Extraction of an Endodontically Treated Tooth and Placement of a Bicon SHORT® Implant

Good afternoon. We have a little over forty countries and over thirty five states. So for this afternoon’s program we are preparing to extract and place a mandibular right second bicuspid. The radiograph, it’s a periapical radiograph of the mandibular, right second bicuspid the five by eight millimeter short implant will fit to perfectly obliterate the entirety of, the, root or of the socket after the removal of the root. So the plan initially obviously is for an atraumatic extraction of this bicuspid which as, all of you know is probably the more difficult part of the entire procedure. Removing this tooth will be the challenge for the afternoon. I think we are ready now, we will be proceeding to the surgical, room. The atraumatic extraction depends on avoiding all flaps and on taking our time and severing all of the periodontal ligament or as much of it as possible so that the tooth is mobilized without having to torque against the, the surrounding bone or the socket at all. And the advantage of using periotomes, as I’m doing now, is that you can go in between the buccal plate, which is extremely thin in in many cases, and the root without risking, serious damage to the plate itself. Okay. So as you see with this apical displacement, we’re going right down the surface of the root and we’re just gently and systematically severing all of these fibers so that the tooth is loosened without need for a lot of elevation. There will still be use for that but not as much hopefully. Another longer periotome is used to go down a little bit farther along the root. The idea is to just try to get as close to the apex as possible. To complete the mobilization, we will resort to an elevator because it gives us the chance to actually start lifting the root and getting a sense of how it wants to move. Are you feeling this at all? So we use specialized forceps that don’t close completely. And there are thin, those with vertical serrations inside that give us the ability to actually torque the root, if we can slide down and grab it. So the idea is to also be as careful and deliberate as possible, as the, slight movement initially will start severing more and more of the periodontal ligament fibers until it’s all mobilized and separated from the bone no matter how thin the bone is. I believe that the best way to atraumatically remove a tooth is the appropriate forceps. Elevation always sacrifices bone or crushes bone. Forceps can hold the tooth and slowly deliver it. Here it is, it’s okay Janet. Okay, so we look closely to see that there is no bone that came out with the tooth. The next step is very critical in that we leave no residual of the periodontal ligament if we can identify it or feel it, we curette it all off of the socket. Also, since this tooth had been endodontically treated, we want to make sure that we remove any extraneous root canal sealer or, gutta percha or anything that is left in there if we can grossly identify it and remove the bulk of it so it’s not interfering with the healing and integration at the apical portion. Then we will use a sterile water irrigation. The idea of using the sterile water is we let it sit there for a little bit. If there are any bacteria or anything biological, even blood cells and so on, they will be, burst because of the hypotonic solution. The pilot drill in the Bicon system has two broad bands. The first one is between six and eight millimeters, so it starts exactly at six and ends at eight millimeters. Then there is a second band that starts at eleven and ends at fourteen. So when and as you can see also, the drill itself is very sharp, and it’s externally irrigated. Notice the two handed technique so that we have stability. And all we will place the implant in is another millimeter or so, and that’s it. We’ll take a paralleling pin to check our positioning first. So the way this paralleling pin is angled, it mimics the root of the bicuspid. Because of a slight dilaceration of the first bicuspid’s root, we have to aim slightly distal. So this is immaterial as long as our emergence is strictly in between and in the middle of that line that joins, or that imaginary line that joins the two contact points. So that slight angulation is immaterial as long as in the end we’re emerging like we are now, right in the middle of that space. From this point on, we will reduce our speed to fifty RPM or less. We will also, use no irrigation because the speed is so low. The markings on the reamers is the same as the drill, the pilot drill. Six to eight first band, eleven to fourteen the second band. And again, two handed technique. And we are just going systematically now in sequence. Any pain? Nope. The three point five has, again, the same bands. These are accentuated by grooves, which makes it even easier for us to see where you are reaming. Because of the slow reaming of the Bicon implant, these reamers, these reamer drills, can last up to two hundred implant placements. We are now at four millimeters. They’re all color coded. Four millimeters diameter. So as you can see, it goes in pretty quick succession, and it’s very logical. There’s no guessing. If you’re gonna place a four and a half millimeter implant, you will ream out to four and a half millimeters. Okay, if you’re placing a five, you ream out to five. And as you see now that we are engaging the walls of the socket, we are getting more bone. And all of this bone is collected and harvested. Now as we’re getting close to the final size, before I commit to the four point five or five millimeter diameter, since both are options, I will take a curette and make sure that we have no unforeseen occurrences such as a fenestration, dehiscence, a fracture, the feel of a root or a very soft, floor of that osteotomy. So we see now, we feel a lot more friction because we’re engaging the the socket a little bit higher, and we are gonna go all the way in. Okay. I’m gonna again make sure before we commit that we have spongy feel to the bone mesially and distally. What’s happening now is that we’re engaging a lot more of the wall, which is the goal and the idea behind our going the full width to five millimeters is because I want to have the implant contacting new fresh bone that was not in contact with a, a root a failed root canal treated tooth. Okay, and that’s where we are now. And as you see, we got a lot more bone. Now, we clean the osteotomy one more time. Okay, you don’t want to leave a lot of debris because at the very least you could use them above the implant. At worst, they may actually sit below the implant apex and prevent it from sitting fully in the osteotomy. So you want to clean it out, curetting it, and lifting all of that because the socket may still have enough of a void in it that, it will hold more than its fair share of these shavings. We’re going to measure the depth of the osteotomy using the implant depth gauge. The implant depth gauge is an instrument that has a flat top. Okay? That will slide right down the side. And when we hit the floor, it tells us that we’re exactly at about thirteen millimeters like we intended. These were the implants that we had the choice from, five by eight, five by six, four and a half by eight, and four and a half by six. Okay? Now, we could easily place a five by six since the osteotomy is the same, but that may place the implant a little bit too deep, in order for us to obliterate the whole socket. So what we will choose is the five by eight millimeter short implant, and that is what we will place. Now, the implant is packed sterilely. The white paper, as well as the blister pack, are sterile. And inside it is another sterile bag which contains the actual implant. And that’s how it only should be handled. The implant should never be manipulated except through the plastic bag or when it touches the bone in the recipient site. So we will now proceed to cut this plastic bag and then handle the implant with this plug and carrier that comes with it. We will carry the implant like such, and we will take it to the oral cavity. And it’s a friction fit implant so it just goes right in like that. The black part is actually used to actually cover the implant. We will cut it to the appropriate depth and then we will take a regular periodontal probe, engage it in the pre existing hole in the center of that black plug and fit it in. In there, okay, that’s it. We’ll take all of that bone that we have collected that we have no other use for. We will place it over the shoulder of the implant and then we’ll take a collagen plug and put that over to further hold the clot intact and protect the shoulder of the implant. Using a silicone dappen dish allows us to manipulate the graft so that we can squeeze the moisture out of it and carry it on the back of our Pritchard elevator. That makes it pretty handy. Alright. And we’ll take this over and pack it over the implant. Before I close it, I’m gonna just pack it so there is more room for, the collagen plug. We use a four o chromic gut suture. Alright. We use an inverted figure of eight suture, or a crossed over horizontal mattress. And we will go from the rim, soft tissue, on the mesial buccal. And to the rim of the soft tissue on the distal lingual. We will just go to the mesial lingual, almost like what a horizontal mattress is, but we’re crossing over. So that will hold the plug down and in place and act almost like a purse string suture for the rim, of the socket. And just the surgeon’s knot here. When we look at this radiograph, it’s at exactly where we wanted it to be, roughly two millimeters or so from the, actually a little less than two millimeters if we consider the way the buccal plate was missing in here. Mesially and distally, it’s still within tolerance of about three millimeters and a half to four millimeters. So this implant, had we placed, for instance, six millimeters implant, in order for us to obliterate the entirety of the socket, we would have had it a little bit too deep, it would have been, outside of the realm of periodontal health, if you will. In this case, this implant will be imminently restorable without absolutely any issues, with it. You know, obviously if it’s left in and you let it heal and then you come back in another time, it’s still there anyway. It’s a very good point. We actually have better control when we do the extraction places. So the question is, what if there is something left in there? Your best shot at dealing with it is right at the extraction and when, you know, you you have any extraneous material left in there, you really can’t control it at all. As you saw, we worked diligently to remove all of it. So. First you treat any abscess like you would. If it is not an acute painful abscess with soft tissue cellulitis or swelling, then we would probably just remove the tooth and wait. If you have any other clinical signs of soft tissue infection, we we treat it with antibiotics. We wait a minimum of six weeks to eight weeks. If there is no fenestration of of the bone, no dehiscences and whatnot. We usually just come back in eight weeks after we’ve had full epithelialization of the socket, surface of the top and sort of osteoid formation, but no bone formation in the socket. If we had to graft it, we would wait a prescribed period of time, in the neighborhood of of four to five or six months, depending on the type of graft and the size of the graft and the defect and whether or not we used membrane and and, and so on. Okay? No. We have not seen that. There are times when I put the implant in and I know it’s not very solid in there. So then I can retrieve the implant and put some bone around it, or use an inserter-retriever to make sure it actually engages the bone. Although it’s a friction fit implant, but the plateaus have vertical slots cut in them that allow every one of these vertical slots, they allow the plateau to become a cutting surface, and they actually can cut their way and mill their way and lock themselves into the bone. So you shouldn’t have the implant moving at all, because if they move after you left them be, if the patient goes and plays a pickup game of basketball or something, that the implant is bouncing all around, you’re not gonna have integration. So no, you have to have primary stability, it’s a given. Do mean in the maxillary sinus? No, in the maxillary sinus and so on, we have other means of stabilizing the implant, such as the sinus lift abutment and so on. Those, I will refer you to previous webcasts where we’ve used those. And again, thank you all very much for your attention. Have a great day.