Extraction and Placement of Three Bicon SHORT® Implants, Uncovering of Three Bicon SHORT® Implants, and the Insertion of Seven Integrated Abutment Crowns™

Good afternoon. My name is Shadi Daher and welcome to this afternoon’s webcast from the Bicon implant dentistry center in Boston, Massachusetts. The first case, the extraction of these two incisors, the central and lateral of the maxillary left. And we will be placing implants in their location as well as in the location of the canine. We intend to use the max two point five implants, four millimeter in diameter by eight millimeter in length or four point five millimeter in diameter by eight millimeter in length. This is the surgical guide. Okay. It is a palatal guide. It has the grooves four, six, even seven implants if we choose to go all the way back to the second molar, and we can easily verify first the fit. Okay? And second, the accuracy of the fit. Alright? We will be using these periotomes. As you can see, the the root of this tooth is fractured. You can see the the fragment moving. We will use a fifteen blade to ensure the freeing of the soft tissues from around the roots. This allows for the periotome to have easy access. Okay. The periotome’s technique allows us to sever the periodontal attachments, periodontal ligament, and create sort of instant periodontal disease, hopefully facilitating the removal of the tooth without loss of additional bone. And in this case with no crowns present, it makes our job a little bit easier. This is a three millimeter front action luxator that we will use to wedge the tooth slightly to loosen it. We don’t elevate the tooth, but rather widen the periodontal ligament space, which has been already severed or severed in large part. Okay. Here we are. Okay. And the lateral. Again, we don’t elevate, but rather we use a carving type of motion until the root has been mobilized but yet not lifted out of the socket. So yes, there is a significant loss of this buccal plate. What we will do, however, since this was not an infection, infectious loss, we will be able to place the implant or we will place a bone graft with a membrane at the same time and secure the area. So that we can ensure that our flap is going to be accurate and adequate. We will mark the location designated for this implant by our stent. Let me have a perio probe first. So we take a periodontal probe and we will mark this spot right there. Okay? Now, as you can see, the stent calls for the placement of the implant at the mesial palatal corner of the lateral incisor. So the incision will go right to the palatal slope. It will involve the edge, this papilla here. However, it will then flare out, preserving the coverage of the buccal plate of the socket. As soon as we have the opening made, we will collect some of the blood to use it with the graft when we get to that point. So this is sort of a mixed arteriovenous blood. We will supplement it with some of the blood we’re not getting a lot, we’re not getting much now but we will supplement it with some from the osteotomies, not from the socket of the teeth. And because of the presence of the amalgam tattoo, I just want to make sure that this area doesn’t have too much scarring to create a problem. And if there’s any pieces of old amalgam still in there we will remove them. There aren’t any, it’s just the tattooing is in the soft tissue already. Okay. K. One, Two. Okay. So initially I will just make a marking. Here’s one, two, and three. K. This one is a little bit off of that plane, so we will make the two the other two match it. That hurting? Feels weird but it shouldn’t hurt. Am I right? Okay. K. Good. Okay. That will work out okay. Slowly bite down. Okay. That should work out well. Open, please. The one thing that you will notice in the area of the canine is this little kind of sclerotic type of bone right at the tip of the instrument. That bone is going to become a bit of a liability because it’s not gonna lend itself to reaming. It will probably slough off as one piece because of the slow reaming that we use. It will not cooperate as well as much as we would like it to. And I’m already feeling a little bit of vibration under my index finger. Alright. Come out for a minute. Good. Good. What I’m going to start doing in the area of the canine is to use hand reamers to selectively carve out the palatal tissues rather than the buccal bone. We’ll again begin this one but not finish it. We’ll finish this one or finish this reamer. Good. Okay. The three millimeter hand reamer will go allow us to continue with the canine osteotomy. And as you can see, I’m just selectively carving out from the palatal area while the buccal area is being expanded or the buccal plate. We are now at eight millimeters. The goal is to go in approximately ten millimeters so that the eight millimeter implant is within two millimeters of the crest, creating an adequate aesthetic profile for the final restoration. K. Move that a little bit so I can get my finger. Don’t suction the bone. Good. And before I go to the final size, incidentally, I like to go in with the curette and make sure that I have walls all around and the floor. And first one is okay. Second one also. And in here, because of the way the lab designed this stent, we have an area that the two are coming close together in the interproximal. However, it seems to have enough thickness for us to do our work. And then finally, the canine. And again, here, I’m gonna ask you to move a little bit, please. Okay. Yes. Thank you. Because the buccal plate was thin and it’s present, it is not thin enough. I cannot feel the curette under my index finger. And I’m taking out all of the bone shavings that were left behind. We will collect those. We will use them over the shoulder of these implants, over the shoulders of these implants. This is the first one. Placing an eight millimeter implant at an appropriate depth from the crest means that the soft tissues at the zenith of the gingival cuff should be roughly about five millimeters above it. So that places the soft tissue right at about the fourteen millimeters mark, which is the top of this second band. Again, with this area, the lateral incisor, we’ll do the same thing. And again, the same thing here. We’ll go slightly more on the side of placing the implant very slightly deeper since I have the depth of bone. And that’s going to require a little bit of finesse to get it to go to the full depth as we like it. I’m going to take three four by eight two point five max two point five implants. And we’re almost there. The canine area, I wanna make it a little bit deeper using the hand reamers with apical pressure. Now that we’ve expanded the buccal plate enough, we can go three hundred and sixty degrees and make the osteotomy a little bit deeper to have a better aesthetic result. Okay? This area here will be grafted, as you can see. We have a buccal plate, which is about a millimeter thick, which is more than adequate for the Bicon plateau design. Somewhere between the eight and the eleven is where I want my bone level to be. Perfect. Somewhere between the eleven and the fourteen is where I want my soft tissue level to be. Perfect. And as here as well. Perfect. We will introduce the inserter retriever into the well of the implant. These lines are at two and three millimeters. Those are useful when we’re using when we can see the bone. Okay. Good. Then we will disengage the implant by twisting the short knob counterclockwise. You can also twist the bigger handle while holding the the smaller one stationary, making sure that this is seated, little tap tap. That’s in. And this one as well. I need it a little bit more convincing. K. And then you can see that these are pretty parallel. And we will seat it in there. But The key is to mix this slurry of a graft as much as possible without so that we can ensure, you know, within reason that all of the little nanoporosities and microporosities in the SynthoGraft have been imbibed thoroughly with blood products. This enhances vascularization and turning over of this bone. See? We save the native bone to put it on the top of the crest. I will measure the depth of the defect. And it’s roughly about eight millimeters at its deepest and about six millimeters or so at its width. And alright. So you don’t need to dissect the the gingiva off of the buccal plate. We will put this inside the socket. Now we will take our graft. And I do want to leave this tail. I will take a Q tip now And then we’ll take a third of the collagen plug, and we will put this over it. We will pack it into place. Okay. And then we will take a gut suture. Okay. We will use a crossed over horizontal mattress or an upside down figure of eight, a sort of an X suture going from the mesial facial to the distal palatal of the soft tissue rim of the socket. Then we’ll go back from the mesial palatal and then going over the plug to the distal facial distal labial. Alright. And I’m going to let some of this bone go into the little bit of the divot in the in the side to just help this one here heal better, And then we will release the retraction suture. And the reason why I am closing the canine first is, a, I don’t want to leave the flap open any much longer than I absolutely must. Plus, I will need the edge of the flap to be brought back down for me to suture over the lateral incisor. And I’ll just use a little bit of a continuous suture to close this flap, and we’ll put a couple of the sutures to close the releasing incisions. And then we’ll close the lateral, and we’ll be finished. So all we’re doing now is just closing the releasing incisions. I’m using the last remnants of the autogenous bone that we had collected and saved and we’ll take a little collagen plug. This suture will sort of have a double purpose. We’ll close that releasing incision as well as hold the collagen plug. As you see the three implants are at the same level relative to one another. The canine implant is at about two point five to three millimeters from the crest. The others are roughly at about four millimeters. What you will see in these cases, because of the shrinkage and remodeling of the crest, these will end up roughly at about three millimeters from the depth of the bone and about five millimeters to six millimeters from the depth of the soft tissue. How do we know this? Experience and then also, you estimate the shrinkage. The measurement was taken from the zenith of the soft tissue cuff and, as I showed you before, the implant, however, has that flexibility, has the versatility to allow us to place the implants within a certain acceptable range. Deeper than this might be too deep, shallower than this would be acceptable, but much shallower than this will not be acceptable in terms of aesthetics of the case. So as you see in this area, the patient had received a long time ago an implant in the area of the first bicuspid. And she’s also received implants in the areas of the first molar and the second bicuspid, with the space being divided into a three bicuspid kind of sized teeth. So we will have three implants taking the space of two teeth. So I’m not going to worry about scalloping yet. I’ll make the incision straight and then we will try to carve out the papillae if need be or allow the tissues to fall where they can. So what I’m seeing here is the shadow of the posterior most, the distal most implant. What I want to see are the shadows of the other two. Here’s one. Let me zoom in a little. Here’s the other one. And here’s the third one. These are nicely integrated. The bone above them is not that plentiful but it’s nice and solid. They are not even hidden in there but we will be able to get the first one out. This is the middle implant. Alright and one more to go. Good. Okay. So this doesn’t bend. I’m pushing at it and it doesn’t bend, it doesn’t move. And I will again test this one. There we go. Good. Okay. Just want to make sure that the suture is in front. Alright, thank you for your attention. Why don’t we continue with Dr. Morgan? Thank you Doctor. Daher. Good afternoon. My name is Vin Morgan and we’re going to be taking implant level transfer impression. One is inserted, the second is being inserted. Round pegs into round holes. You only have to put them in with finger pressure, they do not have to be tapped, and that’s it. Three impression post with their corresponding acrylic sleeves. Inject the light bodied and it’s, it’ll set up in two and a half minutes. So please consider the amount of time it has taken and take an impression. And voila! The impression sleeve is the only thing that came out in the impression. Since there is no posterior occlusion, we’re going to record the occlusal registration simply by using two of the sleeves. Put an acrylic sleeve on the two mesial impression posts. The third post is too high and so we’re going to remove it. It would interfere with the occlusion, be distorted, and you do not need a large volume. You just need something that the technician can stabilize his two models. You must always remember the technician doesn’t have the luxury of having a TMJ that would stabilize. Anyway, close. And that’s it. Open. We’ll just tap it off. There’s the bite registration with the two sleeves. Okay. And we tapped it in. If need be, we could have shaped the, the diameter of this abutment. This is a narrow abutment. That completes our taking of the, the impression. You will see the implants. And as you remember from previous webcast, both mandibular, both bilateral, mandibular bridge split procedures were done prior to the placement of the implant, as well as the two implants that were placed on the, the upper left. You saw the impression, and now you will see the, the insertion. So we’ll remove the temporary abutment with a rongeur, just twisting, and you’ll be able to see. So there’s one, two, three removed. You’re looking in into the well of the three implants. We wipe the the post with alcohol, and we’re simply gonna put a round peg into a round hole. I’ll take a piece of floss. This contact not as tight as I would like, so let’s just rotate it a bit. Okay. Close. It down firmly. Close. And that’s it. Open. You also wipe it with alcohol. And then just place it in like so. Check the contact. Contact is there. We just insert it. As mentioned, round pegs into round holes. You can hear it. It has contact. Close now. Lie down. Close hard. Lie down firmly. Good. Open. So we have contact. Wait down. Though it’s not in hyper, open. Now let’s see if it’s not in hypo. Close. And it’s not. Once again, I’ll use a rongeur. Twist and pull. This has had some overgrowth of the abutment with the mesial tissue. So with that we just insert it into the sulcus. Let’s check the contact. Contact is there. And there’s the contact. Okay. Open. Close. Tap. Tap, tap, tap. Tap. Tap. So now we’re going to remove the two white temporary abutments from the maxilla. So that’s seated. Okay. A little light. Little light contact on the distal, rotate it a smidgen, or alternatively, we could take it out and add to it, but let’s just rotate it. Now we can check the, now we have the contact. Here, here. Close. Open. Close. Light down. Good. Close. Tap. Tap, tap, tap. Tap, tap, tap. Open. So there you can see the contacts that are present. All teeth are occluding. The first thing you will notice, they all have a significant hemispherical base. This is something that we’ve learned through clinical experience that is absolutely necessary. So you must have a hemispherical base. If there’s no hemispherical base, I can assure you, you’re most likely going to lose bone around the implant. Additionally, I want you to pay particular attention to the volume of composite material over the metal. For the last eighteen months we’ve realized that you do not need a bulk of metal to support the restoration, Just the opposite for porcelain. The greater volume of composite material, the stronger the material. This fact allows the technician to save a significant amount of time because there’s no need for his or her, soldering, welding, or trying to get a metal support. The reality is you only need about four millimeters of, abutment length to support a twenty five millimeter restoration. And we will see you next time. Watch for the upcoming dates at w w w dot bicon dot com. Thank you.