will most likely not need this kind of length. We can place a six by five millimeter implant, which is what we will most likely place as it will strain the pressure placed on the floor of the sinus, will reduce it slightly. What we have is a minimal amount of bone, roughly three millimeters, if you look at this translucency from the very crest to the top, this is no more than five point seven. So at the most, this is going to have about three millimeters of native depth. Even if we place the implant at the desired depth of two millimeters in this case, allowing us a better emergence profile for the aesthetic restoration, we will still have two of the plateaus or more in friction in the mesial and distal, but more in the buccal and palatal as the slopes of the bone allow us that luxury if you will. We will be using SynthoGraft mixed with the patient’s own bone and blood and that is a beta tricalcium phosphate. We will be using a fine granule size. So as you see the buccal part is nice and straight and narrow, and the palatal part is a little bit wider. There is a slight weakness at the center of the crest, which we will now incorporate in our flap so that we don’t end up with part of the flap being ill supplied with soft tissue. And so we have now a we will use a fifteen c blade that will allow us to make a buckally based paddle shaped flap. The idea is although this is meant to be an internal lift with this small amount of bone always one has to be prepared for any possible eventualities and for that we will hedge our bets and make a flap that could be utilized for a lateral sinus lift. Okay? So it is papilla sparing. We’ll open the flap ever so slightly. So we’re using a straight curette. So what I will do is use a periosteal number nine mold and lift up the flap. Okay. So here is our flap open now. Okay. So we just need to collect enough of the blood even if it may congeal the plasma and the clot products will be enough to moisten all of the micro and nano porosities of the intended graft material, which is the SynthoGraft. So we will just take a bite and we will fasten the flap to the buccal mucosa thereby creating sort of an automatic perfect opening that we don’t need to worry about every time we carry an instrument in and out of the surgical site. We try to avoid making punctures right through the, surface of the gingiva, just to reduce the number of of entry points for any saliva or oral contents. So I take the bite from inside, the flap. So the first thing we’re gonna do now, we know that our depth is roughly three millimeters. So making a a drill, or a pilot drill osteotomy is probably not going to not going to give us too much more information. But what it does, because it’s spinning at a high speed, even if I drilled a millimeter or two, it will give us a positive marking of the center of this osteotomy. Okay? And it’s pretty soft. I can feel the bone. Now so I’m at about a depth of, oh, one and a half or two at the most. And as you can see, we’re pretty darn close to the center of that space. So look at the contact points. Imagine that line. We should be going right through the middle of it. Now although this is nominally two and a half millimeter, but because it’s not getting to the full width of the parallel walls of the osteotomy, it really is acting more like a two millimeter. And so that’s why the pilot, bur would not sit in there. We are now under prepping this osteotomy because if we were to leave only one or two millimeters, all we needed to drill really is about a millimeter. So we would see our implant migrating if we don’t pay attention toward the palatal, but that won’t affect the final placement because we will pay attention to it. One other way of using the hand reamers is to actually put them on a latch adapter that goes into the handpiece Because these latch reamers have a slight offset at the very tip, you can actually deepen the osteotomy. The Now we’re getting close to a possible size, which is a four and a half or five millimeter. Our intent is to use a six millimeter. However, a five millimeter would suffice if we had to stop then because, let’s say, of the ridge not being sufficient, etcetera. But let me verify the walls. Thank you. Okay. So now we are at five millimeter, and that’s important because five millimeter is a great sort of halfway size that gets us to a molar size crown without any compromise whatsoever. Four and a half would be also the same category. So what I will do now is selectively carve out the palatal plate and leave the as it’s thicker and leave the buccal plate intact. So as you see, we can selectively go from one side to the next from the distal going to the palatal stopping on the mesial. So it’s a hundred and eighty degree rotation. Once I get into the full depth, I will then be able to to turn three sixty degrees as well I would have expanded the buccal plate rather than splintered it. So now I will start really going after the floor as I left a considerable depth, not too much pressure. The bone. Okay. So we’re getting all of that little bit of bone. Always before you go to final size, verify that your walls, your floor are adequate and intact. One thing we have to make sure is our palatal. Great. Okay. So again, now the buccal wall is actually about the same strength as the palatal, so it won’t favor either one. I’ll just go in circular fashion. And we are now at about a depth of roughly three and a half, four millimeters. So the center of our osteotomy, if you look if you could see closely, and I’ll try to show you, you can see already the little sheen of the green sheen of the sinus mucosal lining. We will use the sinus lift osteotome which is trumpet shaped and it’s also color coded. It’s green with the same tiger stripes. Now I try to use a straight if the mandible allows me. Now we will use an offset driver. I prefer a straight as I see better and I feel better with it. Okay. So again tapping with the mallet. Okay. It’s a small five ounce surgical mallet. Okay. And just gently. Meanwhile, as you can see in the top left hand corner, the, assistance is pressing on the nose bridge stabilizing the facial skeleton so that the patient doesn’t feel like she’s getting a concussion at the same time as having a dental implant. So we tap gently but firmly. And it’s important to use many small taps. The idea is you are or a and now you can feel it. You can almost you hear the different tone and you can see it mobilizing. So we are now at depth roughly a depth of six millimeters, which is well below that. This is the SynthoGraft. 50–500 microns, zero point five grams, it comes in this handy vial. You see that after mixing the graft, on the corner here is the autogenous bone, some of it which I will leave to seal over the implant and this is the graft. It comes to sort of this kind of putty stage. So if you look at it, you see that it’s kind of putty. We will use a graft carrier syringe, which has the same markings as the Bicon implants. You can see those three rings. It’s at six, eight and eleven millimeters. Hopefully you won’t need to graft anything beyond that ever. The idea is the graft material will act as the way we dissect the mucosa off of the floor. So I’m using a little bit of wiggling action and we push it slowly. Alright, but surely. We’ll use a sterilized cotton tipped applicator to just push it in and give it a, you know, imbibe a little bit of the liquid out of it and slowly tapping it in place. Again, it may sound that we are hammer happy here, the fact is, small taps of a very small mallet are a lot gentler than putting your body weight or your arm weight, which is a lot more than five ounces, and trying to force this very delicate area up and trying to dissect the mucosa up. So this is sterile, if you want, if you’re that peculiar about sterility, I’m able to handle it with my sterile gloves. And the little plastic bag in which the implant came, which was inside that little package, was also sterile. So now we’re going to place our, I’ll need a sinus lift abutment, please. Okay. So we’re placing our implant and we will tap it to near full seating. And it sounds like I’m using a jackhammer but I’m not. It’s just light taps but a lot of them. So what’s going on? Why is it harder to tap the implant in than fracture the floor? Well we have a lot of friction now with all of this graft material. So what I will use now is a sinus lift abutment. The implant is not at full seating yet. So before I place it and seal it, I will put it in lightly. And I think that in this direction it will be just within the flap and I think I’ll be happy with that. Now, because it’s a little wider than the implant, I can use this seating point that is obviously with no hold on the implant. Now, what I will do now is just tap it till it’s in the final seat. There we go. So now it just went in and now we’re going to stabilize it fully with the sinus lift temporary abutment. And this, the proof here that we’ve done our job, is when we close the flap, it should be perfectly flat. No need for releasing incisions or anything like that. Okay, now that looks great and that completes our surgery. We will now close the flap but you can see the flap now is closed absolutely tension free there are not even sutures in there. That’s that. We will now suture it. We will close it. Now let’s take a look, see if I need more. That is what we have just placed. There’s enough of a sinus lift to contain the implant. The implant is secure, it’s in the proper angulation location and at the proper depth for this restoration. The bone that you see on the mesial is mostly on the buccal side as I hope you saw from the flap. The, actual orientation matches where we we need it to go. As you, can see sometimes the top of the bone when using the sinus lift abutment will dictate where it goes a little bit more. However, the the total lift in this case was roughly six to seven millimeters from the floor of the sinus to the top of the dome of bone which is roughly two and a half millimeters to three millimeters above the apex. This is a five millimeter long implant plus three, it’s obviously eight, we went to a depth of two from the crest. Remember we started with two to three millimeters so two plus, eight is ten. Started from three so that gives us a lift of roughly seven millimeters. Now the Bicon implant will integrate that. You will have a bone. This may remodel and drop down, but you will have enough bone to engulf this implant, heal it, secure it in place. The internal sinus lift with SynthoGraft presented by doctor Shadi Daher. One sort of seminal paper that gives you a lot of information on that was published in the clinical oral implantology research as a supplement in two thousand eleven by Janner, and I invite all of you to look it up. I get it. It does have incredibly detailed information about the dimensions of the sinus and so on. As the title of this talk implies, we are not talking about lateral sinus lifting, but rather only about internal sinus. However, we still need to know the anatomy of our surgical site. Now, we’ve all seen images like this one. This is from Grey’s Anatomy book. It’s a very old plate and it shows the osteology of the maxilla, the maxillary bone with the teeth in place. What is important to us is this area, the area from, say, the first bicuspid or second bicuspid all the way to the second molar. The alveolar process is where we are working, and it says that right there in this nice script, alveolar process. The alveolar process is obviously where the roots are, and this is where the implant will need to be. Now, when the sinus is pneumatized or hyper pneumatized, it will occupy that bony space. And all of a sudden, instead of having room for implants to be placed unhindered with plentiful bone all around them and good circulation, now you have the space or the void of the maxillary sinus and air cavity. Now, the talk obviously is about managing that and pushing it out of the way. What do we push out of it? What is the it that we push out of the way? It is the maxillary sinus mucosa, and the mucosal lining of the sinus is composed of a very, relatively thick, adventitial layer right in this area, and the innermost lining, which is the respiratory epithelium, is the pseudo stratified columnar ciliated epithelium. It is important for us to remember that because number one, we don’t work with this single cell layer, we work with the entire mucosal layer, thankfully so, because we could never dissect these single cells with our macro instruments. Even the thinnest and finest of our instruments can cause tears and perforations in such a thin mucosa. The mucosal dentition layer at the base with the periosteum at its base as well give us something to work with. The real key is that the cilia are our friend. If we protect this and preserve this, they will help fix our mistakes. If, on the other hand, we cause significant perforations and tears, introduce foreign objects and not protect the patients, we can get an infection or the weight of fluids from mucus, retained mucus to pus or other fluids that can cause a mechanical pressure on the implants as well as other organic pressure shots such as infective. Okay, the dimensions of the sinus are not as important to us when we’re talking about internal sinus lifts, but they are important in case you’re considering lateral lifts. Every case is different and obviously there are ranges of approximately a centimeter, a variation in width and height, etc, etc. But it is important to know our patient and know where they fit in that kind of spectrum. What I do want to mention is the sinus septum. In the anterior and middle area, this is again from that paper, we find about two thirds of the sinus septa, and they are present in a way that can influence our surgical technique, and they can be pretty significant. Here’s an example. This is just the panorex, and as the previous slide says, most of them are easy to detect on panorexes, if not all. And on this one, you see this, you know, a hint of one. So when we went in, we thought this would be easy to manage, But as we went in, this is for a lateral lift, but for the sake of illustration, this turned out to be a whole chamber practically. And, surgically, we could not bridge over the gap and ended up doing two side by side lateral sinus lift windows as such. So recognize the presence of the septa as if we are trying to fracture the floor as we do for internal lifting. And you come right at this septum vertically becomes a very significant thickness of difficult bone to fracture. So you do not want to try to break that. It’s unpleasant for the patient and it’s fraught. If you break it, you know, it’s not really a success because that piece can then pierce the sinus mucosa and you end up with bigger problems. You’re better off kind of glancing and avoiding it. The hypertrophic sinus comes in many different presentations. We can detect some of them on periapicals. We can detect them on pan panorexes, we can see them in our cone beam scans. So this is another panorex. What we want to look for is not just the bare kind of essential information that a panorex gives you, such as, you know, the line of the floor of the sinus. You want to look for other hints. And so play a little bit of detective because that will color our treatment planning and our treatment sequencing, as well as, show us where, things can become a challenge. In this case, for instance, we know that this patient has been having significant caries, been having pain as a diabetic, and his problem was mostly on the left side. And as we see this molar tooth, which was endodontically treated with the sinus proximity, and yet we see this area right above the root of the molar that shows some separation or widening and sort of in a cystic development. When we extracted this tooth, this area deflated, for lack of a better word. And so when we went to do the sinus lift, this is a prime area for adhesions, in other words, the scars between the sinus mucosa and the bone that will be very hard to separate in a surgical approach. And this is where, if we’re going to have tears and perforation and lateral lift, this is where they most often will happen in an area of multirooted teeth that have had, infection and or endodontic treatment. So when we are doing a sinus lift, the sinus lift is a graft. The graft just happens to be sort of in the sinus or underneath the sinus cavity per se. So obviously a graft requires a grafting material. So what is the ideal grafting material for a sinus lift? First of all, we want to do this procedure once. We’re not going to re enter and do touch ups if we don’t have to. So we want to have volume stability. When you lift the sinus, you want it to be lifted and stay lifted. You want it to be able to produce bone. But that’s for every graft material. You don’t want it to have infection. Again, that goes without saying. But in the sinus, since it’s a closed, not very easy to access location, you want it to have low incidence of infection. In other words, you want to be able produce it, to have it or to procure it sterile, keep it as close, as clean as possible, as sterile as possible. You want it to be easy to handle. You know, patients obviously or more often are awake. We have and they go about their business. Some of them have the procedure done on their lunch hour. And so you would want to have them able or want yourself to be able to place the graft and have it stable and steady and not moving and easy to handle. You don’t spend five hours doing a simple procedure. You want it to be available and you want it to help you stabilize the implant because that obviously is the ultimate goal. So the autogenous bone was was long thought to be the gold standard for internal lifts. They work very well. You hear every now and again of someone’s experience anecdotally or some papers being published. There was a consensus conference in ninety six about lateral lifts. And in that conference, they came out with sort of the politically negotiated almost terms saying that, you know, autogenous bone is really the best, is really great, but it’s okay to have a xenograft mixed with it or xenograft and so on. Well, I’m here to tell you that we’ve done hundreds of those cases, and we are now probably approaching thousands of the cases with the tricalcium phosphate, the beta tricalcium phosphate in its purest form, the SynthoGraft. And we have not had any major issues with it. We have had great success with it. That rivals the ninety five percent or so success that has been reported in that ninety six conference and in subsequent publications. So just to situate ourselves where the calcium phosphate is represented is a subgroup of the alloplastic materials, which is a subgroup of any bone augmentation material. The autogenous group is by its lonesome on the far left. Allografts, these are the material obtained from bone banks. And those are in great use, but they have their obvious limitations from allergic reactions, disease transmission risk, etc. And xenograft, again, their lack of resorbability can become a problem, and their sort of inertness can present a challenge. Our alloplastic materials, the synthetically derived material, I find they offer us the best of both worlds, especially the beta tricalcium phosphate, and that is because the tricalcium phosphate is made of calcium and phosphate ions, just like our own bone or any non demineralized or mineralized allograft. And so those, as they break down, the breakdown products, the calcium and the phosphate, are taken up locally by the cells and used up in the laying of the nonorganic matrix or nonorganic components of the bone. And we want that. That’s desirable. And in the case of the beta tricalcium phosphate of SynthoGraft, which is the most or the purest stoichiometrically, so if you took this and analyzed it, it has the highest percentage of tricalcium of beta tricalcium phosphate available. And yet it is manufactured in a way that gives it multiple micro and nano porosities, rivaling, if not best, the naturally occurring bone, giving it the ability of turning over very, very quickly. And recently I’ve had the pleasure to work with colleagues Doctor. Larry, Ewers, Quell and Bonfante. And we published this paper from one of our patients who wanted to have non metallic implants placed and insisted on having his Bicon implants, which were functioning beautifully, removed. And the paper shows a series of analyses of this slide after we retrieved this implant that was placed with a sinus lift using SynthoGraft. This was the original, or the line of the native bone. Above it is the line where the SynthoGraft was introduced and below it was the native bone. On the left side of your screen, you see a prepared slide, a section right through it, and then we go through magnifications. In the paper, we only selected three spots, one here, one here, and one here, and that is one in this sort of distal or posterior sinus graft, one in the anterior sinus grafted area, and one in the native bone. Showing that, and here I’m going go sort of clockwise, showing the native bone with different growth rings. Incidentally, these implants were in function for roughly three and a half years in the patient for about four years. So those integrated, they were in function. As you see, those growth rings with vascular channels and some cancellations and so on. This is going a little bit farther up. We’re still in native bone, little farther up. We see a little bit less magnification. Now we’re encountering some of the graft particles that have been encased and very few of them are left. And yet what’s telling is that in the plateau spaces, which are bone growth chambers in our consideration, the bone has formed very well, the graft particles have resorbed or been incorporated, and this implant is integrated. Now remember that the implant and the graft were placed together at the same time. And so continuing on to the other side, this again is an area in the graft just above the level of the autogenous bone or native bone. And there’s a close-up of it with a different staining. Incidentally, the stain here, it shows the bone with this kind of pink fuchsia color. When these are forming new bone, turning over bone, you see the growth rings. The point of this whole exercise, and this is the native bone, is that the difference between the native bone and the SynthoGraft filled or grafted sinus floor is minimal. The SynthoGraft with the plateaus interact so well together that you get that new bone formation at the same time as the implant integration, which is why we are emboldened. And we have been for well over a decade now placing implants in majority the SynthoGraft, some of them barely touching native bone at all. And after a period of anywhere from five to six months, we are uncovering or loading them. And you see that in our publications, in our lectures, and I’ll show you some of them today. Now, before you start drilling and fracturing floors of sinuses, you need to select your case as well, because our goal is simply to reclaim the depth of the alveolar process, right? We don’t want to stack the deck against us before we even start. So we need to create bone in the posterior maxilla. We need to get the implants to osseointegrate. And obviously, after what I have just told you, it’s not that hard if you get the modicum of stability of the implant and you encase it in a SynthoGraft that has been well mixed with the patient’s own blood. Now, our ultimate goal obviously is to get the support for a functional loading of the prosthesis with as little morbidity and complication rate possible. So when do you do a sinus lift separately first, I. E. A lateral lift, and when do you do both? Now if you use Bicon Ultrashort implants and you’ve been to any of our courses, you know that we try to do the immediate or simultaneous implant placement for virtually every case. That’s been my mission to eliminate the need for lateral or sinus lift first. So our goal today is to expand on this, the Crestal approach. Now, for those of you who practice in the United States, the CDT code for the internal sinus lift or the crestal approach is the vertical sinus lift, and that’s a D7952. Okay. For the lateral window approach, it’s a D7951. I have used the D7951 a handful of times over the past year or two, whereas this is virtually a daily, probably sometimes multiple times in the same day that we deploy this technique. So as you’re selecting your cases, you are making that decision. What are you going to do? What are your limitations? Basically, the cutoff is a) dependent on your experience and expertise and level of comfort in the type of implant or length of implant you want to place. I strongly urge you to use the ultra short implants. They work and they minimize your risk. And secondly, it depends on the native bone and the combination of the two. As I said in prior talks, we control what we know, but we can’t control what the patient has. We can just select them. And so if you have somewhere in the neighborhood of about four to five millimeters of residual native bone, it should be a good place to start for an internal sinus lift. Less than that, now the interplay between your expertise, the type of implants, and the type of techniques that you’re familiar and comfortable with comes into play. So also we must select, we must look out for sinus pathology because you may have a lot of bone, may need to do just about three or four millimeters of a sinus lift, and yet you have significant pathology. Things like sinusitis, even rhinitis, allergic or infective or viral rhinitis. You may not want to approach the sinus because the mucosa, when inflamed, becomes very friable. And a procedure that would have been minimally invasive can cause complications. So a lot of our patients, when we’re confirming, we do ask them. And some of them will tell us, you know, I’ve had a cold or I’ve been I’ve had a head cold or I’ve had sinus infection. Those typically we reschedule them until the sinus is clear. These can be treated with antibiotics or decongestants or just simply time. Other surgical management for infected processes. We’ve approached the sinuses transorally or trans nasally. But what I find, especially in the town where we are, we have a lot of specialists. It’s easiest to just refer them to a friendly specialist of your choice or theirs. And so when we look at CT scans, this is a hospital CT scan. We see this is a significant sinus disease. It’s filling up the sinus. And even though we have roughly about six or seven millimeters, just drilling in this area causes a risk. Small puncture, even inadvertent, even microscopic, can cause major failure. But worse, this mucus that could be infected can cause infection in the bone like osteomyelitis or the sort. And when you see calcification, this has to be sorted out. Is it because of a benign process or more malignant or otherwise? But sometimes we get fooled. We see on a panorex something elevated like this, and it’s just a little bit of mucosal thickening. But since we have a prevalence of cone beam scans available, when we look and depending on the size of your cone, if you have a small cone that shows you just the very bottom of the sinus, then you have to make a judgment call here. Do you expect that it’s only the five millimeters that you see or is it thicker than that? I prefer a little bit larger cone like this one where I’ve set my cutoff at nine millimeters. Anything higher than nine millimeters, I find that it’s not totally arbitrary, but the weight of the mucus or mucosal lining will weigh on the implant and push it down, especially if I need to do a sizable like three or four millimeter or five millimeter sinus lift. Okay. And so, when you see on top of that some air bubbles, this is an actively bubbling infective process. And so these patients should see an ear, nose and throat doctor. They should have this area cleared. And if they get to a point where this is calm and it’s not infected, it’s just a reactive and reactive thickened mucosa, but otherwise it’s not actively infected, we can then contemplate the sinus lifting bilateral window or otherwise. You also can see things like a large cyst. I would not approach this. This is about two, two and a half centimeters of weighty, homogeneous fluid filled lesion, as is this one. And in this case, have an air fluid level. So those are the cases that you would want to avoid starting an internal sinus lift on or any sinus work for that matter because, you just simply have no control, over that situation. And this is in terms of case selection. This is what you select out. This is what you exclude from your practice until it’s cleared up and cleared out. Now, we prepare our patients with antibiotics and consent, etc. You know that. The main principle of the internal sinus lift or the vertical sinus lift is that the implant be placed at the same time as the sinus is lifted. And so we are grafting, so we will use bone particles. Now, there have been studies, and I know some of you may have tried it, I know we have done it, where we just tent the mucosal lining of the sinus and allow a blood clot to form with the plateau spaces of the implant and the minimally invasive procedure. Get bone forming with no problem. However, the bone grafts are not just as a graft, they function as a surgical instrument. And that I will elaborate on that in a little bit. But suffice it to say, I am a fan of using them, especially the fine particle size and especially making that fine particles into a slurry like very wet, near viscous liquid. And that will help us complete the treatment. It is very important, however, that the implant be stable at the end of the procedure so that it doesn’t move and cause perforation, dehiscence, herniation and most likely failure of the graft because of the constant movement. The consideration for the Bicon implant, particularly because it’s intracrestal placement and the sloping shoulder implant, have to have a significant thickness. So parts of the base of the shoulder and maybe another plateau or two be touching native bone. So it gives you stability. You want about five millimeters. If you do the math, that gives you about two millimeters of full contact between two or three of the plateaus and the bottom shoulder. Now, if you cannot achieve that, you have less than the five millimeters or so, you will need to extend your implant. This is where the sinus lift and a temporary abutment comes in play. And that basically makes the implant longer so that it grabs and fits and makes use of the full crest right onto the top of the crest. But there is a certain way you have to use it so it embeds itself into the bone, creating an additional means or an additional way that it stabilizes the implant. I’ll show you some cases on that. And so when you have a very, very thin bone, two millimeters or less in the past, or for many of you, even now, you have automatically shifted to a lateral lift technique, and that’s perfectly acceptable. I think it’s expected even. But with ultra short implants and some of the techniques that we can deploy, it may be unnecessary. Now, one of the other limitations of the internal lift or the vertical lift is how much can you really push that membrane blindly, vertically through a hole in the center of it and expect it to kind of follow you and not tear. As a rule of thumb, I’ve noticed when the osteotomy is small, you know, intuitively, the amount of pressure I exert on it and not cause it to perforate is a lot smaller, and therefore I can make it travel only about a distance roughly equal to the diameter of that osteotomy. And therefore, whenever I wanted to do an aggressive sinus lift without a lateral lift, I would go to as wide an implant as possible, but that taps out at about six. So I can lift it six millimeters. Well, what if I needed to lift it more? Say I want to place a six millimeter long implant, but I only have one or two millimeters of native bone. And so to put that plus the six and another couple on top, I’d have to lift it about eight millimeters. And so for that, I would want to make a wider surface area without losing the contact for the implant. That’s where the floor transport technique comes into play. So let’s quickly go over some quick points because I hope that by the end of this talk, will find at least some pointers that will help you treat the patients with internal, using ultrashort implants and the SynthoGraft. Now, we beat that point, I think, to death with respect to the different depths that you can work with. But what you do is as you are preparing the osteotomy, it is not a complete osteotomy. You are going to prepare to within a millimeter to if you have fairly soft bone of the floor of the sinus. Now, how do you know where the floor of the sinus is? There are many different techniques. The best one is you measure and you measure and you, again, you drill very slowly and keep measuring, coming out, measuring and drilling or reaming very, very slowly. For the Bicon system in particular, you have an invaluable tool, and that is the hand reamer, which are able to remove bone in very, very slow, meticulous increments. So if you know the depth, you know the location where you’re working, you can approach that floor extremely cautiously and avoid perforation. And even better, if you are a little bit more than aggressive with the hand reamers and remove all of the bone, if you’re doing it slowly without a lot of apical pressure, you could actually remove all of that bone and still not damage the soft tissue of the floor of the sinus mucosa. Okay, learn how to use the hand reamers. The edges of the osteotomy come together. That’s the shape of the apex of the reamers. And so that comes to a funnel. And so you would still need to fracture them. Otherwise, they will not allow the implant to move relatively freely. You need to use a lot of hammering, which is very unpleasant to the patient to seat your implant. So I advise that you use an osteotome, the round sinus floor osteotomes, then introduce your graft particles. This is why I want to mention to you the non Newtonian fluid characteristics of the fine SynthoGraft particles when mixed with blood. Non Newtonian fluid behaves like a solid when it’s impacted with high inertia, with tapping, with a mallet. So what happens is as we introduce those particles, obviously very carefully, meticulously, we just inject them into the osteotomy and then we take an instrument, typically I use expanders and we give it light taps with a surgical mallet. That tapping compacts them and makes them behave as though they are part of the instrument, lifting the mucosa off of the floor. However, because of the shape that they are in, because they are spreading in all three dimensions, you will not force the mucosa only vertically, but rather you will push it on all sides and causing the mucosa to separate from the floor of the sinus. And then when you are not tapping, that simple weight of the mucosa elasticity of it, will make the graft kind of relax and go back to the sort of liquid phase and they stay where they are. And we repeat the process. And then at the end, when we introduce the implant, it will keep them where they have injected themselves. That’s why the internal sinus lift using the SynthoGraft particles that are wet, works so well with the Bicon Ultra Short implants. So again, my point about lifting the mucosal lining is revalidated because it is the limiting factor. Now, you can sometimes, if you have plentiful autogenous bone, can use that in cases like this one where we place a short implant. And, placing autogenous bone, you just have to get the x-ray just right so you see the shadow of the lift. And yet, as it consolidates over months, that bone becomes more and more defined. And then when you put it to function, the definition increases. And then after about two and a half years in function, you see that this has been maintained. Okay. And so this is what we see with our sinus lift with the SynthoGraft. So let’s look at now the first case today, a forty three year old woman who had failed molar. This is an upper left first molar on the six year molar that had been repaired and restored. Eventually, the tooth gave up on her. So our plan was to remove the tooth and place an implant at the same time. This is looking at the periapical, and we can see that a five by six millimeter overlay fits just barely and it will require maybe a two or three millimeter sinus lift. However, when we removed the tooth, the socket was pretty traumatic extraction. We decided to let it heal first so that we can do a sinus lift. And then a short three months later, when she returned, you see the bone consolidated. Okay. And that, which used to be about five or six millimeter deep, is now just about three millimeters deep or maybe four millimeters. Now the sinus lift has to be a little bit more aggressive. Now notice the orientation of the overlay. Okay, like with every implant, what you should be focused on is the space of the crown. So we draw an imaginary line connecting the contact points. Okay. And we try to have the implant axis, long axis intersected at its middle like so. Okay. And that’s the goal. Now, this is, you know, all fine and nice with drawing, but let’s see if we can achieve that clinically without a guide. And even with a guide, because of the reaming of the Bicon system, it still relies on your ability to maneuver in the area. After about three months, this is the clinical presentation. We look at the way the socket healed. We still have nice attached gingiva, but we will not be sacrificing that. So we will open a flap keeping the papilla. It’s a papilla sparing flap. As soon as we make the incision for the SynthoGraft, and this is a very important point, given the inventor and manufacturer’s recommendation is that it be mixed only with blood, the blood of the patient. So I usually, as soon as I make the incision and we draw some of this mixed arteriovenous blood coming from the incision, we pull it and set it aside. For a single tooth graft or for a minor internal lift, need maybe a fifth or a quarter of a cc, if that. Okay, that will get a quarter gram very nicely moistened for the procedure. Set that aside, even if it coagulates, we break down the coagulant and mix it with the graft, you know, kind of mix it thoroughly. Elevate a flap. You don’t need to over dissect the flap, so keep a finger as you’re lifting the flap so you don’t rip it and protect it. I use a retraction suture. It may be to you, maybe a waste of time, but it just makes the procedure so much smoother. And certainly if you’re taking pictures, it’s invaluable. And then I made a couple of little back cuts so that I can be sure I see the edge of the palatal slope. And then this is from the Bicon kit, a six millimeter sinus floor osteotome. I’m not lifting the sinus yet, but what I am doing is seeing where a six millimeter abutment, because that’s for a molar, that’s the recommended abutment, where it would emerge. Does it emerge with good room for the papillae? And it shows plenty of space. Okay. And then I can make a mark with this edge as to where the distal, where the mesial edge of it, and then using my pilot drill, I will then just mark the center of where the implant has to go. And that’s roughly a millimeter or two deep, which I can then check. Okay. See the little notch from the osteotome and the marking. Again, I’m focusing on, that imaginary line drawn between the contact points. Yes, I may not have a guide, but I have a lot of teeth in there and I will use them as my guide. Okay, we need to be in the center of the crest. And if we have sort of thin crest, I favor going a little bit closer to the palate. I want thicker buccal bone if I can help it. And certainly if I want to be about a millimeter or two, maybe even more, away from the buccal cortex. Okay, we complete our osteotomy and here as you see, this is the first black band, so this is six millimeters to eight millimeters. We’re getting to about within two millimeters of the bottom of this one, so we’re at four millimeters depth. By our measurements, have about five millimeters depth, so we are keeping one millimeter of safe bone away from the floor of the sinus. We put the paralleling pin. You notice the paralleling pin doesn’t go in very deep. That’s because obviously it goes in until that pointed part of the pilot drill starts and then it obviously is stuck. Then we start with the reamers. These are at very slow speed, fifty RPM or less, no need for irrigation. Again, we’re going only to a depth of about four millimeters. Okay, that’s the three, the three and a half, the four. And then when I get to this point, I noticed that the buccal plate was starting to show a little bit of a shadow. So I have about two millimeters or a millimeter and a half. So what I did is went to hand reamers and ream to only the palatal part. So we start with this cutting edge on the distal buccal, rotate roughly a half or two thirds of a turn, stop and pull out. Okay, Like so. Collect all of that bone. All of this is excellent bone that we could use in the graft. You can use it over the implant. And quite sometimes, a few times, we get enough bone that we do not need any bone graft or just use the autogenous bone from the osteotomy. Here’s a five millimeter reamer. Again, notice how much bone is coming out. All right. Now we take an occlusal view of this. Okay. The palatal bone at the crest is right here. It’s about the same thickness. I don’t want to have dehiscences, so I had to sort of split the difference. Now, when you look at this, it looks like it’s a little bit more mesial. And with all of our measurements and everything, what happens is the bone is a little denser on the distal. So it moved us ever so slightly. And yet we will use one of the advantages of the Bicon system and make sure it fits. So measuring the depth at the edge of the osteotomy, it’s still about four millimeters. We take the implant osteotome. These are called the trumpet or the Bicon osteotomes. Those have an outward flare and that outward flare allows us to fracture a wide disc, maximizing the surface area and thereby minimizing the risk of perforation. Introduce it. It will sit also more shallow because, again, the osteotomes are come to a funnel edge. So this sits at the top of the funnel, not at the bottom of it. And then we tap brace the patient’s kind of bridge of the nose so that they are not rattled and then tap until you hear or you see the floor of the osteotomy give out. Okay. Prepare your implant on the inserter retriever. This is going to be a five by six. Take your SynthoGraft. This is the fifty to five hundred micron. This is the fine. A quarter gram is adequate for one tooth. Okay, mix it thoroughly until you get to this sort of mud or slurry phase. You want it to be more liquid. Now, for a bone grafting over an implant, you can have it relatively dry. But for a sinus lift, an internal sinus lift in particular, you want it to be kind of a slurry phase. If you shake it a little bit, it has a little glisten on top and it settles with a smooth surface. That’s the consistency you’re looking for. We introduce it to the osteotomy with a syringe, metal syringe carrier. Okay. Again, you don’t blast it like a shotgun blast in there. You want to inject it very slowly. That’s starting to work on lifting the mucosa off of the floor. We use the next size down side expander. This is the four and a half or a five millimeter osteotomy. Its round, smooth shape, helps sort of, deflect and, push the particles in all directions. Again, when we tap, they behave like a non Newtonian fluid, lifting the mucosa, separating it and also compacting against the bone, etc. Then we take our implant with the inserter retriever. Learn how to use this because in case you make a mistake, you can retrieve the implant. Okay. And with gentle tapping, we seat it to final seating or very close to final seating. We know it’s stable, it’s secure, it may need another millimeter of seating. More often than not, you know, we’re finished with that. Then we disengage the inserter retriever. Trim our black healing plug, place it. Okay. Then we take the autogenous bone, which I set aside. Know, more often than not, I will leave it if I’m doing a two stage implant and just place this right near the incision. A) It heals more quickly. B) If some particles of it are out. Noticed by the way, cleaned all of these little loose particles and stray particles of the SynthoGraft are gone. And when we put autogenous bone in there, if a little bit of it comes into the incision or into the soft tissues, it is not a problem. It doesn’t cause this irritation to the patient that can be inflamed and tender and so on, okay? So it heals better, it looks better, it feels better, and it heals more quickly. And then the removal of the retention suture. And we use, resorbable chromic sutures, and this is, a figure of eight and two interrupted sutures. So if you remember what I told you, we went slightly more mesial. However, if we look at, again, the space in between the two contact points and we draw a line straight down through the center of the implant, vertically through there, we get sort of right in the middle or near the middle where we want it to be. Okay. This is five months later at uncovering. Notice how this settled. Okay. You can see how well this bone remodeled, integrated, and all of that had settled nicely. Just for one implant, it’s totally worth it to do the internal lift using the ultra short implant. Another example, and I chose this case because it illustrates very well how do we deal with the presence of septum. This patient has a septum right in the middle of the space. It’s evident on the periapical as well. This was a recent extraction. So we open a very conservative flap. It has a high lip line, even camouflaged with the beard, but you can still see the necks of the teeth. So we did not disturb the papillae or the gingival margins of the adjacent teeth, just all within the socket, okay, using the pilot drill and immediately went to hand reamers or latch reamers. You know, I wanted to feel for that bone and the hand reamer was a little bit too easy. Going back to the latch reamers, and these are in sequence going all the way up now. The depth to which I reamed was roughly about six millimeters, okay? And finished it with the hand reamer at five millimeters, but now instead of using the sinus lift osteotome, what we used is one of these, the blunt osteotomes or the site expanders. Now, they are osteotomes in only if you fracture the floor of the sinus lift. And so notice the angle in which this is introduced into the socket. There’s a significant mesial tilt coming from distal occlusal to mesial apical. Okay, the idea is the tip of this osteotome, which is a little thinner, is going to come at or near the base of the septum. Okay. And as I tap it to introduce it, it’s going to bulge through the floor, glancing off of the septum itself. And then I pull it toward the mesial, sort of body movement of this instrument, push it this way and give ourselves as straight a position as possible. Okay, we’re within about ten degrees, which is, you know, as good as straight in my book. Okay. And then now instead of having a bony floor to our osteotomy, Okay, we have a, you know, hole in the bone and yet no hole in the soft tissue. Okay, you can verify that with a curette. We take the SynthoGraft in this case, I mix the SynthoGraft with the bone. If you want to do that, expect it to be a little bit drier. And don’t over mix it because the mixing can kill all of these viable cells in the bone. Now, in this case, we did not need to do a lot of lifting, just a little bit. So I wasn’t relying on the graft particles to finish the job, just wanted them to be there to cover the apex of the implant. And indeed, we introduced the particles, lightly, placed the five by eight short implant, seeded it using the seeding tip, sealed it, and a little bit more of the graft particles. This is where we learn our lessons, right? This is a relatively old case. Those little pieces of the graft that are stuck here and there, those can become annoying to the patient. That’s where we switch to saving the graft, the autogenous bone, for the crestal component. So this is what we end up with. The implant has a sinus lift and the sinus lift is contained. The septum is pushed to the side and the implant is in place. This is the implant restored okay, and this is the implant years later. Look at the bone level, how stable it is with the SynthoGraft, okay. If anything, the patient with the loss of teeth lost some of the crestal bone. You waited too long to have these teeth that have been treated. Now, there is a nice variation and a nice adjunct to our placing implants with internal sinus lifts, and that is the use of the guided surgery. Now, the one shift with guided surgery is when we plan our case, we plan it as to where the top of the implant is going to be. But for an internal lift or for a sinus lift for that matter, if we’re going to use the technique I’m going to describe, which is a guided osteotomy, but not implant placement, Just the osteotomy is guided so that we don’t overdrill and cause the perforation. We will focus on the apex of the implant. Okay, so we place our implant as though it’s a, you know, say a four by five, a five by five, or a four and a half by five. And we use the appropriate kit. In this case, we’re going to place an implant in the maxillary first right maxillary first molar area. We took cone beam scan and on the cone beam scan, we planned the surgery. And if you look closely, we see that we plan to do a five by five millimeter implant coming right up to the floor of the sinus. Okay. And so if we were to place this implant like we wanted it to be, we would have had a little bit would have been way too deep. Okay. So what we did instead, we just placed it so it’s coming right to the floor, not through, but to the floor. And that’s too shallow. This is where the bone is going to end up. And what’s even more important in this case is that, you know, when we sent this to sci cat, they they worked with us and and they said, well, you know, this is the angle you want it at, this is where your ring is going to be, and this is where the implant is going to end up. Okay? And that’s clearly above the crest by at least a millimeter. Okay? And remember, in the interim, this bone is consolidating and healing and so on. The sinus hopefully will stay in the same spot. It didn’t take too long for us to get the guide back, probably a couple of weeks. Okay. And we brought the patient back and the procedure was very, very, we have all of the design features, how it sat in there, etc. In the presentation. But what I just want to go through is the actual procedure itself. This is the clinical appearance, the guide in place, the punch okay, right through the ring. Okay? So that’s one step. Take the guide out, collect that, little gingival plug, set it aside. That’s step number two. Okay? Now with irrigation, we take one pilot spade drill. We do it once, and that takes roughly about five seconds. With irrigation, the bone, remember, is very soft and it’s very shallow. Okay. Then we use the five by five, first reamer in the kit. We get that. Now you may have to go a couple of reamers if you’re doing a longer implant, but if you’re doing an internal lift, I will tell you ninety nine percent of the time, you are going to only need the very first reamer. Because otherwise you could just put a short implant with no sinus lift, period. Okay. So you’re gonna do the five by five. You get some bone. So that’s step number three. Okay. Set it aside. Take the guide out. Keep it aside. Okay. Then make sure you still have a floor and place your osteotome. This is not guided now. Tap it lightly. You will then effect the fracture. And remember, this is a punch right here. Right? Mix your SynthoGraft with the blood. Okay. Introduce it. Tap it lightly. Now for sake of illustration, we use the surgical guide to place the implant, but only at the fullest depth, because I wanted to show you how it looks. Guided surgery kit, place it right through the guide, till it’s fully seated. But as you can see, it’s still pretty proud, very high in there. It needs to sit two or three millimeters. So I use these markings on the regular inserter retriever to tap it until I see that I’m happy with the seat. Okay? Then I seal it with the black healing plug. Then the autogenous bone goes over and the gingival plug is then retrieved. We keep it on saline and placed over, and then kind of a strapping suture holds it in place. You could then, you know, obviously you could either open the flap if you don’t want to use a punch. You could also, if you lose this for any reason or you don’t like it, you can just use a collagen plug. If you’re not going to use the gingiva, I suggest you do a flap and retract it fully to one side so it doesn’t interfere with your guide. But this is a quick, the procedure took minutes, you know, result in the end. Okay, that’s before, this is after. And this I found in a case where the bone was not clear. Even on a cone beam scan, as you saw, it wasn’t very well defined. We would have had to wait, you know, probably months, maybe a year or so to have it nicely defined. And so in this case, it helped us. Once we restored it and we put it into function, you see how the bone, just like Wolf’s Law implies, that as you use it, it consolidates. It responds to those stresses. And over a period of, what, four years or so, you see the bone is stable and consolidating and consolidating. And so I want to talk about the enhancement of the stability using the sinus lift abutment, which is an important adjunct to your sinus lifting work with the ultra short implants. It gives you that full flexibility to placing implants in very low residual bone. It was designed to have an oblong shape, and it was designed to also separate the implant to a depth of two millimeters from the flat top to the shoulder. So we use all of those to our advantage. Sometimes we turn it so that it is mesiodistal or somewhat in that kind of angulation or sometimes it’s buccal lingual. Just be cognizant of the fact that this sharp or relatively sharp edge that can cause the hissances. So orient this sinus lift extension or abutment to the most favorable way so that it is nicely covered and padded by the graft and by the tissue overlying. Okay, let’s look at this seventy one year old patient who had a failed first molar. Okay. So we removed it, very large span, close sinus. We let it heal. About two months later, she presents back and you see this is the soft tissue and this is the residual bone. The bone was so soft I didn’t need a pilot drill, just did everything by hand, two and a half to three to three and a half, all the way up to six millimeters. We’re collecting all of that bone, but all of it is really mostly sort of, osteoid and the clot. We set those aside. This is the six millimeter and take the six millimeter sinus floor osteotome with this little flare, introduce it into the osteotomy, and we tap it and it fractures fairly quickly. We mix the SynthoGraft with the bone, it is plentiful, and it was fairly wet, so we got to sort of a slurry stage. Now we mixed a quarter gram with all of the bone and the blood and so on. We ended up with a total volume of about a third of a milliliter. And so that reinforces our kind of notion that, with SynthoGraft fine, the numeric value, of the weight is kind of indicative of the volume you’re going to get if you wet those particles together. And a quarter milliliter is a significant sinus lift for one implant. We introduced the particles and, you know, obviously gently, they moved fairly easily, introduced the implant fairly quickly there. Now, we had quite a bit of those left. Now the implant is sitting fairly high in the socket. I would not close over that. This will be cause for failure. Left quite a bit of bone on the facial, not so much on the palatal, slightly low. So I want it to be lower. Okay, so I take the sinus lift abutment. This is just the suction tip. You can hold it with anything. Now it has two millimeter locking taper well in the center. You can take it with that. Okay. We introduce it. Pat a little bit of bone over the shoulder. You don’t have to do that, but I had so much graft. So we put that in and push the implant. And the nice thing about the sinus lift abutment is it gives you a bit of a nail head in this case. And, there is an even wider one for the six millimeter implants, but that has a little bit more technical challenges because it can be pretty wide. But for those of you afraid of falling into the sinus, do use it. It helps you relax. It helps you be secure. Okay, so we tap the implant until the top of the sinus lift abutment is flush with the crest and so that we can close, we can suture, and, you know, it’s flat. And that’s the sign that we did our job and the implant is flush with the crest. So as we can see here, only about one plateau is contacting the native bone. And in this case, you can make a case, well, you know, maybe it got more, so it probably got more stability. But look at the orientation. And I was able to seat it more deeply so that I can bypass that slightly lower or thinner palatal plate without fear. And the amount of the sinus that we grafted and lifted is significant, is almost, equal to a, you know, small conservative lateral lift. And after about five months, the patient comes back and we have new native bone. You cannot even tell. And that’s one of the advantages of the SynthoGraft is incorporated so quickly and so completely in resorb that it becomes trabecular, almost like the native bone, and quickly at that. The last case, this patient is sixty two year old. She has a missing all of the molars in the maxillary left and soon there on the maxillary right. But we also have a bit of a vertical defect, so we have a bit of a subtle deformity as well as pneumatization of the sinus. The combination makes for a difficult defect to treat. If you were to place a platform type implant, how will you place it? Will you shave the bone down, thereby compromising the health of this tooth? Or would you try to graft the bone vertically, which is very unpredictable, and in my hands, it yields almost always less than a quarter of what you hope Whereas when using the Bicon implants with the sloping shoulder, the internal sinus lift and a sinus lift abutment, we’re able to achieve that with minimal fanfare, which is a lot more relaxed and much easier. So the day of surgery, you open a conservative flap, again papilla sparing, but I make it fairly wide just in case I have to do more than the internal lift. So always think in terms of contingencies. Okay, we, open the flap, put a retraction suture, mark our location and go about a depth of about two millimeters or so. Just check the angle and location of the implant. Okay, now the thing is, know that the implant or the osteotomy is going to be very deep on the very mesial end of it, but very shallow on the very distal end of it. So we place the implant after a series of reamers going all the way up to five millimeters. And then check the integrity of the walls and the floor. Okay. And we fracture the floor using this osteotome. And so it’s a, it’s then fractured. The graft is lifted, is mixed again with bone. It’s not a slurry stage because most of the lifting was done in this case and there wasn’t much to be dissected with that. We didn’t need a very large graft. So I introduced very slowly packing and so on. I placed the sinus lift abutment with the five by six ultra short implant and carried them as a unit into the osteotomy and seated it. Okay. Tap hard. This is key. A sinus lift abutment is meant to wedge itself into the crest And by wedging itself with your tapping into the crest, it gives you added stability. And as a sort of a pedestal, it will hold the implant even though some parts of it may not be touching a lot of bone, maybe a fraction of a millimeter. That will still give you stability, especially if you have the buccal and palatal walls contacting the implant at the base of the shoulder. And in this case, we see on the radiograph that this implant was barely touching at the very base of the shoulder on the distal, and yet it’s got this almost full surface on the mesial contacting. And, on the mesial, it’s two millimeters, maybe two and a half millimeters below the crest, and it’s about a millimeter and a half below the crest on the distal, right? So all of these are the features of the implant that we take full advantage of with the use of the SynthoGraft and the internal lift and the sinus lift abutment. So in second stage, we see that bone is healed nicely, the crest is nice and smooth and straight, And when we uncover our implant, we see that you can actually tap on it. You can hear that it’s bone hard, very metallic sounding sharp note. And then we grab it with a, rongeur, give it a bit of a twist, comes off. We check integration, ream it to the proper size, and then place after the impression, place, the IAC once it’s fabricated. And this is the IAC in two thousand seven. We have several year follow-up on this, six year follow-up at least, and actually we do have seven years. Okay, and finally an eleven year follow-up on it. Notice how stable the bone, how nice the shoulder sits and the sinus lift.