Floor Transport Technique

What we will be doing this this morning for us, this evening for you, is the placement of two implants. Now without the use of the Bicon ultra short implants, we would have had to open a Caldwell-Luc window and do a sinus lift first, then six months or so later, come back and place two implants. However, with the ultra short implants, the six millimeter implants, we are able to enter this crest and open a window at the crest, not on the side, but right here, Elevate the floor of the sinus, with it the sinus mucosa Place a graft and implants at the same time The design of the flap and design of the window will have to obey the actual anatomy and morphology of the soft tissues and of the bone. As you can see the bone in the area of the first and second molars is a little bit thicker and the bone immediately next to the implant is also thicker. So the window will have to be about three to four millimeters posterior or distal to this implant and will end right about the area where a tooth used to exist a few months back. The design of the flap I will show you. Do you have any questions before we start? We understand. Fully understand. Great. We fully understand. Everyone else? Very good. So I’ll get ready. The patient is anesthetized. I’ll just scrub in, and we will get started. The question now, if you can hear me, is whether the little scar in the center of the crest is going to allow us to bridge that gap, or do we have to make the incision right through it? Alright. Now before I go on too far, just will open it up. Don’t suction all the red stuff I needed. And we’re gonna collect some of the patient’s own blood to use in the graft. Okay. As of the good anesthesia we’ve obtained, we don’t have a lot of bleeding. But we will get enough to get us well moistened. And just draw very slowly. And for a volume of about one cc, all we need is about a third to half a cc. Volume of half a cc of graft, we need only about a third cc of blood or milliliter. And we’re getting what we need very easily here. And we’ll just now finish up the flap. I may need to do more releasing incisions, but we won’t do that until we know where we are. As you all know, we need to keep our releasing incisions away from the surgical site and in an area that can be hidden and that can be aesthetically acceptable but at the same time gives us enough visibility Suction here. Suction right here. Good. Okay. Alright. Take our time. We need to have all full visibility here. And a combination of blunt and sharp dissection. It’s very hot in here. Good. All good here. The window will be from about this to right here. The implants will be on both ends of the window. So these sutures are placed temporarily called the retraction sutures. Some of them are just sutured to the adjacent soft tissues. Some of them are just dangled freely from an instrument. We’ll show you in a minute. Okay. By doing this, we free up one hand and it expedites matters a little bit. I’ll place one on the palate. We’ll then just dangle the needle holder to the other side, thereby creating sort of an open wide, okay good. Chin up a little bit more. Okay, now what I need to do is design our window. If you remember from the x-ray, from the radiograph that is, we need to stay approximately three to five millimeters posterior or distal to the existing implant. And we can go about a centimeter in total length then. So this is a five millimeter osteotome. So by going from the back of the implant, I can estimate where I can make my cut, and that will be right here. I’m go right on top of the crest. Okay. Hold this now. Okay. Now swap. Good. A little bit of tapping now. And so the idea is to score the rectangle, and then we’ll go and score the other end of the rectangle, which is going to be right about here. Okay? And now we’ll go ahead and just score the sides. The thickness of the bone is somewhere about three to five. So I’m not going all the way through, but I’m gonna score it so when it breaks, it breaks exactly where I want it to. Thank you. Now the question always comes up, why don’t we use piezo surgery for instance? Cause I think this preserves the bone a lot better. But it is a lot noisier, that’s for sure. Our patients are great and they allow us to do this but it’s not a pleasant thing, suction. Not by any stretch of the imagination. So we, again, we’ll go back to scoring. Yes? Doctor, what are you using right before? Oh, alright. I’ll show you in a minute. I’m sure for the scoring, I’m using ridge split osteotomes. Okay? This is a five millimeter one. Alright. And the other that the for the other, it’s the sinus floor flat osteotome. This is the three millimeter one. We have a two and a half, three and a half, four, five, and six sizes. Okay? So it’s kind of flat. It just pushes against it. I want to score it some more. I’m using a smaller osteotome now because I want to go slightly deeper, but not too deep, and selectively cut where I need to go. Okay? I can feel it starting to move, but it takes a lot of work and a lot of patience. Yeah. Switch to a smaller sinus floor osteotome, and these actually come in the Bicon kit. The one area that’s not giving in is the palatal cut. I’ll just reinforce it. And that may be just because of the palatal slope of the sinus cavity or sinus floor. Either way, it will eventually fracture. We just need to make sure that that is in a controlled manner. Okay. I can feel it moving already. . So we will continue. Now I went to three point five millimeter osteotome. Okay. We’re starting to mobilize it. If in a minute, I will stop and give you a very good view of it. But that is really the floor transport technique in in essence. Now my osteotome is actually going into the crest. It’s about four millimeters inside the crest, which is the thickness of the floor. But on the mesial and distal, it’s a lot deeper than that. So we will keep mobilizing it until it’s free of the friction of the sides. However, you still have to be very careful because as you’re lifting it up, the sinus mucosal lining has to give. So as you see, I stopped to talk to you, but in essence, if I weren’t talking to you, I’d be stopping because we wanna allow the sinus mucosa to kinda swell and lift itself up slowly. A key to this technique is to be patient. So as you can see, how the rectangle now has mobilized in. It’s telescoped in. Okay. It’s very nice, healthy bone. Okay. The one diff difference in this in this particular case is that the posterior, the distal implant is going to start in the uncut bone because it’s thicker, and then we will use the we will burst into the window. Because this bone here is too thick to lift. This bone here is ideal. So we will start from this end and we will finish right about there. Okay? So the idea is also that the sinus lining, the mucosa of the sinus is not the most tenacious kind of thing. Will start to tear up. Okay? So now we are finished with the sinus floor transport. We will go on to the sinus lift. I need the sinus lift curette. You can go in and just make sure that your sinus mucosa is intact and that it’s mobilized. The only thing I don’t like is this corner, so I’ll go after it with the smaller osteotome. Hold this. Thank you. That will be more selective as to the corner only. So here we are. I’ll aim more to the distal. Okay. And you can hear it when it’s no longer resisting you. You hear that there is no resonance. It’s sort of a flatter. So now we’ll go ahead and place our implants. So I am using the pilot bur at a very slow speed still. And we’re going to go right here. Okay? And all I need to do is go in approximately six millimeters, which is the depth. So now I will go to hand reamers and do the whole osteotomy with hand reamers. Or with site expanders. So the posterior one will start here. Okay? And since I already know hold this please, I already know that the window has given me a significant width, so I won’t need to start with the reamers for the mesial implant until I reach the size of three and a half or four. So I will continue with hand reamers. Okay. What I don’t like here is the window wasn’t as I want the osteotomy because of the bone thickness, etcetera, it’s going more toward the palatal. So we will correct that by making a secondary osteotomy more mesial and buccal and joining the two. When you’re not drilling at high speed, you can maneuver a lot of things to your advantage. Okay. Good. And go back to the three. Alrighty. I will do this one so that it bursts. Yeah. Go to three and a half. The idea, I want that little bridge of bone to sort of be obliterated. Clean that. Okay. And we go now to the anterior part, and that is wide enough. And we go to the four. And now we should be able to get some friction on both. Chin up a little bit. Good. Are you okay? Good. We’re now approaching the eighty percent. Okay? Good. And that’s exactly what I want. That little bridge now will be removed so that we don’t create any additional trauma. We’ll put it in the graft. So that little bit that joined our window would have been too thick to cut all the way out here. So we’ll have a combination. We’ll still have the try not to shake like that. If you can. Okay. Okay. What I will do now is use a an site expander in the posterior one to see where where I am, And I will combine that with the hand reamer. Yeah, and I’m using the expander in a circular fashion. And this is basically just a blunt instrument like that. And you can use it by tapping it in as well. As you see now, the key to the technique is that the sides of the sinus or the sides of the alveolar crest are narrow enough so that they would exert friction and pressure on the palatal and buccal of the implants. And that way, although we don’t have mesial and distal contact sometimes, and certainly no dense and solid and immobile floor, we can still have primary stability of the implants. Open wider if you could. Thank you very much. That and I can still feel the floor of the sinus there. It’s that deep. And this is also a site expander at five millimeters. The goal is to go to six millimeters in the posterior. Time. Time. Watch. Yeah. Oh, yeah. His head. It’s okay. Alright. Good. And so now the mesial implant is prepared. I’m going to go to five millimeter by six millimeter in the mesial or in the bicuspid. It’s a little bit too tight for my liking, so I will use the hand reamer as well, and loosen it a little bit. That posterior one, we will go to six, and that will be also done with expanders and hand reamers. I’ll shave maybe a fraction of a millimeter here, but enough to give me a little bit more freedom of movement. And the same here. We’ll go to five point five millimeter hand reamer for the molar implant. For the second molar implant. Are you okay? Getting close to the ninety percent mark here, okay? Alright, so as you see now, the two osteotomies have merged. Don’t suction that, that’s the bone. There’s a little bit of bone that kinda got left behind. Don’t waste anything with the Bicon system, as you know. And this is the final size for the second molar area. Turn slightly to the left. Good. And Move the camera. Right? Okay, don’t suction there. Don’t suction there. Okay, we’re almost there. Just a few more taps and then I will, put the implants in. I’ll take a five by six and a six by five point seven. I will also take the graft now. Mix all together the, clot we collected, the bone we collected, and SynthoGraft fine, one half gram. We can churn the whole lot together. And instead of spending all kinds of time and money on PRP, we allow the coagulant to break in to the bone graft particles and by mixing them with significant force, we’re able to create a sort of a putty consistency. So we’ll keep mixing it now. We have to get to a good level. Now we’ll use a metal syringe to carry the graft into the sinus. And as you can see, we’ve used less than a gram of graft, whereas a sinus lift, even of the smallest size, would have cost you at least two grams, if not three or four, of graft material. In this day and age, every little bit helps. The technique is a little bit more challenging, but it will cut down on healing time for the patient. And I do tend to overfill it a little bit, cause this action right now is what is lifting the sinus floor. We’ve mobilized it before, we’ve pushed it up before, but this is really let me have that. And we will imbibe some of the liquid, and then we will go ahead and place our implants first, the anterior one. And this is a five by six millimeter. Goes in. Right? And the front end of that mallet, please. Retract a little bit more, Janet. Turn slightly to the left, a little bit of tapping. Very good. I will stop shy of the full depth because I don’t want to risk the implant floating into the sinus. Okay, for that, we take the sinus lift abutment, which we will then carry. You can carry it with a rongeur or other carrying device, or you can just use the suction, which holds it very nicely and neatly. We will put that right this way. The decision I have to make now is what’s the best orientation for this oblong type of an abutment? I think having the longer side oriented buccally palatally will be better because of the way the bone architecture is. Now, take this. I will take the inserting point which sits in a groove right at the center of the top of this abutment and will place it to the full depth. The sinus lift abutment then prevents the implant from freely floating into the sinus. Also will give it added stability by engaging the crestal bone. And because of its design, we’ll make it exactly a two millimeter depth. Now we’ll move to the distal implant, the implant at the second molar, and that will be a wider implant because we have the width. And that will be a six by five point seven millimeter implant. We will place that now as well. Using the inserter retriever, this one had even more depth, and the question is, do we even Okay, perfect. This one will have enough friction of its own that I probably won’t need the sinus lift abutment. And I put it to the full depth now. I think at least. Let’s double check it. As you can see it is nicely placed. I will place it a little bit deeper. The two implants will be a little bit closer together and a little bit far from the mesial healed implant because of just the nature of the movement of bone, the nature of the flap design and so on for protection of the sinus. There is not much we want to really change about that. What we really need to do is make sure that they are placed at the proper depth because with Bicon implant design, that the two implants are close together is not a big deal and that they are far from the front or neighboring implant also is not going to be a big deal. So in this case, I will just go ahead and place the healing plug because there was enough thickness at the distal end to give us stability. And that way I will keep enough bone over the implants to create a nice crest. And for that, I just cut the black healing plug outside the mouth, and now we’ll just turn slightly to the left. There you go. And we’ll go ahead and place it in there. And as you can see, it’s pretty solid. Okay? So we took advantage of all of the anatomical changes. And finally, we’ll just fill up the, or backfill the osteotomy. And no more hammering. I’m sure you’re happy to hear that. Okay. Okay. And I’ll take a Q tip. Okay. Good. And we pack it all in, and I’ll take the scissors now, Kim. And if you would open the The gut suture. Gut suture. Okay. Good. Alright. Open that gut suture. And now we’ll just release it. Okay? Just have you take one final look. Chin up a little bit for me and to the left. OK? I might try to seat Okay. Let’s see how it’s going to close over. And just want to make sure this is still under no tension. Because if it is, we’ll have to Okay, perfect. Suction. We have to release it some more, but we don’t have to because it looks pretty darn good. Alrighty. And we will continue the closure with a continuous horizontal mattress suture. Alright, and then we will reinforce the releasing incision. Okay, I’m gonna go to another retraction device here. Good. And okay. Great. Continuous baseball type running suture because I don’t need the eversion in this end because there’s no abutment to cover. Okay? And that will give us good coverage. Go back deeper. I know you’re tired now. I can’t I can’t believe it. I can’t blame you. It’s a long morning, but it’s only an hour. Still is a long morning. Seems like five. Right? We’ll we’ll end the suture now. Okay. Don’t be afraid of combining types of sutures that will serve the patient and the incision best. In this case, start with a horizontal mattress, we finish with a running suture. Either way, we have closure that’s tension free and complete. What I want you to see is this right there. Okay? And that’s it. Great. Turn to the left, and that’s the releasing incision now sutured. Great. Okay. I’ll take questions. The key is not so much the number of teeth as it is the thickness of the bone that you can actually fracture that you can mobilize into the sinus void, into the cavity of the sinus. Yes, you can. It will cost you either the implant or the window opening. The best way to prevent that is use the inserter-retriever, and that way if you go in too deep, retrieve it, or to put the abutment in, the sinus lift abutment early on so that you don’t go in too deep. If however you lose the implant in the sinus this is the other indication for a lateral sinus lift window. You have to open a window, go after the implant, bring it back and then repair your sinus. So in this particular case your best bet is to use the inserter-retriever. If we were to do a lateral sinus lift we would have had to let it heal for six months, then place the implant and with a little bit of luck we would be able to uncover it in five months, four months. So by doing the two procedures together, we’ve gained the difference. And now in about five to six months, the patient not only will have these implants integrated and ready to restore, but he will most likely have the restorations. Not unless I have a defect in the periosteum or if I have to graft on the outside of the bone. For the crestal, graft, as you saw right now, we don’t really use a membrane. In fact, the membrane is detrimental because it will slow down the healing of the incision as well and it can cause breakdown of the incision. So I have not used the membrane for this technique yet. We do that routinely. We do a thorough curettage of the area, remove all remnants of any soft tissues in the socket. If there is purulence or any type of active infection in the socket or a missing buccal bone then we may graft first. However, that’s a small minority of the cases. Most of the cases would have some slight residual scar from a root canal treatment. For those we will remove the tooth as atraumatically as possible. We will curette the socket forcefully and very thoroughly and irrigate it with water because you want the hypotonic solution to help destroy whatever living cells, especially bacteria, are in the area. Let it sit for a minute or two, suction it out, clean it and then freshen the whole socket with the implant reamers and then put your implant, you don’t need to seat the implant all the way to the full depth of it but it is important that you freshen up, you remove all of the old bone out of that socket to create a favorable environment for healing. I’ve used all of them and the one that works best in our hands with the techniques that we are using nowadays is the SynthoGraft. It mixes very well with blood, has very good handling consistency and it is replaced with the natural bone very quickly in as little as five months. And so these are the reasons I like to use this SynthoGraft. I just find that in my hands it works very well. Well the Bicon design is for an intra crestal placement. The sloping shoulder of the implants are designed specifically to be within the crest. It doesn’t affect the healing and the integration but it will affect the aesthetics of the case. As you can look at the case, actually the implant immediately to the mesial of the two that I’ve just placed, you will see that, a part of it on the distal, the shoulder is not actually within the bone and it doesn’t affect its longevity and integration. However, the only way to make it look aesthetic is with an integrated abutment crown. So if you don’t want to use an integrated abutment crown, you want to use porcelain fused metal crown, your best bet is to have the implant within the crest. It doesn’t have to be deep in the crest. It just has to be about a millimeter, two millimeters, up to three millimeters within the crest. And that will give you the best or all of the options for restoration.