Mandibular Ridge Split, Placement of Two Bicon SHORT® Implants in a Ridge Split and the Uncovering of Bicon SHORT® Implants Placed in Ridge Splits

We will be showing you the phases, all three phases of the ridge split procedure and implant placement in the mandibular arch. We will begin with the left side and we will open a full thickness flap. We will then, if possible, practical, and safe, we will show you where the location of the mental foramen is. We will then proceed to make these cuts. And then we will close this side and move on to the right side where the cuts have been made somewhat above the mental foramen, is right in this area, about three millimeters, and right at the top of the wide basal bone, which will receive the apices of the implants and give them primary stability. Our patient has been anesthetized and is patiently waiting. Okay, so you can see that the width of the bone is actually about as wide as the attached gingiva. Okay? I anticipate that we would be able to, to split the crestal maybe four or five millimeters, no more. And we will expose the crest completely. What you will see always when you’ve had a significant amount of atrophy of the crest is the very crest has a scar band, which in many patients is all they have to support a denture. And in this case, as we go distally, the crest actually widens pretty quickly. Okay? Right there is where the nerve emerges from the body of the mandible, okay? To make the crestal incision or the crest excuse me, the crestal cut actually, we will use a piezo surgery unit from Mectron. For the vertical cuts, we either will use the piezo surgery or a seven zero one burr on a contra angle, forty five degree contra angle handpiece. And we continue. Actually, this is a newer saw. It’s actually cutting very nicely. The secret to the piezo surgery is that you have to keep moving. You cannot stop. It overheats and it doesn’t cut and it may actually break down. So you have to keep moving. Okay. And as you can see, the cut is now roughly about a couple of millimeters deep posteriorly, and we’re moving that to the mesial now. So now you see if I I’m gonna suction away from it, and you see there is blood coming from the depth of the cut. That means that we’ve gone through the cortex. Okay? It is not as swift, but it does work. You just have to keep moving. And as you can see right now, I’m cutting right about against the flat part. And the anterior portion, I will move out. Don’t worry. Okay. So let me show you how you can make this cut with a we need some irrigation with a high speed and a thin bur. So all I wanna do is place the bur and sew it in and bring the cut up. Okay, see how simple it is? It is important when you’re retracting to keep in mind that the nerve, the mental nerve is there. So always retract away from it. And. I think the other saw was a little bit old, so it was either gonna break or but it wasn’t cutting. Certainly, it wasn’t cutting efficiently. So whatever happened, we’ve got it now covered. And again, you wanna make sure that the corner the corner bone is joined between the vertical and inferior and crestal cut. So all of the cortex in all directions has been severed or at least penetrated. So what I the only part that is a little iffy to me is the distal inferior part. Okay. And that’s it. We’ll irrigate it and then we’ll have the suture. Good. Okay, so we’ll take out the retraction suture. We will use it again for the other side if need be. Okay, don’t pull so much. Give me some slack. Good. So first you wanna make sure that you secure the edge the corner and then we will close it all up. Then we’ll use a continuous or actually, we’ll use a running suture here. Alright. Suction. This is the tedious but absolutely essential part of suturing so bear with me this won’t take too long. So as you see the mandibular left, you see the block that has been outlined. The distal cut was just about as long as the mesial cut. However, because of the angulation of the film, it looks pretty small. It looks pretty thin. And the anterior cut is exactly about two millimeters away from the tooth. That protects the tooth structure, and it ensures that our implants are about two millimeters away. The Bicon implant can be as little as a millimeter and a half away, or even a millimeter away from a tooth, or even less than a millimeter away from a cortex. The plan is to place two implants per side. Okay? And so today we will place two implants on the mandibular right. It’s a very thin tissue. And at this point, all I want is to feel the crest. Okay, and I actually can run my curette right in the crestal cut. And I’m going to slip out toward the lingual like so and just reflect the lingual. See how easy that is? And if you look closely, turn slightly to the left. Let me see if I can show you this guys. Alright. We can see the crestal split, the crestal cut. In this case, have very little clearance in the area of the bicuspid in terms of the presence of the mental foramen nerve. But the bone rectangle is so small that I just actually just by feeling it I was able to separate it just now. Okay. We’ll place our curved caudal chisel. It allows you to avoid the interference of the maxilla. And you can slide it until you reach the end of your vertical cut. Okay, it’s already split it. You can feel it move and you can hear it move as well. And in this case, because the crest was less than two millimeters or just about two millimeters for that matter, I have to make sure that it is out of the way completely and mobilized completely before we do anything in terms of implant placement. Okay. Okay. So I feel the bone moving, but it’s kinda bending. So there must be one little spot that is catching. The buccal plate is pretty thick. It’s pretty, you know, resistant and pretty strong that you can mistreat it a little bit. It will, you know, break off rather than break. And we can’t really go too hard here because we again have the mental foramen pretty close. It feels like it’s not offering, okay that’s it. So you see how the two split parts, this is the buccal and it’s right completely under the flap. See? Okay. Okay. My reamer is going straight down about a distance of six millimeters. Kinda hard to show you that. A pretty tight space. You’ll have to take my word. I’ll try to show you as you know, after I do every step. Okay? Suction it. And I have to aim slightly toward the lingual because of the mental. Good. Alright. Let’s take a paralleling pin. Good. That’s it. Okay? Okay, so I put my finger underneath and I feel that I’m bottoming out and I’m not touching my finger. Okay? And I’m at about eight so I don’t need much more than that. Good. K. Keep supporting. He’s okay. Keep retracting for me. Thank you. Okay, we have a nice floor. And as I’m coming up, I want to feel bone all the way. Maybe there is a step but there should be no void. A step is okay, a void is not. And nice thing about slow reaming is that it will find the path of least resistance and follow it, which in this case is the previously started osteotomy. Okay, we’re very close to the mental foramen and mental nerve, etcetera. Here’s our implant. And again one of the main reasons we are able to do these kind of procedures is because of the ultra short Bicon implants. And it went right in. So let’s see now what we have in terms of closure. The implant is designed to heal in a healthy blood clot and that’s exactly what we have here. And we will put a figure of eight to start it. Scissors. Very thin tissues so I’m trying to take bigger bites to try to bunch it up a little bit so we’ll have a better protection to our bone and implants. The key part here is to not lose the periodontal attachment, excuse me, the periosteal attachment to the buccal bone. Okay, any pain? Starting to or no? And so on the mandibular right, you will see that the bicuspid implant, the four by five, is actually within approximately a millimeter or two from the mental foramen, which right underneath it, right there. And the molar implant is well within the body of the mandible. The split part is just forming a bit of or it’s forming the top part of the actual crest, creating the favorable environment for the integration, as well as the long term survival and thriving of these implants. We will uncover both of these sides. And in fact, they look very similar to the case that we just placed with the difference that we had a little bit more width to work with on the side. So if you look at the mandibular right, there are two implants in the areas of the second bicuspid and first molar. In the mandibular left, There are three implants. One was placed shortly or immediately after the extraction of the first bicuspid. And the second bicuspid first molar implants were placed through a ridge split. So I’ll make a crestal incision to preserve some of the attached gingiva at the neck of these implants. This is the second bicuspid and this should be right there. The more actually we need to extend even more. Alright. So this ridge was about a little bit thinner or about as thin as the ridge that we just dealt with. And as you can see, the proof is right in front of your eyes. And I’m quoting a good friend is here who’s gonna be taking over in a minute, Doctor. Morgan, it’s seeing is believing. So here you are, you see it. There’s no question. The bone is actually cortical and it’s grown over the shoulder so much that it’s going to be difficult to even remove these black healing plugs. We will engage the center of the plug with this screw like device which will sorry got a lot of bone growing over it. It won’t come out. Here it is. Just lift it out like so. I personally prefer this one hundred ten reamer that engages, it’s easy to engage and it comes right off. We will now put this in. This is integrated. I’m moving the whole head. Okay, you can take a look. If this were not integrated, you will see the movement. This exaggerates any movement of even the minuscule, the minor most minor movement, they will exaggerate it. Okay? And on the second bi, again. Again, a crestal incision. I can feel it stepping over one by one. This seems that we have quite a bit of bone that I actually might have to drill out some of it. It’s just that it’s so much. Let’s take a look. This is an area that was so thin that we could not have placed even these four and a half millimeter implants without the split. And yet, look at now, we have too much bone, almost more bone that we need. And let me expose it completely for you. Right there. And that is all a testament, not only to the technique, but the way the implants work with the technique. So let me get under this bone in the anterior part and just peel it back. Okay? And we see the central part of that black plug. When it’s like this tight in there, what you do is just screw as you’re pushing down. Don’t try to pull it at the very beginning suction, please. Then what will happen is it will bottom right through it and will start kind of uncorking it, almost like a bottle of wine. And there it is. You can use a scaler or a root tip pick is my preference as surgeon, I guess. And you can just engage the side and lift it up. Okay? So we’ll take a sulcus reamer, maybe a five millimeter sulcus reamer with a short handle. And we will make sure that we’ve removed all interferences so that our abutments would heal would fit and sit and lock. One by one, put a suture or two if need be. In this case all I want to suture is the mesial area, the mesial papillae. And these are healing abutments. We will tap them in place. So this is how you would select these abutments. Whenever you’re doing healing abutments, go on the side of smaller. I will turn it over now. Again, we’re going to fast forward in time. The patient now gets to the restorative dentist. The restorative dentist now has the option of either placing final abutments or taking an implant level impression or placing a final abutment and taking abutment level impression all with a closed tray system. And after that, so to expedite things, I will show you how to suture the area. Good afternoon, my name is Vin Morgan. And we’ll pretend that these abutments have been in there either an hour or two weeks, it doesn’t matter. So I, as the restorative dentist, would simply remove them one, two, three, four, and five. So you simply put one, two, three impression post round pegs into round holes. And then you take the fifth and this pressure material sets in two and a half minutes. So, basically, in four minutes or five minutes, we’ve taken impression for five units. So in two and a half minutes, that’s it. So there it is, two and a half minutes. And voila, the sleeves have come out. And now the stealth shoulder abutment should be chosen so that the hemispherical base takes into consideration the soft tissue. You want the hemispherical shoulder right at or below the mucosa. You can always alter the the shoulder. Always place the flat surface toward the buccal. It just will help you orient these components in the future. But we have a vacuum press of, her teeth. We would slowly extrude this material. And we’ll make a strut if you will connecting the three. So you can see within ten minutes we can take an impression, an implant level impression, demonstrate a second impression technique, and begin to fabricate the temporary. Close please. And she’s closing. Just bite down that. That’ll give us our vertical, her own occlusion. We’ll add more here for bulk and strength. And if you avoid adding it to the cervical, you are not faced with a lot of trimming and polishing, etcetera. So there’s our cervical aspect, our occlusion. Now we can just add to this, make it look like a tooth if we wish, leave it as a block. But it just shows you the true flexibility. And Dr. Daher will now suture. I will try to bring the papilla together obviously. If we had that luxury where we could flatten the crest, then we wouldn’t have needed the ridge split. Because the whole problem is that we are limited as to how deep could we go by the presence of the mental nerve and foramen and by the mandibular canal. The other issue that I have, I’ve always had that with flattening. In other words, shaving the taking the top off of a thin crest is the fact that it creates a very unnatural step, especially when you have natural teeth. If you have natural teeth and you create this flat step, you know, a flat surface, you place an implant, and then you have a three or four or five millimeter rise, and then there is a periodontal ligament space and a tooth, it’s just it’s untenable, it’s unnatural, it will always create a weak spot for the teeth. As for trying to actually do a split and put a one stage non loading technique, that’s also very risky because you are exposing that bone to more permucosal or even more of the oral environment than you’ve bargained for, and will create some macro movement, which will cause loss of the buccal plate, which is now kind of dependent on its immobility to get new bone forming inside it. And then, finally, the and there are plenty of cases that we’ve done this way. In cases of the maxilla and some in the mandible, when we’ve done the ridge split and we’re able to stabilize the implants immediately and put them in function by tying them to stable structures, whether it be teeth or implants, we’ve done that with great success. So the whole issue is to create that space, widen the crest, place the implants, but make them and keep them immobile. So there’s nothing that says it has to be always a two stage. But if you choose to do it in any other way, I would choose the immediate function where the teeth are bound and bonded and stabilized with the adjacent structures. Yeah, if you break through it, make sure that you’re doing that very gently. And you treat it as an internal lift. The difficulty now becomes how do you stabilize the implant? Because you have the crestal part is open and basically not exerting any inward pressure. And then the floor is hollow. So hopefully you have at least two or three millimeters between the split bone and the floor of the sinus where your implant can actually lock into place. And we’ve done this routinely where, in some cases, we’ve done a concomitant sinus lift, internal sinus lift, and ridge split. In the area of the nasal floor, the same thing can take place. However, because of the ultra short implants, okay, we have had to use this very, very, very rarely. And the other thing about the nasal floor mucosa, it is a lot more vascular than the sinus mucosa, and it tends to bleed a lot. And so you have to be extra careful. And we use the nasal floor lift as an absolute last resort. Okay? But the same things will apply in terms of stabilization, in terms of how you deal with it, and so on. Okay? Try to avoid it. Okay? I actually didn’t mean for it to be as big, but it’s just so easy to reflect in some cases. Once you find that pocket underneath the periosteum, it just slides wide open. And so, the whole idea is I wanted to have all of the visibility be toward the lingual. I want all of the dissection to be toward the lingual. Whether it is a very small flap or not, it’s really inconsequential. It’s not that big a deal. Don’t be afraid of it if the flap opens up. Plus, it is so easy that periosteum lifts off so quickly that you sometimes can’t help it. It just opens right up. Make sure you just don’t leave anything fall into it, right? You don’t want a subperiosteal abscess. Just keep it clean, keep it neat, and you should have no problem. Thank you again and goodbye.