Guided Bone Regeneration

Good afternoon and welcome to the third webcast in a row, the third in three days from the Bicon Institute in Boston, Massachusetts. Today’s webcast will be about the utilization of the SynthoGraft in conjunction with the placement of an implant. My name is Shadi Daher. I’m an oral maxillofacial surgeon. And this afternoon we will be placing an implant in the location of the maxillary right first bicuspid in an area where the buccal plate is deficient and with moderate proximity to the maxillary sinus. We will see can we have the radiograph up please? As you see on the radiograph, right in the center of the screen is a slight defect. That will not be of any clinical significance as we will have the implant placed within the crest itself. And for that we will be able to avoid having to graft the crest. However, the buccal plate as you will see shortly is deficient. The complete plan for treatment of this gentleman is to eventually replace the canine with an implant and the cantilever pontic with another implant. The staging is such that we will now complete the implant in the location of the first bicuspid. Upon its healing and uncovering, we will be able to use it for temporizing these two other teeth, which will then be replaced with implants. And the final restoration will be three individual crowns on three adjacent implants. Let’s take a look at what we see clinically. So, as you see, there’s this depression between the bottom right hand corner of your screen, which is the canine, and the center of your screen, which is the cantilever pontic. Okay? And there you see that the buccal plate has caved in. So we have that slight buccal defect. The design of flap and incision will be a paddle shaped design that will go from the crest with papilla sparing incisions, mesially and distally. So what we’ll do is start this incision right there. Do you feel anything? Suction please. Okay. We’ll have a little beveled incision and we will carry it on up, suction. Make it right straight through the periosteum. We have used the no epinephrine in this case as per the patient’s request so we’ll have a little bit more of suction necessary. And again we will extend our incision slightly anteriorly. Come out. So you just kind of lift it up. Now since we’re anticipating the use of a SynthoGraft, we will collect some of the blood, okay, and save it, set it aside to use with the graft itself. So we don’t need to do anything fancy. All we need is some of the blood even if it congeals and clots, we will break the clot with the graft. So all we need is about half a cc. We set that aside. So we have this flap. Okay, good. Thank you. We’ll take a bite. I try not to pierce the gingiva too many times. There will be plenty of these punctures when we’re suturing. So I’ll just take it from the thick part, the submucosal part. And then we will tether it to the outside to the cheek mucosa. Okay. The markings on the Bicon pilot drill are two bands. K? Laser etched bands. And they the first one starts at six and ends at eight, and the second one starts at eleven and ends at fourteen. Good. So before we go too far, we will make our initial perforation about three millimeters or so. We check the location and the angulation. So this is pretty angled this way. We got to fix that angulation right off, right? Okay, and now our osteotomy is at a six millimeter depth. Now it’s at eight millimeters. And we’re gonna go a little bit below eight only because we can and with the Bicon implants tolerance, we can go two or three millimeters below the crest. Use another retraction. Okay. Now, we can see that the angulation is a lot better. All right. Now we will switch to a much slower speed and that will be under fifty RPM and we go with the reamers. This is two point five millimeter reamer. Then we’re going to let me take the medium length ones please from now on. Suction. Good. As you see, the buccal plate is pretty thin. It’s almost translucent and we are seeing it now. The reamers always try to go the path of least resistance. In this case, it’s going to be the buckle as that’s the plate that offers the least amount of resistance. And in fact, that’s fine. Suction on the buccal and the distal part. That’s where we are anticipating we will want to go. Suction, please. Good. Okay. Suction. Okay, and the key is to introduce the reamers. Fully suctioned on the buccal, don’t worry. Okay, good. The one thing about the hand reamers is with the proper vertical pressure we can increase the depth of the osteotomy slightly. We’re collecting quite a bit of bone. So all of this bone, all of the splinters of bone that we have, all of these are useful. The cortical cancellous, autogenous bone that come free. Okay, suction now, let’s get all of the loose parts off. If they’re still attached I won’t really traumatize them. Okay, so what we’re doing now is selectively carving out from the palatal side while somewhat expanding the buccal aspect. Okay? And so we are now at about six millimeter depth. We need to go another two or three. Okay? So now that we’ve reached the basal part, I can go full circle. And that will allow me to get to the full depth as I want it. Now, the periosteum in the area is largely intact with the exception of that little band. Let me have a round here. Soft tissue round here will help us clean up the little loose pieces of bone. I don’t want any obstruction. And we have enough bone that I don’t want to have these. You can take that off. I want to make sure that the whole area is nice and clean. The autogenous bone kept off to one side. The bone graft, it’s the white particles in the bottom of our silicone dappen dish. We will use some of the blood that we had collected and saved. We will now mix it. The next step to do is to take a little paper template, is the wrapping of the resorbable membrane. As you see, it comes in this wrapping. So we will peel it, take the membrane out and secure it. Then we will take since this is sterile paper, we will cut an approximate piece and then modify it until we’re happy with the size and then use that as our guide to trimming the membrane. Okay? So all we need to cover is the very top. Okay? So in this case, all I need to do is make it slightly shorter and slightly thinner. And that’s it. This I’m happy with. It’s away from the incisions and it’s going to cover the shoulder just exactly where we want it to. So we just trim using the obviously the paper as a template. So that’s our membrane, our barrier membrane. It fits well. I want to avoid getting it moist because then it will lose its structure. We’re using this inserter-retriever as it gives us a handle on the implant. We’ll then position it in place. You can use a twisting motion. Okay. Hold this, please. Then by twisting the knob that’s closer or closest to the implant counterclockwise, it disengages the locking taper, freeing out the post of the inserter-retriever, allowing us to leave the implant behind. Now we’ll take an inserting or a seating tip and fully seat the implant in there. A little tap. That’s it. Suction. Before we seal this implant in place we want to just verify that its location and angulation are what we want them to be because if you don’t like it, this is the chance you have. This is one chance you have at let me have the mirror, That mirror. Where you can actually take it out and change it with impunity. So we see that the location angulation are acceptable, workable actually pretty good. So what we’ll do is estimate where the healing plug wants to be relative to the bone adjacent to that implant. So we’re going to go about two millimeters above the edge of the bone. There is a small hole inside the black healing plug that allows it to be draped over the periodontal probe and then it is introduced into the implant well. We’ll seat it fully. If it’s still too high, we can always trim it. That looks pretty good. Okay. Now, we’ll go ahead and place the retention suture. And the retention suture is sort of a means for us to stabilize the membrane right over the implant. So that it will not move and also will hold the graft. So now we will take another bite and that will bring it out to the palate again. And you want to bring it out on the other side of the implant and deep. Okay? This suture will also help reduce this bleeding that’s coming mostly from the palatal. Okay? Probably the trickiest part is keeping those dangling sutures and all the suture lines straight and keeping them where we want them to be. Now take this please. Good. So we have a little bit of bone. It’s autogenous bone. Okay. And this will be pretty much most of that quarter gram. It’ll just go as a second layer. Okay? I’ll take the Q tip and then I will take tissue forceps. We’ll position the membrane right over the graft. Okay. And this is where you have to really move swiftly as you don’t have much leeway in terms of graft is kind of moving on you. There’s a little bit of bleeding especially when you haven’t used any epinephrine. So we want to just drape it over. This is the suture. It goes right over this membrane, we hold it down, want to make sure it doesn’t fold. Great. And we pull that down, we pull that down as well. We still have a little tail, so we’re going to use a cinch knot instead of a square. One, two, three and four throws here. First of all we will release our retraction suture. Pick ups please. Thank you. We want to make sure that our membrane is exactly where we want it to be with the two sides of the retention suture straddling the implant. Okay? Then I want to pull this and see that it is closing with no tension. Okay? Here’s one. Okay. It’s important to have all of these suture ends uncrossed. Don’t fall, gently. Good, that’s it. So this is the main suture that will hold everything at the crest and now we’ll re approximate the releasing incision. First things first, Again, you feel that at all? A little bit. Okay. Remember, this is a pontic space so we’re not violating the free gingival attachment of a tooth. That will soon be replaced. In these circumstances sometimes a P3 needle may work better. However, we do have the FS2 now and it’s working okay. If we need another suture we will use a B3 needle. Hold on. Okay. Okay, just the necessary but not so very glamorous part of any surgery and that’s the closure. Alright. Last, certainly not least, this last suture. Okay. One, two. And that’s it. It’s a good thought, but from the very beginning, if you recall, I pointed to you that there was a thin, straight scar. So there was no bone to dilate. There was a very thin, paper thin amount of bone. Even with the pilot drill, which is only two millimeters, we were already seeing it. So it was that thin that it was translucent. If we were to dilate it, we wouldn’t have saved anything because it would have burst right through at the height of contour on the buccal. So it wouldn’t have saved us anything. It would have rattled the patient’s skull, but not saved us the graft. Absolutely. If one of the mainstays or one of the real important principles of treating any implant for that matter is before you start the surgery on that particular day, you take a periapical. If there is any pathology of the adjacent teeth, especially periapical pathology, that should be treated. Because when you go in and you stir the whole thing, you mix it up, you may drill right into that periapical lesion, you not only are risking infecting the implant site, you are risking making it all of blow up with pain and an acute pulpitis of the tooth and a failure of the implant. Thank you all for your attention. I enjoyed having you today here at the course. And for all of our friends online, we’ll see you next time.