Placement of a 4.5 x 8.0mm Bicon SHORT® Implant

Good afternoon. We have a little over forty countries and over thirty five states. So the first molar has been recently extracted as you will see. We’ve just infiltrated the area. So if we look at this recent extraction site, alright, it’s granulating in slowly. This one, little divot is a site that is weak. If we were to incorporate this in a flap, this will be probably an interruption of the blood supply and cause the flap to necrose. So we will incorporate it in the incision rather than the flap. I have a 15C blade. With that we will be able to turn these tight corners negotiating these little creases and weak spots so that we don’t jeopardize our final placement. Make a little releasing incision on both mesial and distal lingual ends. And then I use a plain old curette as it is smaller And we can then lift the soft tissue. And if we need to, we will extend this releasing incision a little bit more. So we’ve protected the papillae. We’ve reflected our soft tissue. We have a full view of the crest. Now if this tissue keeps falling over, we can easily retract it with a retraction suture. But instead of suturing it to a side or the other, we’ll just dangle the instrument from it. What we can do using the Bicon pilot bur is first mark it. The bur itself, the drill itself is very sharp. So by just putting some pressure, we can start where we wanna start. And then we do a little bit of a spin and we can now evaluate where we are before we commit to anything. Then we’ll take a slight beginning of the osteotomy to roughly about four or five millimeters and we can evaluate that. Now the point here is not that our osteotomy is in the middle of the bone expanse, but rather is in the middle of the crown space between the distal contact point of the canine and the mesial contact point of the bicuspid. So we use a paralleling pin. Okay? And we’re able to see that we are indeed right there. Okay? Water. Now with the pilot drill, always use it, obviously you can see it’s at a higher speed than fifty rpm, it’s about eleven hundred, and use a pumping action in and out so that the irrigant can get in to lubricate. So we are roughly at about a depth of ten millimeters or so from the crest of the bone. Now we, again, will verify our trajectory. Again, these are the same markings. Suction. The reamers allow for the osteotomy to sort of guide you in because they are mostly a cylinder and so the actual bone will guide the reamer in to the correct course. The idea is you want to leave enough bone for the support of the papilla and you wanna leave at least two millimeters of bone from the adjacent teeth. There we’re going very slowly. Using the retraction suture limits the amount of trauma to the flap as we don’t have to find it all the time and retract and push it, etcetera. We are now roughly nine millimeters. This will bring us better? You feel that a little bit? Mm. Okay. It’s just toward the very end. I think you’re getting number every second. Now, notice the amount of bone coming out. This is type two bone. It’s dense, it’s pink, it’s filling the flutes. And I think with the mesial distal space being so tight, I think we get to four or four point five. We’re in great shape. Okay? Good. We are at about seven and this is eight. Felt that a little bit in the end again? Mm Okay. Notice this nice dense bone. Before I go to four, we will curette the area, make sure that we are not, in any jeopardy. Okay. Good. That’s four. And this would be the last size, the four point five millimeter. Okay. Great. Now we’re finally comfortable somewhat. And that’s it. Now the one thing that you wanna do is make sure that we have blood into the, osteotomy. You need the implant to be, even if the blood is extraneous, you need it to be inside a blood clot. We take our implant through the sterile packaging. We handle it only through the sterile package, comes in and we will then just cut the, bag, lift the implant out, grasp it, alright so the implant goes now, although this is not a screw type implant, it’s not threaded, but if you twist it back and forth, you’re able to get it past the rim of this osteotomy and any soft tissue or hard tissue flash that may be there. And sometimes it requires a little bit more convincing than just twisting in pressure and we’ll take an angled seating handle and we’ll tap it into place. So now you can hear that it bottomed out and we know where it is, so we’ll place this in there. We can squeeze it I suppose, here we are. So we cut it flush with the top of the bone. Alright. That will then create the marker that will allow us to see where the implant is as well as prevent the bone from healing inside the well. And yet there’s still a little bit of an edge that I don’t like to it, so I will just trim it down using the fifteen blade or the 15C as it were here. And we will shave it down. Alright? And the key is not to have it high, or so high as to, wear through the soft tissues. We’ll take our little bit of bone, I’ll take a gut suture again. We’ll pack some of that bone over the shoulder, we have a little too much bone here to be able to use all of it. But we’ll pack it over. That gives you a little added protection onto that nerve, excuse me, onto that implant. So we just go ahead and use a figure of eight suture. One. Okay. These two releasing incisions don’t need to be sutured individually They’re nicely closed Our patients are premedicated with, appropriate antibiotics. One gram of amoxicillin, if the patient is allergic to penicillin, they get, three hundred milligrams of clindamycin or two fifty milligrams of Biaxin. And post operatively, they get at least an additional day, and up to a week, depending on the patient and the location of the same antibiotic. The other medications that we give them is a pain management medication, usually non narcotic, such as ibuprofen six hundred milligrams, and finally, an antiseptic mouthwash, which they are instructed to use, more for swabbing the area as if they were brushing, but, a lot more gently, and that is with a cotton tipped applicator and chlorhexidine, rinse. The real key point here is if you feel it. Okay? The problem is if you don’t feel it and you destroy it, then you have a bigger problem. But if you have your index finger, as I always say, always put your index finger against the buccal, plate. And if you start feeling it give away, back up, stop, come back, and use expansion methods instead of reaming because that will then push that bone as it’s still attached and vital, and it’s still it’s vascularized because it’s attached to the periosteum, and then you can place your implant, you can put a bone graft, etcetera. It you will have no problem. If, however, you fail to recognize that you have a problem with the buccal plate until it’s too late and you’ve already destroyed it, then you have to make an assessment. How big is the fenestration or the dehiscence? Do you have a tear or a destruction of the periosteum? Do you need to control your graft with with a membrane? And those are all clinical decisions and questions that has to be answered before you can make the next step. However, if everything is being equal, this implant will, as I said before, will heal very well with healing bone graft around it, and you’re able to, to do the grafting technique at the same time if you can obtain, an atraumatic or tension free closure, and the full coverage with soft tissue. If you can dislodge the implant while removing it, I presume, well, let let me ask to clarify the question. If the implant, is integrated, and you’re removing the black healing plug, it’s a non issue, as long as you see the entirety of the black circle on the top. If, however, the question pertains to what I just did, and that is place the implant in there and then take out the black plug, cut it, or reposition it, or tap into it, and so on, well, that’s your ultimate test, isn’t it? And you can place that implant and engage it and then remove the black plug in there and keep the implant in its place. If the implant continues to move, then you have to stabilize it. And, we sometimes take it out. We will use an inserter-retriever, and again, I will refer you to our, other, webcast for those of you with us today, you will get to use that tomorrow during the, the hands on portion of the course. And that gives you a handle on the implant that then will allow you to lock the implant securely in place, no matter how dense or soft the bone is, and then you disengage it, leaving the implant intact in its place. So again, if you’re referring to the placement procedure, not the uncovering procedure, and your implant is moving when you’re removing the black plug, you should restabilize it. Okay? You should make sure it’s stabilized. Okay? Yes. We could we could have placed a healing abutment. However, the patient is a smoker. Remember what I said about smokers. Always in smokers placed as two stage. It’s a very good point. This would have been ideal for a one stage placement. We had solid bone. We had a solid, you know, five by eight millimeter short implant, which is also pretty sizable. Would have been ideal, however, extracting and placing one stage in a smoker is is kinda risky. It increases the failure rate about five to seven fold. And again, thank you all very much for your attention. Have a great day.