Placement and Restoration of a Bicon SHORT® Implant

This video will demonstrate the two stage surgical placement of a Bicon five by six millimeter ultrashort implant for a mandibular left second molar area and its restoration with an integrated abutment crown, IAC. Our demonstration begins with a clinical and radiographic examination. Radiographically, there is sufficient height of bone for the placement of our intended six millimeter ultrashort implant. Clinically, there is still a slight depression of the mucosa of the alveolar ridge where the buccal and lingual soft tissues have not completely become rounded, even after five years after the extraction of the tooth. Although the freeway space has been slightly encroached upon by the over eruption of the maxillary second molar, it is still adequate for the placement and fabrication of an implant restoration. Due to the difficult access, a non papilla sparing crestal incision is made. In order to allow for the full visibility of the crestal bone from the buccal flap, a silk retraction suture is used to hold the flap open. Since the intended implant is five millimeters in diameter, we shall initiate the pilot osteotomy eight millimeters distal to the first molar. This will provide a two or three millimeter space between the implant and the molar. Ideally, the pilot bur should be centered in the middle of the intended tooth with the same trajectory as the first molar. Initially, the pilot osteotomy will be made to a depth of only six millimeters. This will not only allow for change in the osteotomy’s trajectory, but also its positioning. The initial positioning of the osteotomy is confirmed by inserting a paralleling pin into the pilot osteotomy. Since the pilot osteotomy is too close to the first molar, the side cutting properties of the pilot bur will be employed to move the osteotomy distally. Because there is adequate depth of bone, the osteotomy is prepared to a depth of eight millimeters, thus avoiding the compromising effect of the sloping buccal plate, which often results in loss of buccal bone height as the osteotomy is widened. The paralleling pin confirms the appropriateness of the changed angulation of the osteotomy. The osteotomy is prepared sequentially with half millimeter wider latch reamers rotating at fifty RPMs without irrigation, which means a quarter of a millimeter of bone shaving is removed from the radius of the osteotomy with the use of each reamer. The latch reamers should be rotating prior to their being slowly inserted into the osteotomy. The parallel walls of the osteotomy will guide the latch reamers into position. Care must be taken to avoid displacement of the latch reamers by either a discrepancy in the height of the bone at the orifice of the osteotomy or by denser bone at one portion of the osteotomy. Once the parallel walls of the reamer are fully engaged, the clinician’s grip may be relaxed and the surgical preparation may proceed more quickly as increased apical pressure is applied. A curette is used to remove any bone chips from the osteotomy and to evaluate its floor and four walls. The removal of any bone debris is critical to assure the utilization of the full depth of the osteotomy. A depth gauge is used to confirm the final depth of the osteotomy prior to the insertion of the implant. The implant is transported to the osteotomy with a black healing plug and is then twisted and wiggled into position. The black healing plug is removed and a green three millimeter seating tip attached to an offset driver is inserted into the well of the implant prior to its being definitively seated with gentle taps. The cut healing plug is transported to the well of the implant on the tip of the periodontal probe. Harvested bone from the preparation of the osteotomy is placed over the implant and healing plug so that the healing plug is ever so slightly visible. The silk retraction suture is removed and a resorbable figure of eight suture is placed to close the flap. After three months of healing, the implant is uncovered with a crestal incision cutting mesially until contact with the molar is achieved. A second incision is made with a slight buccal orientation to avoid risking contact with the lingual nerve. An angle curette is used as a periosteal elevator to reflect the flap. Since the black healing plug is not visible, a number four round bur with copious irrigation is used to remove its overlying bone. Although the exposed healing plug could have been removed with a healing plug remover, a rongeur, or a C1 scaler, in this case, a #110 endodontic reamer is used. Integration is checked by placing a green three millimeter guide pin into the well of the osteotomy. Bone contouring over the implant is achieved by placing and rotating a green six point five millimeters sulcus reamer attached to a threaded knob onto the seated guide pin. This contouring facilitates the insertion of a corresponding 6.5mm abutment. A wide healing abutment is inserted into the implant with finger pressure to help contour the tissues prior to their being sutured. The white healing abutment is easily removed for the making of an implant level transfer impression by inserting a green three millimeter titanium impression post in its corresponding sleeve with only finger pressure into the well of the implant. Purple impression material is injected around the impression post and sleeve, and after two and a half minutes, the impression is removed containing only the green acrylic sleeve. To assure accuracy of the transfer impression, it is essential that the green titanium impression post remains in the well of the implant. The green titanium impression post is then removed for the insertion of the white healing abutment. After the laboratory fabrication of the integrated abutment crown, the IAC, the six point five millimeter wide healing abutment is removed with pliers for the initial insertion of the IAC. The well of the implant is cleaned with a cotton swab and the post of the IAC is cleaned with an alcohol wipe prior to its insertion. Initial seating is achieved with finger pressure prior to the evaluation of the interproximal contact with dental floss. More definitive seating is achieved by having the patient apply occlusal pressure onto a cotton swab. Since the interproximal contact is slightly too tight, it is relieved by the use of an abrasive strip prior to the IAC’s definitive seating with occlusal pressure. The occlusion is evaluated, and a slight sliding contact on the distal buccal cusp is relieved to complete the prosthetic IAC restoration.