Placement of a 5.0 x 6.0mm Bicon SHORT® Implant

Welcome to the Bicon webcast. Today is Thursday, January twenty eight, twenty ten. Welcome all of you who are watching us. We have several hundred. We have fifty five countries and I think somewhere in the neighborhood of thirty states with us. Today, the first case will be extraction and placement of the maxillary right, second bicuspid, which is carious. If we need to, we can go to a five millimeter long, five millimeter wide implant. Otherwise, we would place a six millimeter long implant. The idea is this extraction should be atraumatic and the placement should be relatively simple. So I’m going to move to the other room where the patient has been waiting patiently for us to start. Now, as we are removing this tooth that has been decayed and fractured for some time, I’m gonna freshen up the edges of the soft tissue around it using a fifteen blade. Atraumatic extraction is paramount in this technique, and for that, we will use periotomes, a straight periotome that will allow us to go all around the periodontal ligament, sever as much of it as possible, and continue to loosen this this root. For atraumatic extraction, it’s always, better to use thin instruments that allow us to get around the surface of the root and between the root and the bone without wedging against any particular part, too much, too or too hard. In this case, we are using a luxator. In this case, we are just carving, making sure that the entire root is mobilized. And okay. Now that’s okay. So as you saw, the tooth was ready to leave. It jumped right out. It is important to remove as much as possible of the remnants of the periodontal ligament by curetting the surface of the bone thoroughly. This will also give you a way of assessing or a means of assessing where the bone thickness lies. In this case, we know with the orientation of teeth that the roots come out toward the buccal plate more than toward the palatal plate. And by, using sort of a bidigital palpation, but one finger is replaced with the curette, you’re able to assess to an extent how much bone you have. We will irrigate and clean out the socket. In this case, we’re using sterile water. Now we don’t need to make any penetration into the floor. This is the floor of the osteotomy. If you recall from the radiograph, we have less than a millimeter left under the sinus floor. However, we if we were to start right at the depth of this, socket, we will end up being way too close to the buccal plate, and that will with the use of the reamers at a very slow speed, will create an unfavorable, amount of pressure, excessive, that will then, lead to the fracture of the buccal plate at the depth of the vestibule and jeopardize the health and the survival of the implant. So all we wanna do is reorient our depth toward the palatal slope of the socket, and we will go only to a depth equal to the depth of the socket. We will try to now use the, paralleling pin, and and that’s where it stands. Okay? So as you see, this is the the latch reamer. It’s rotating at a very slow speed. It’s at, fifty RPM at the most, And we can slow it down to rotate slower, of course. So when we are using this, because it’s such a slow speed, we need no irrigation. We can then expand the first osteotomy that we laid in. And the depth from the edge of the soft tissues is roughly eight millimeters. Now we will, in sequence, go in point five millimeter increments from two point five, which is the one I just used, all the way up to the final size, which is five millimeters. And this is a three millimeter latch reamer. Again, it goes in the same more parallel, palatal direction. And as you know, when we are reaming at such a slow speed and with no irrigation, it’s almost like shaving the bone. And that allows us to harvest the bone. And as you see, some of it is already coming out on these reamers and this is now the three point five millimeter reamer. These markings start, the first one are, we have two bands. The first one starts at six and ends eight and the second one starts at eleven and ends at fourteen. In this case, we will, finish every osteotomy with the top of the first band at the edge of the free gingival margin, thereby placing the osteotomy at a total of about eight millimeters from the edge of the soft tissue. K. You see it again. Also, the bands are, outlined with, grooves etched into the body of the reamer. This is the four millimeter reamer. Incidentally, the Bicon implant was the first implant that had a root form design and therefore the reamers, which correspond to the size of it, excuse me, the shape and size of the implant, have that kind of tapered root form appearance. Now we’re getting to the near nearing the final size where all of the sides of the osteotomy are starting to get involved and get reamed in this process and so we have to be very careful. And as you see there is a little bit of wobble but it’s not excessive and it certainly is within tolerance. So we are. Okay? So to finish it up, to have even more control, I will switch to a hand reamer. They give you a lot more, control. They cut on only one side as opposed to the latch reamers, which cut on two sides. Okay? So it also has markings, but instead of bands, in addition to the grooves, this one happened to not have the bands, but all of the the Bicon implants will eventually have, excuse me, these instrumentation will eventually have these reamers with the bands on them. Before we go to the final size, it is always good practice to use a curette and palpate and examine all of the walls and the floor of the osteotomy, collect any bone that may have been shaved but not removed, not collected. And make sure that we still have a floor of course, a palatal wall, distal, and a mesial wall. K. Open wider, please, if you can. That’s great. Don’t move now, please. Okay. So we are just at about six millimeters. We are now at roughly about in a couple of twists, we should be at about eight. We will take our curette and we want to make sure that we have a floor and we do. What I will do is check first the edge of the bone from the soft tissue and it’s about three millimeters. Then from there we will feel the floor of the sinus as we had left it or the floor of the osteotomy and it’s roughly at about eight millimeters again. So what we will now, use is a five millimeter implant. So the Bicon implant is supplied in a doubly sterile pouch. So when handling the Bicon implant, never touch it except through the plastic and allow it only to touch the bone where of its host site. The black part is a handle and a healing plug attached together which is made of a polyethylene and it’s cut to the level of the crest of the bone. In this case it will be right about flush with the top of the implant. So what we expect to do here is to place this implant, but to have good control since we are very close to the sinus, I will swap the black plug with this inserter retriever. The inserter retriever is made of titanium and it’s also color coded appropriately and it fits, its thinnest part at the very tip, fits inside the well of the implant and the same mechanism as the abutment would attach to the implant and that is the locking taper. Once we’ve engaged the two together, they become relatively tight, not as tight, and permanent as the implant to abutment, but tight enough for us to be able to insert, modify, move, retrieve the implant if need be. And the way we do that is by by holding the implant through the bag, then cutting slightly around it, moving the plug out, retrieving it, securing it somewhere, because we will use it in a little bit. Then we take the inserter-retriever and simply push the two together. Now we have a big handle on a small implant. And we go and place this implant into the osteotomy. The markings on the inserter-retriever correspond to the two and three millimeter depths. And because this is a friction fit implant, can actually tap it into place. Can I have a surgical mallet? You don’t want to tap too hard because although we left the floor, but that floor is pretty thin, we may mobilize it a little bit too much. And now the implant is roughly at about three millimeters or so from the crest of the soft tissue, which should put it right within the the crest itself. I will always check the location of the implant before I seal it into place. You see that we are right in the middle of the space. Okay. That’s good. All right. On this plug, if you look closely, there’s a little bit of a dull ring. That is the mark of where the implant actually touches or ends relative to this plug. So we will cut right above that mark, thereby creating a seal that is right over, the top of the implant and at the crest of the bone. Then we will take a periodontal probe, and that goes into the hole that’s inside the black healing plug. And then we place the plug inside the implant. That prevents bone from growing inside the well, and we will take the little bit of bone that we harvested from the socket itself to cover the shoulder of the implant, creating another layer to protect the implant from the oral environment. And with that, bit of bone acting as not just a little bit of bone graft, but rather really as an additional layer for protection of that implant. And the collagen plug, we’ll plug that in to the area to cover it. What we are looking to achieve is just enough control of the clot and of the bone to allow for the healing by secondary intention from the surrounding soft tissues to take place. And the closure is then, achieved with, a four o chromic gut on a, FS2 or a PS2 needle, reverse cutting, a traumatic. I use a crossed over horizontal mattress suture. By using this type of a suture also, we’re lifting the scar from the suturing itself outside of the aesthetic zone. As you can see, the implant is just within about a millimeter of, the crest of the bone, or less, actually. Okay? And that’s exactly what we intended. Yes, we would be concerned, in fact, just the patient before this case we actually did not place the implant because the periapical infection was, pretty, marked. In this case, there was a little bit of space, a little periapical radiolucency, but as we curetted the area, I did not see that there was any soft tissue, any periapical scar, or any periapical parulis or anything like that. So if it were infected truly so or even symptomatic, we wouldn’t have. The protocol was basically, as you saw on the radiograph, we calibrate the radiograph and after a clinical exam that tells us that the width is acceptable, then using the, electronic templates that are included in the software, we try to overlay the best fit implant. And seeing that we have adequate depth to place implants that are five or six millimeter in length that’s adequate. We don’t need to use anything longer. Thickness, minimum thickness of bone to have osseointegration of the Bicon implant when you’re placing it, the buccal plate or, the palatal plate or lingual plates need to be a minimum of one millimeter As long as you have bone that’s, healthy, you should be able to place the implant and expect integration Well, to put it in perspective, when we talk about long implant in the Bicon system, it’s an eight millimeter implant, which for everybody else is a short implant. And the long and short of it is, we don’t need to use anything longer. If it works in this compromised bone, if it works in this situation where, we have you know, relatively, very, very little amount of bone, we have about five or six millimeters of native bone, why wouldn’t it work in any other type of bone? As a matter of fact, the next case, that we have scheduled, the one where we will be uncovering an implant, you will see that there was adequate bone for placement of an eight or even a longer, implant and yet we are very happy and successful with the six millimeter long implant. What can happen if you have the implant so close to the oral environment is that the saliva can wash off all of the little bit of blood and if you have any infective, agents or a patient who is a little bit, with a very active, curious tongue, etcetera, you may get permucosal loading, you may get, food debris plaque and so on around the implant. So I personally either would seal the socket with an abutment, make it a one stage non loading technique, or seal the mouth of the osteotomy and the socket with a collagen plug. Patient is ready, it will be the uncovering you had at the time of the extraction that may indicate that you have loss of the periosteum If you have loss of periosteum, really should address that before, you should isolate that tissue away from, the implant and the bone graft So for that you will either choose, and my personal choice would be to not place the implant at the same time, to actually use a barrier membrane, graft, site prep the area, and then place the implant. Now, on a delayed basis, okay? If you however have a perforation that’s more because of mechanical, manipulation of the area, and let’s face it, we have, buccal walls in the maxilla, especially, where the bone is so exceedingly thin that a little bit of curettage would remove that bone. If you’ve done that and you are reasonably assured that the periosteum is still intact, then I usually proceed and place the implant. In that case, I may, pack a little bit of bone, around. If the extraction is traumatic, you don’t, you know, you had to drill, you had to section the tooth, you don’t know how clean and how, healthy the bone, is, then my tendency would be to, at the very least, do a delayed immediate in which the implant is placed six to eight weeks after the extraction. Now, if we had, you know, sort of significant amount of bone destruction, and need for remodeling necessary, we have, you know, we may have a need for, grafting, etcetera. So what would tell you is, whenever you’ve used a rotary instrument, whenever you’ve removed bone, then at the very least, consider delayed immediate. And by delayed immediate I mean wait enough for the bone to sort of start healing itself, phagocytize all of those debris and stuff that didn’t heal and then place the implant subsequently If, you know, you’ve done a significant amount of bone removal, sometimes these are ankylosed or what not and you do have to remove a buccal plate or something, which by the way you should try to avoid at all cost, but if you had to, then this is a definite indication for, grafting the area, allowing it to heal fully and that usually takes a minimum of four months, sometimes up to five or six. And then, excuse me, coming back and placing the implant there. The short answer is yes. Yes, we’ve done it, we can do it. The longer answer is a little bit more nuanced in that we have a very short implant, okay? We have, in a situation where adjacent teeth may have been, crowned or, where we can’t bond adequately. We have a situation where the aesthetics are not that crucial because we’re slightly outside of the aesthetic zone. So for this case, you know, that we can do it is no question because when we’ve placed implants in immediate extractions in the aesthetic zone and we had some of the implant surface engulfed solely in a blood clot, not even a bone graft, we have success that is, at the level of the two stage placement So, the key is not the contact with bone per se, but rather the stability that is based on bonding the implant abutment to the adjacent tooth structures and again once more I want to thank you for your attention and we are out, Thank you all.