Internal Sinus Lift Variation: Floor Transport Technique

What we will try to do is distribute the force or the pressure of elevating the sinus membrane. Instead of doing that through a lateral window from the buccal surface of the alveolus, we’re gonna do it from the crest by using the actual floor of the sinus in a kind of floor rectangle fashion. And we will then slowly but surely elevate it so that it lifts up the membrane and leaving the sides of the alveolus to allow us to use friction to hold the buccal and palatal surface of the implant and stabilize it in place. We will still use a graft. What we will end up with, if you look at this X-ray, as a matter of fact, on the right side, the six by five point seven millimeter implant that appears to have a temporary abutment is actually placed with that technique. So we’re gonna do the left side with that same technique. The main reason we’re able to apply this technique in this situation is because of the use of the ultra short implants, six millimeter or shorter. Turn your face to me, please. Okay. And the incision, we will make to mimic a lateral sinus lift incision because it gives us visibility, but at the same time also gives us a sort of a backup plan. If we need to, for any reason, we can. How are you doing? We can expand this to become a lateral. It’s gonna have to be open this. What is your hand, please? It’s gonna have to be pretty wide because we need to see the whole crest. You don’t wanna make it so wide as to cause bleeding from the, branches of the greater palatine. Turn to me, please. All the way. All the way. I’m a big fan of doing curved incisions. They are easier to suture. Yeah. I’m gonna hear my that many times. Doctor next to me is shouting my head is in the picture. Forgive me. I always bring it back out. Okay? But I do have to see sometimes just like you do. Okay. Let me have the big mirror. Okay. Can we show them the incision? Okay. Can can you show them? Okay. You see the incision? We do. Great. Thank you. Thanks, Clive. Okay. Now to the easiest way to elevate these kind of flaps is to actually lever off your thumb. You’ll go and you wanna feel bone all along the incision, and then you will push with the left hand thumb, and it peels right off. Okay. This is an area where there had been an extraction not too long ago, so we’re gonna be able to protect and and lift it up a little bit of a tear here. It’s not a big deal. Here we are. Okay. Okay. Good. Okay. And let’s have the Seldin. What we will use then is a retraction suture, suction. Hold on please. Okay. We’ll make sure we free it all up. And you see the whole entirety of the crest. Let’s see what you see. You can see it pretty well this way, right? Okay. Good. Let’s have a suture. Now just to simplify my life a little bit, we will use a retraction suture whereby the flap is maintained open without our having to chase it all the time. And since there is a tear, I’m going to first protect that tear so it doesn’t propagate, and that is by putting a suture temporarily in there. Little details can can make a a case go a lot smoother. Hold this, please. Tissue forceps. Yeah. Thank you. You have it. Yeah. Thanks. Okay. We will remove this at the end of the case. Let go. Now retract, please. Okay. Like that. Suction the back, please. Doing great here. This is only so that this, this tear doesn’t get propagated, while we’re working just to protect it. How are doing Kathleen? Okay, good. Alrighty. This is the boring stuff, but it’s necessary for the smooth functioning of the technique. The goal here is to place one or two implants. Two preferably, one if the area is difficult to dissect and so on. That will give us certainly a second bicuspid occlusion. Alright. And we don’t want to keep you here all night while we’re placing two implants. And the suture, as you see, is just to the cheek mucosa. Now the flap is open as soon as the mouth is. Okay. And we’re just using a plain keep your eyes closed, hon. Silk suture, which is kinda kinda disposable. Alright. So now we’ll take another look. We will outline our rectangle. First, what I will do is just mark without making a perforation, but mark where I would like these implants to go. I am planning on using six x five point seven millimeter implants. And that will dictate the width of my turn your face to me, please. The width of my rectangle. Turn slightly more. Okay. Good. Open as wide as you can. Yes, please. Question was whether or not to use water. We’re gonna make a little mark here and a little mark here. The distal one, it’ll be ideal if we could get it both, get them both. As you see, it’s just the mark. No. I don’t need that. I’ll take the mirror, intraoral mirror, and we’ll show you where those two marks are. Suction on the mirror. Okay. Hold this, please. So this allows me a chance to critique my placement. K. Can you shine on the mirror, please? Get zoom in and a little bit more focus. It’s out of focus. Perio probe. I got it. Okay. Hold on. I’m not even stop moving it. Move a little bit. Okay. Okay. That’s fine, Nick. Okay. So this is the first suction it real quick. Right a few. Okay. This is the first perforation right there. This one here, and this is the second. Move it back a little bit, Drouse, so it focuses better. Can you see the little oh, hold on one moment. Okay. Here we are. Stop. No. So Yeah. That’s there. Okay. Alright. So is one and the other. So the rectangle has to encompass these two. Take a mallet, please. Thank you. So now, in order for us to do this, we will start with the mesial cut. And this is an osteotome that’s five millimeters wide. Now, if I make this excuse me, let me see what they see. If I make the stay there, I’ll move the chisel to you. The shorter cuts with this one, and then I make the longer ones inside these two, then I know that the width of my rectangle is not gonna be more than five millimeters. Okay? And so it goes. Turn a little bit to me. Okay. If you remember from the X-ray, the mesial and distal side are different in thickness. The mesial side is significantly thicker. Okay? The distal side, open as wide as you can. Here, it’s not as thick, so you’ve got to keep that in mind. Sorry about my hair, I can see it in there. Okay, Now, so I’ve made these two cuts. Now we’re going to make the connecting cuts between the two. And for that I’m going to keep turning the patient to us that way. Okay, good. Stay right there, Kathleen, please. Thank you. Suction this way. Okay. Here we are. And this is gonna go right in here. Now these are, by by the way, the same osteotomes that we use for maxillary ridge splits. You can get fancier ones, but I think these work the best. They are sharp and available. The bone in this in the mesial area is softer because this is, an area that had had a recent extraction. So the healing isn’t complete. Try not to punch the patient when you’re doing that. And you stand behind her. It’s better, please. So what we’re doing is Carrie, our circulator assistant, is bracing the facial skeleton. Okay? Basically at the nose bridge, at the frontonasal suture, if you apply pressure at a forty five degree angle to the face, you are dampening these blows. You read in the literature about, knocking off some calcifications off of the inner ear. So on by doing this, you limit the amount of vibration transmitted to the skull and the skull contents, including the inner and middle ears. Okay. I just wanna make sure that these cuts are complete. And you can feel it really. And always err on the side of shallower because the idea is the bone, when it’s scored, will fracture. In there, you don’t need to cut it all the way because you risk cutting the membrane. Okay? Kathleen, how are doing here? Good. We’re gonna go over it a few times. You know, the bone is never of uniform thickness. The X-ray gives you, you know, one dimension. Even if you have a CT scan, it’s still gonna depend on where you end up connecting with that bone. Suction. And that can vary by, you know, within a millimeter, you’ll have a much thicker area or harder area, which a CT will not control for you. Okay. So now we will show you a picture of this rectangle in a minute. Alright. And also, incidentally, you know the markings on your osteotomes are at six and eight millimeters. So by staying within about the middle of the distance, it’s about three millimeters, which is the thickness and the thickest part in there. Now, we’re gonna go to elevating this floor, and that’s by completing the fracture. For that, we will use the sinus osteotomes that are available in the Bicon kit. We start with three point five or two point five or four, whatever fits best within the confines of that rectangle. Let’s show you the rectangle. A small mirror, please. Okay. Don’t suction it too much. Alright. Can you see it? Very good. Yes. We can see that. We can see that beautifully. Thank you. Okay. Very well. We’ll continue then. So the first area where you wanna concentrate is the area that’s hardest to fracture. Which one would you guess that would be? Yes. The mesial one. So we start there, and all we do is just tap on it. The idea is you’re going to mobilize it slowly, and if it doesn’t move, you can feel the resonance of it. Yeah. Might need you to turn your head a little bit. It’s an osteotome. Oh, okay. I’m told that the osteotome is a chisel in the catalog. Okay. Turn slightly to me. Okay. Great. Is it Can you see me okay? Good. Yes. We can see. Thank you. So can I? So the name of the game here as I repeat usually is patience. This is the the time where you really have to exert all the patience that you were given and then some. Because what we’re doing, we scored that bone, now we we’re gonna fracture it and carry the membrane up with it. This part, our patient did not like the last time, and it caused her to feel a little bit syncopal, so we preempted this time and made her sedated. Right, Kathleen? In fact, the very first case I did was without any scoring with the chisels. What I want to do is I think we have a little binding area in the in the corners. I’m gonna use a smaller chisel, the three millimeter chisel, and go into the corners. Those are the hardest to cut. And just kinda make sure that the cut is complete. Okay? So we’re not doing the work twice, just completing what we started. Okay. Alright. That’s good here. Make sure this is here. When we move too much, when it’s zoomed this much, it it gets in and out of focus. So if you find the movement is too much, avert your eyes so you don’t get motion sickness. Unless Clive is providing you with Dramamine. Dramamine. Yes. And immediately as as soon as we we freed up the corners, I feel a little bit more movement now and a lot of tapping with this with this technique. Okay. We’re moving already. You can feel or maybe you can see how that is starting to sort of fall in to the sinus. You probably see it better than I can. So now I’m gonna switch to a wider one, the four millimeters. Sorry, thank you. You okay? Good. We’re gonna continue that. Now it’s a four millimeter osteotome. And the idea, you have to do it very slowly because this time elapsing between the initial mobilization and the completion of the elevation allows for a tiny amount of swelling to infiltrate the adventitia of the sinus mucosal lining, thereby allowing you to lift it up a little bit easily. I switched to a smaller one only because this corner didn’t free up and I don’t want to use regular chisels just to mobilize it like that. This kind of technique allows you to really free up a lot of your stress. You use a lot of hammering and makes dentistry a lot more enjoyable, don’t you think? Give me a hammer any day, right? We’ll go back to the wide one. As you all can see now, that window has mobilized. Floor does not need to be completely jolly and flat and happy as long as it moves where I want it to move. Before I continue, since we’ve completed that, I just want to make sure that the membrane here is still intact. This is a regular sinus lift curette. I’m going to make sure that this is freed up, no hold ups and hang ups and so on. That allows us to sort of hug the floor of the sinus, mobilizing everything. Okay. We’re gonna free it up some more in there, push it in some more. I wanna get the distal part freed up and and cleaned up, and that’s exactly what just happened. So as you see, this is very similar to what a window would look like, only on the crest. Okay? Is everyone with me? I hope. Yes. We are. Alright. Nobody fell asleep yet, Clive? About three quarters of the audience. Okay. Well, good. That’s better than being nauseous and throwing up, you know. Okay. So we’ve mobilized the membrane. I just deliberately will slow down now just to make sure that we are not forcing it too much. We mobilized the rectangle, the floor so to speak, suction right on my instrument. And the idea is we want to make sure that this mesial or anterior aspect is freed. Okay? So now, you don’t have to worry too much about it if you don’t have the time. But it is always a good practice to lift it up as much as possible, then completing your osteotomy and quickly going from osteotomy to sinus graft to implant. And I like to use the little gentle tapping. It’s better than pushing it, although there’s nothing to fracture now. I’m just elevating the membrane, really. Okay? So now we’re finished with this part. What I would like to do now to dissipate the force is to finish up the osteotomy and then push the rest of the membrane while having the graft in place. How do we finish it up? Obviously, by hand. As you saw, I’ve already been able to use the four millimeter osteotome. So there’s no need for me to ream the four millimeter again. I’m going go straight up to the four and a half. And and even that is nice and thin. We try that. We can go to the five. And for that, we could even use the dilators or site expanders. I will try it with the reamer. Again, that’s pretty wide, nice and wide here. And we’ll go to five and a half expander. Okay? It’s like a bullet shape. And again, with mallet, now this is gonna snag a little bit, not too much, enough for us to do this. Okay. And then for the second one. Remember, most of the holding for the implant is going to be from that rim and the side of the alveolus. So I wanna make sure we use that. Okay. Again, a little bit of hammer use does the body good. Right? Absolutely. We finalize it with a combination of hand reamers and expanders. The idea is I don’t wanna have dead, crushed bone, but at the same time, I don’t wanna cut away, anything if I can use it. So I’ll just do the very top of that osteotomy. Okay? And then I will dilate the rest or expand the rest. I use the term dilate and expand interchangeably. For the purest, they may not like that, but to me, they mean the same thing. Okay. So this is the six millimeters. So you I can feel the friction. So the idea is now to to keep the implant in an area where there is friction, and it will stay immobile. Okay? And same in the mesial part. And we’re almost finished with yes, sir. Shadi, the first line on the instrument, on the end of the instrument, six millimeters or eight millimeters? All the all of the Bicon can you zoom in? Can you focus on it? All of the instruments in Bicon’s kit are consistent, and that the first line should be six, second, eight, third, eleven, and the third, fourth is fourteen. Okay? So it’s always consistent. The chisels are the same way. The dilators are the same way. The hand reamers, latch, you name it. All of them have these lines. The only exception the only exception is the shouldered abutment depth gauge. But that is relative to the to the abutments, not to the implants. So now we have finished. Thank you. We have finished with the preparation. What we will do now is place the sinus graft and place the implants and be finished. No suction in the area. Okay? And that’s it. I’ll take a gram of fine. Okay? Any questions from the audience? We’re going to use synthographed fine. You can mix coarse. You can mix it with fine. The idea is Any questions? Yes, we have one question here. Yes? Would you consider using the new piezo surgery unit as a way of cutting the bone? It doesn’t give me the tactile sensation. I can, you know, I can score the bone with it. Yes. And I considered having it you know, I would consider consider it to thin for thinning out the bone. But I think it has some technical challenges that I haven’t worked out yet. Is there a question or a demonstration? We have another question. Yes? I’m going to take Hi, Shadi. It’s John Yes? John in England. If you come across a buttress there, either with that or if you perforate the membrane, what would you do in this situation? I’m sorry. Would you repeat your question? I missed the first part. If you come across a buttress in the sinus The buttress? On that floor there. A buttress. Sinus buttress. Yes. Or if you perforate the membrane, what would you do then with this technique? Okay. We have everything ready here. We have SurgiCel. We have if you look on the website, we actually one of the first cases, we cut the membrane on one corner inadvertently, and we sealed it with just a collagen type of containment device, collagen tape, if you will, collar tape, or surgicel. So like Or Biomed. Yeah. Biomed might linger on too long. Just move the mouse. It may linger on for too long, you don’t need it. All you need is a containment your graph, just much as you would do in a sinus lift, you see? Thank you. Five, six point five, point seven, please. Any other questions? Yes, who else? Hi, Shadi. Just wondering, what if that bone is very thin, the floor of the sinus? Does that matter? You have to choose the case where you can reach the walls with your window. So if your floor is so wide as to be far away from the palatal and buccal plates, okay? Then your sinus, your implant won’t have the primary stability necessary for that. We have another abutment in development right now that will overcome that. At this point, I will use this technique when I can have friction against the buccal and palatal walls, so that the implant is immobilized thusly. When you don’t have like you said, it’s very thin, very wide, very flat, you need to have another means of stabilizing it. And I have an abutment in development right now. Does that answer your question? Yes, it does. I’ll need the inserter-retriever and the two abutments. I’m just getting ready as you’re asking your questions, if you don’t mind. Okay. Very well. Let me place those implants and suture, and then we can take our time answering all of them. How are you doing? Patient is sleeping, so you can ask as much as you want. Yeah. There’s a quiz at the end. Do know? On this? Oh, I don’t. Okay. So, again, much like an internal lift, you will place your bone graft can we back go back to the mouth? Okay. Good. Right. We’ll place the bone graft first and use that to mobilize the membrane. Okay? So I was just told that for some of you who don’t have the new Can you turn down the phone for me? For those of you who don’t have the new white kits that are full, you may not have these dilators in your kit. So I apologize for any confusion. You may not have them. You won’t need too much graft, but put as much as you can compress gently. Okay. I’m using a stainless steel syringe and we’re using, as I said, synthographed fine. Turn your face slightly to me. And the idea is, as you see now, as I’m pushing in material, it’s kind of oozing out. So I know I’m almost at capacity. But what will happen now, when we place our implants, the implants will apply pressure against all of the particles, rather than just against the floor and the membrane. This, by putting the graft in, will reduce the excuse me, will will dissipate the the pressure and allow for more elevation of the sinus. Take this. Take a gauze, please. When it’s a little bit drier, it’ll be a little bit more compact. So to dry it out, as you all know, use a little gauze on the suction. I will suction up the liquid, leave the particles in there for us. So I’m gonna use an inserter-retriever with a six by five point seven millimeter implant, coated. And you most often with this technique will need to go to the very wide implants because that is sometimes what it takes to get to the undisturbed buccal and palatal plates. Okay? So, again, although we could force this by hand, it’s better to use the the gentle tapping with the mallet to seat it because this, although it sounds not very pleasant, is actually a lot gentler on the tissue and advances a lot more kind of conservatively. Now I stop about a millimeter short and then watch where you are. Okay. Can you open wider, Kathy? There we go. Good. That’s okay. We’ll just leave the implant in there. Then let me put the other implant in. We’ll put the mesial one, then we’ll put two abutments, tap them in place, and finish up. And actually, this is the first time we do this case under sedation, because we wanted to entice the patient to come and wait for us for a while while we get everything worked out with you guys. But most often these cases are done in about twenty minutes to half an hour, and there is no need for sedation. Turn your face to me a little bit. I thought you were laughing at my joke, even though you were saying my head is in the way. So I’m feeling resistance. That’s always a good thing. By putting the abutment on now, that will act as a nail head. And put that on, please. Let me have this. Okay. Now we’re almost there. I’m gonna need just a little bit more graft. No. No. No. Right here. It’s plenty. Okay. I just need you to fill up. Just pull it up back about half an inch. Okay. Good. Now the for those of you who’ve used the the sinus lift abutment, it was designed specifically to have sort of an oblong shape. And you can choose which way to place it based on the anatomy of the flap, the bone, and the area where it needs to work. In this case, I’m gonna put it with the longer part, mesial excuse me, buccal palatally because that will catch the edges of my osteotomy. It also it don’t swallow it. You can use the the And that will allow us to then seat the implant fully with the abutment. Let’s have the second one. Thank you. If you were to put it the other way, it may not catch because of the rectangle that you’ve cut. Okay? So we’re almost there. Everyone see okay? Now, we take the there’s a notch in in the center of these abutments that’s made specifically to fit the three and a half millimeter or three millimeter seating nib or point, and that we will tap it to full seating now. Turn slightly to me. I need see where that goes. Those will be a little bit at some angle because of the mesial cut is always angled. And you wanna sseat it at the floor as much as possible. Let me see it better this way. Let’s see it better this way. Here we go. That’s one. Open wider. Okay. Back. They need to have minimal amount of stability. They don’t have to be rigid. Because now, we’ll seat them at the bottom. Here we go. Good. Now we’ll bond the whole lot with bone graft in between. K. Let me have the shoulder depth gauge. This works very well as a condenser. We’ll pack them in between. Okay? And don’t worry about this slight movement in a little bit once it’s all wedged together with a blood clot. This does not move at all. We’ve done this all the time. Need the mirror, just want to see the back of it. Make sure that the shoulder is covered. Yep. So here’s what we’ll put, some more bone in the back. Now, take scissors. It’s going to be bone, I’m taking the liberty. It’s not bone. Dr. Morgan made a point. It is SynthoGraft, that’s correct. We’re going to remove the sutures now, and I’ll take a gut suture. And that’s it. So before I suture, however, we will hold on. Compress everything. Okay. I wanna make sure that we didn’t overfill it, that there are no points of pressure on that. And then the idea is you wanna close it as gently as possible. Okay. Seldin. Wait. Wait. Okay. Okay, any questions now? Yes, Shadi. There’s one question from Hold on one moment. Five, please. I can’t hear you. One second. Go ahead, please. The one question from the floor is that could you do this between, for example, a second premolar and a second molar? If there was a second molar, can you do it in the first molar region? It’ll just be a smaller window. You won’t have as much latitude. It is very difficult to do this for one tooth if you are limited by the adjacent teeth. In other words, if you only have, like, one molar missing well, how do you answer that? If you have one molar missing, okay, it’ll be a little bit more difficult. You just would go to a regular internal lift, but you can do it. The idea is you need to have a an area to access, and you need just to be able to see your osteotomes and how they’re cutting in there. I just for the for those of you who are watching, the the needle actually cut the suture. That’s why I’m tying again. So yes. Does that answer the question? Yes, it does. Thank you very much. Any other questions? Here we go. Janet, can I? A question about does it set? It does not set. This is not Capset, this is not calcium phosphate. It does not set. But a blood clot does, and this is imbibed only in blood. And by the time this x-ray is taken, you will have a nice congealed clot with the synthograph nicely embedded within it. I notice in the little manual on synthograph, they’re talking about a venous blood draw and mixing that with synthograph? Which is exactly what we did, I just didn’t let you see that, not to scare you. You don’t to do a venous blood draw, the idea is you need to get blood. So if it takes to you know, it takes you to draw blood to get it, that’s fine. Remember, we started the sedation. So when I started the intravenous catheter, I just drew about a cc of blood and left it on the side. And when we needed it, we just used the clot from there. Thank you. Another question Alternatively, you can use the incision itself in the mouth, okay? You may have to stir it up a little bit and get some of the bleeding from that area. For those of us, you know, like our Roman friends, who are afraid of drawing blood, this is a very good way to do it. Is that actually Doctor. Hi, Sherri. Yes, who’s this? This is Michael Wood from London. Hello, Hi. Presumably, what you want is quite quick bone turnover and osteogenesis in this area. And we know that tricalcium phosphate turns over in about nine to fifteen months. Wouldn’t irradiated bone be a better proposition in this area? Well, that’s assuming that the only thing you’re going to heal with is bone turnover of your graft. You will also have bone formation by the the presence of the blood. So it’s not just the the the beta tricalcium phosphate. And I think the information you have maybe a slightly may not apply completely to the Bicon synthograph because the turnover is a little bit faster than that. And I don’t think that will make a significant clinical difference. Shadi, I’m going to ask Bill Schafer to have a word. I trust he’s impressed as impressed as I have been. Hi, Shadi. Very smoothly done. I’m very well. Thank you. Why did you use coated implants instead of the nanotype that you have available over there? You know what? That’s a very good question. I’ve I’ve used both, and they work. I just wait longer for both when you’ve had done a big graft. I my experience with has been it’s longer, and I it’s more of a habit that I ask for it, but they would both work. Anyone else want to? Do you have a Okay. Question at the other side of the auditorium, Shadi? I’m just going around there. We we are gonna quickly as we are answering the question, we’re gonna quickly take a periapical X-ray. And if the patient is able to walk, we’ll get a Panorex very in short order. But at least we’ll get an X-ray to show you what we’ve done. At least I’d like to see what I did. Right? Shadi? Yes, sir. What’s your rate of infection with this technique? Don’t even talk about it. We haven’t had an infection in years with any sinus lifts, much less with this technique. So I’d like to thank slim to none. The patient is premedicated, and they are placed on an antibiotic for a minimum of five days. Okay? I’ll show you me have the small mirror. So it’s I think it’s equivalent to any to any oral surgery from wisdom teeth and on. Let me have the Seldin, please. Okay. Any antibiotic with the graft material? No, I don’t. The Let’s have can we show the the inside? We don’t we don’t mix an antibiotic with it. The synthograph itself has a bacteriostatic effect. Can you show the open wider Good. Can you see the closure? Sorry. I moved my fingers. Okay. I’ll remove that silk suture now that we have it secured. Alright. So we don’t mix sometimes I have in the past, whenever I’ve used the, you know, the the bovine origin allografts, I’ve used a smidgen, you know, a seasoning of tetracycline, if you will. But with degree of can you retract for me, please? With the degree of acidity of the tetracycline with the beta tricalcium phosphate, we were advised by the inventor that it may alter its composition and make it resorb fast too fast, so we stop putting that in. Okay. Just gonna remove that. Thank you. Sure. That suture. That’s all. Okay. Good. All set. Any questions? Well, let’s go ahead and take… Another another question another question here. You used Marcaine. What what what percentage was Marcaine of the anesthetic? Only because we’re working with you, I didn’t know how quickly you guys would grasp the concept. We needed longer acting anesthetic and the Marcaine, half a percent Hey, you walked into it, I’m sorry. It’s 0.5% with 1:200,000 epinephrine. Hi, Shadi. Are there any circumstances where you would use membrane over the graft? I don’t like using I don’t you like using membranes under incisions unless I absolutely must. In this case, we had an intact periosteum. There was no need for us to do any membrane. Why don’t you like the membrane under the incision line? It’s a weak spot in the area. It prevents the blood supply in the area, and I’ve seen a little more incision breakdowns when there’s a membrane underneath then I care. You know? So I don’t like putting incision membranes under incisions unless there is a compelling reason. And then we will have to spend time immobilizing it with tacks and/or stay or retention sutures. Bite down there. How are feeling? Does that answer your question? It’s a matter of preference, but I think it’s unnecessary. And the other thing that was notable was the curved incision line. And that goes throughout your surgery for placing Bicon implants, I mean on a regular basis. It is. The curved incision lines, as you saw, basically the hardest part in making the straight line incisions, you know, H type or square type trapdoor incisions, is the corner. And you end up always overshooting those corners in order for you to cut those last few fibers. That can cause a weak spot at the corner, which can necrose. It can also overshoot, kind of across the palate and hold on, just give it a minute. And across the palate, you will see the we’ll show you the X-ray now in a minute, and you can have some serious bleeding happening. Okay? Hold on. Let me just do the X-ray for a minute. Okay, sorry. So by using a curved incision, it’s easier to show excuse me, to close it. It’s easier to also open it. Okay? We’re going to show you the X-ray now. Here it is. The only thing that we would change would probably make the window slightly more mesial. But at this point, those two will serve very well with the angulation of the mesial implant. We’ll be able to replace these missing teeth. Okay? We’re not complaining in London. Thank you. How long are you long are you going to leave this before the second stage? Four to five months. No less than four and more than five is not going to make much of a difference. That looks very fine, Shadi. That has been a very, very impressive demonstration, if I may say so. Thank you. Vin, I think we need to wrap this up now. I just want to say a very big thank you to you and to all your Bicon team for having put on this amazing performance. It is just quite fantastic that we are talking in real time and watching surgery in Boston real time. And it does mean there’s a lot of educational opportunity for the rest of the Bicon family worldwide to tune in for the future. And thank you very much for allowing us to be the first to receive this. You’re entirely welcome, the credit goes to other people.