Extraction and Placement of a Bicon SHORT® Implant and the Uncovering of a Bicon SHORT® Implant

Hello and welcome to another edition of the Bicon webcast. We will, today, share with you two cases, the first of which is the treatment of a non restorable maxillary left lateral incisor. We will remove it and replace it with an eight millimeters short implant and we will be using the MAX 2.5 Bicon implant that is coated with Integra CP. The second case we will introduce as we move to it. It will be a second stage procedure. This tooth had been crowned for a great number of years and it seems to now have had a complete calcification of the canal system, precluding the ability to endodontically treat it. The treatment plan, as previously stated, will be to remove the tooth, or remove the root as it is right now, and to place an implant in its location. Making sure that everything is severed and cut cleanly. We will then take a periotome, a straight periotome. The periotome, as you all know, is used to sever the ligaments, the periodontal ligament. And it should be introduced into the periodontal ligament space and it should be rocked back and forth to effectively sever this ligament. We will go around as many of the sides as possible. Even the facial can be treated thusly because this instrument is that thin that it allows the introduction or it allows its introduction into the facial periodontal ligament space without fracturing the buccal plate. Take great care not to twist and try to elevate once the periotome has engaged that PDL space. But rather just rock and push strictly apically. Try to go again as as much around the root of the tooth as possible. Push apically first and give it a bit of a rocking twist, sort of a figure of eight luxation. For the atraumatic extraction, I favor the use of forceps a little bit earlier in the process as they will rock and expand the periodontal ligament space as well as the walls of the socket, effectively allowing us the removal of the root with a lot less trauma. Make sure there is no granulation tissue, that there are no fenestrations. And I see no fenestration. I feel the buccal plate. It is thin but it is present. The nice thing about the lateral incisor is that they have a slightly palatal pointing to them. However, if you go straight at the apex of the socket, you run the risk of getting too close to the facial aspect. So we’re going to go into the palatal apical corner, roughly about three to four millimeters occlusal to the apex, engage the bone, and then go slightly deeper. The idea is to place the, implant in the, palatal pyramidal bone keeping the distance. Now I will drill to a greater depth than I need because that would give me positive lock as to the angulation and direction. And we will just expand this osteotomy. And always using a two handed technique with the index of the non dominant hand playing the role of a sentry over the facial plate so that as you get close to it, before you perforate it, it will bend and flex under the spinning osteotome or reamer and you will be able to avoid unwanted results. And again, we wanna maintain full control of our reamers as they are progressing in there. Okay? This is the four millimeter, and I believe it would be it will be the final reamer. Okay. I don’t feel anything against my index finger. I want to make sure this osteotomy is complete. And we know now that we have contact with fresh bone all around as you can see from the harvested bone. Make sure that the walls are trabecular in nature. In other words, they’re not the glassy surface of the dentin of a root. We want to make sure that none of the little shavings of bone are going to be staying in the bottom of the osteotomy preventing our full seating of the implant. You may suction now. We will then engage the inserter-retriever, gaining a handle onto our implant. We will then seat our implant. Now, it only needs to be about three millimeters below bone. So what we will do is seat it until the bottom of the bevel on the inserter-retriever is flush with the facial soft tissue suction. Now at three, this is four. That’s it. Drape the cover or the black healing plug onto a perio probe, seat it fully. We will take whatever little bone we shaved from that area, we will pack it over the implant. It will act as yet another barrier and it will help speed up the integration of the shoulder portion of the implant. We used about half or a third of a collagen plug. Then we will take a figure of eight suture to hold it in place. This plug will serve the purpose of closing over the implant while allowing the body to migrate over and heal it naturally. So, what I do now instead of tying it, we will go back as if it were a horizontal mattress suture only, it’s crossed over to the other side. This will now allow for a provisional to be made and cemented or even a flipper move. Okay, so as you see, the radiograph shows basically the implant in its position. I told you it will be roughly about three millimeters, two to three millimeters below the crest of the bone, exactly where we want it. It is occupying the socket almost entirely. It is a good two millimeters distance from the root of the central root of the canine. It is exactly where we want it to be, and as you can appreciate clinically, or at least when you’re looking at it, we have good parallelism in terms of the position of the implant and the emergence of the abutment in that area. And as you see, some of you may wonder, with such available depth, why did we use a short implant? The short answer is that because we do not need a longer implant. But there is also another reason. When you’re working in the area of the second molar, it is very difficult for you to introduce the long abutment excuse me, long reamers or drills necessary for the development of a deep enough or a deeper osteotomy. In this case, we are able to easily place an osteotomy that’s about seven millimeters or so in-depth, fully allowing the seating of a six millimeters long implant. With that, we will now begin the uncovering. We’re able to make a crestal incision, and as you can see, there is actually the divot of the previous incision that was used for the placement of this implant. We will drag it mesially until we hit the distal surface of the tooth and we will allow for the development of the flap to become sort of circular. So, what I’m going to do without risking great proximity to the lingual nerve is take a slight buccal direction and then using an angled curette as a periosteal elevator, we will elevate it. It’s a testament to our patient’s healing capabilities that the black plug is completely hidden. So we will now expose it by using a six or four round bur with copious irrigation. I see the black shadow of that post. So I will just very slowly keep going with the water. More water. Good. Okay. Alright. Good. Good. Good. You see the black part? Maybe you do, maybe you don’t, but I do. Trust me. Okay. Good. That’s it. Suction. My preference is to use an endodontic file or reamer, 110 size. Okay? First we check integration. Okay? Let me open it a little bit wider. Okay, great. Alright, so this way we know that when it comes time to inserting the final restoration, the patient will have an easier time tolerating that insertion because the bone and the soft tissues have been prepared. Great. Now, I will put this with finger pressure, suture around it, take it out, put the impression post and turn it over to Dr. Morgan. So, we will first suture the mesial part. And again, like I said, a buried suture or a buried knot will be used so that it doesn’t interfere with the way the impression is being taken. All you have to do is reverse it so that the knot is on the other side. Okay? It is very easy to retrieve. I will now put this for Dr. Morgan, turn it over. Doctor… Good afternoon. So what one simply does is put a round peg into a round hole. It’s simply a matter of injecting. You must always remember that the technician does not have a TMJ so if you were to take just a quadrant tray or a triple tray you would, may have stability major distally but not buccolingally. So two and a half minutes has passed and we’ll just remove the tray. And if all goes well, the impression post remains and the only thing that is picked up in the impression itself is the green acrylic sleeve. So as you can see it worked. And once again it’s simply a round peg in a round hole. It could not be any simpler. If you all remember when you were in kindergarten, your teachers gave you square pegs to put into square holes, triangular pegs to put into triangular holes, and round pegs to put into round holes. And clearly, a round peg in a round hole is the easiest. Dr. Morgan and I thank you for your attention and we appreciate your taking the time to be with us this afternoon.