Placement of a Bicon MAX 2.5™ Implant using an Immediate Stabilization and Function Technique

Good afternoon Good morning, good evening. This is Shadi Daher coming to you from Boston Today’s program is going to be for the placement of a MAX 2.5 implant in the location of the maxillary right canine So that will be number six in American and number thirteen in international speak. The plan is to stabilize this implant, or we’re going to immediately load it. We will immediately stabilize the implant with a bonding to the adjacent integrated abutment crown and the adjacent tooth. That would be the bicuspid and the tooth. Okay? Now, to just put this in perspective, this canine was scheduled to be extracted today and replaced with the implant today However, it became symptomatic not too long ago, about ten days ago and was actually, extracted then So what we will do is, freshen the socket removing any of the scar tissue and then treat the area as if it were an immediate, extraction The extraction has left some kind of jagged edges. That’s not gonna be a major issue. As long as we leave some of the attached gingiva, we should be able to create enough of a healthy, peri implant soft tissue, profile. I’m just gonna freshen the edges of the socket. Do you feel this at all? No. Good. He’s finally numb. And we will now go ahead and just remove the little bit of a scar that is starting to form here. When we’re using a two handed technique, okay, what you’re trying to do is to have your hand that is driving the handpiece completely engaged with the handpiece and the handpiece only. I’m right handed, so my right hand is going to be holding the handpiece and moving the handpiece in and out, whatever it’s doing, none of my right hand fingers are in contact with the teeth. A one handed finger rest technique will mean something like this, but that gives you a pivot. It’s limiting. By using a two handed technique, zoom out any more if you can. Alright. By exactly. When using a two handed technique, my left hand, the left index finger is a sentry and the left thumb is providing that guidance and the finger rest. The right hand is driving the handpiece. Okay, if it were for instance on the mandible, it would be something like this. We have the left hand holding the handpiece and the right hand driving it. Okay? Okay, and once we’ve engaged the bone, we straighten it out and come in. Now the markings on the Bicon handpiece are two bands. The first one starts at six, ends at eight, and the second one starts at eleven and ends at fourteen. And obviously in between them, there is the other band which is, starting at eight and ending at eleven and alternating the colors. Alright, now what happens as well in this case is that the teeth, the crowns of the adjacent teeth are starting to interfere with the head of the handpiece. So what do we do with that? We will go to a longer drill. That longer drill will afford us an additional seven millimeters or so of clearance and that should be plenty for our purposes. Now, before I commit to the full depth, we can check the parallelism and the location of that osteotomy before we burn all of our bridges and that’s what it looks like. Okay. And there we are. Can you zoom out to see how the two handed technique works? Okay. That’s good. So now you see that my right hand, okay, is just holding the handpiece. My left hand is providing the finger rest. Okay. K. Let me see. Alright. Just wanna make it a little bit deeper. We can afford to go deep. We don’t have to seat the implant to the full depth, but that gives us good guidance. Okay? Can I have the x-ray up on one of the screens please? Thank you. Okay, so as you see now when we start reaming at such a slow speed, and since we are using such a slow speed, there is no need for irrigation and there is an actual bone harvesting. Now, this is three millimeter diameter latch reamer on the extender again. The most important part of your armamentarium here is your memory. You’ve to remember where your osteotomy was and the trajectory in which you went in to perform this osteotomy. Okay? And again I am reaming to a distance of about eleven millimeters or so from the crest of the tissue on the buccal. Okay. You hear a little bit of clicking as we are starting to, engage the lamina dura of the socket. And here we are. As you can see, the wider we go, the more bone we’re harvesting for obvious reason. We want to make sure that our, socket or osteotomy has bone Okay, has bone all around. Okay, and this is part of the scar so you can suction that. Okay. All right, perfect. Good. Alright. So we’re pretty far. The osteotomy is is a good distance away from the buccal, so it should be fine. Hand reamers have, the distinct advantage of allowing you to have a better tactile sensation to slow down the reaming and to direct it with a lot more ease and sensitivity, if you will. K? So what I’m gonna do is go in to the same osteotomy. Turn back to me ever so slightly, Eddie. Back a little more. A little more. Perfect. So what you wanna do is engage that osteotomy and keep on reaming it. Okay. And making sure my index finger turn back to me, please. There you go. My index finger is feeling, making sure that the buccal plate is not being, torqued or violated at all. I always check between every reamer and the next. Okay? Just to be safe that none of the walls have been fractured or fenestrated and that’s the advantage of being so slow in the progression You have the, advantage of collecting all of that bone and always being sure that your osteotomy is in the correct angle. Turn back to me, Eddie, please. Turn to me, to the right. Okay, and Alright, okay, good. And the Bicon implant was, as you probably know, one of the first implants to be shipped sterilely to the practitioners. And the packet comes in a plastic bag that contains this cardboard, sterile cardboard package with inserts and literature, as well as a blister pack that also contains, which is sterile, that contains another plastic pouch that contains the implant. And this is how the implant comes and it’s sterile. That plastic bag that contains the implant is sterile and we can handle it. It’s dropped onto the surgical field and we will remove this post. You could place this implant just like this because this comes with a healing plug and carrier. However, in this case where we have the severe slope, we have the reach going to be kind of hindered. So we will go ahead and use an inserter retriever, which uses the locking taper mechanism and its properties to place a handle onto the implant. There are lines that indicate depths of two and three millimeters and that’s where I want to place the implant, roughly about two millimeters to three millimeters no more from the crest of the bone. But in this case, since the bone is uneven, I’ll go with the weakest point, which is the buccal plate. And we place it at that level. Okay. And then we disengage the locking taper. What I’m going to do as well is pack some bone against the buccal plate. There is a very minor dehiscence which is not going to play a role in here so we don’t need to graft it because it’s well above the implant. And this is our implant in its position. So before I turn it over to you Doctor. Morgan, I’m to pack the bone in there if you would be so kind as to keep it there. Okay. May I have the depth gauge please? And it’s important to put something in the implant well before you pack any bone, buccal, lingual, palatal, whatever, because otherwise you’re going end up with bone inside the well. It’s just going to make it difficult for the restoring dentist who’s going to be immediately loading it. Okay? And that will give us an extra added bonus to preserve the canine eminence and preserve the aesthetics of the case So, all of these now I turn it over to a more capable hands, Doctor. Morgan for immediate loading of this case. Good afternoon. The maxillary first bicuspid implant was restored seven and a half years ago with an integrated abutment crown. Those of you who are unfamiliar with the integrated abutment crown, I would strongly encourage you to, learn about the merits of it. As you can see the flexibility is phenomenal. This restoration has been in for seven and a half years and yet with a simple twisting and pulling motion of forceps it is removed. We will use the stability of that implant to provide stability for our recently placed implant. So now we will use the post into the recently placed implant. We’re just removing the guide pin. Okay. It’s best to use the smallest abutment. You don’t need a prosthetic abutment as though it were a prepared natural tooth because the longer the abutment, the more problematic it becomes with its trajectory and angulation. So you can see if these are not perfectly, in the right trajectory, the shortness of them allows them to be quite usable without the trajectory being problematic. We’re using a product called Integrity by Dentsply and the key is to slowly extrude it, being mindful of the fact that there’s no need to go cervically. And if you were making longer splint restorations, bridges with this technique, you’d initially make a strut. You’d allow this material to fully set and then continuously add to build up the, aesthetic anatomy. Once again the purpose of going slowly is to prevent a lot of extraneous material from going apically or gingivally. The object is not to have much extraneous material cervically because we can always remove it and add to this material add this material cervically once we’ve taken it out. So in a sense less is more. You’ll find that you’ll be able to use this technique for a single tooth as we’re doing here today or even if you were to have twelve restorations for full arch. It’s very straightforward. And we’ll polish it. So you’ve just seen the temporization. So unlike temporizing for a natural tooth, this is very straightforward as are all implants because of the fact that the margins are given to us. So now what we will do is we’ll just fill in these voids with restorative material, polish it a bit, and seat it. Knowing that we have absolute stability of the canine recently placed implant because of the osseointegration of the bicuspid, implant that was placed seven and a half years ago. But the short answer is no, because the implant will heal with a blood clot. So that we had the bone that will give us a bit of a matrix to prop up the blood clot is fine, but I’m not going to go through additional lengths to just put bone graft that is really unnecessary at this point. That addresses the essential question about the immediate loading technique with the Bicon system. The stability of the implant and restoration assembly at the end is not entirely or solely or even principally the function of the implant stability within the bone. It is really the function of the bonding of the restoration, sort of the casting of that restoration, and tying it to the adjacent healthy teeth or restorations. And that’s essentially what happens. So, that’s why you can have immediately loaded, immediately functioning Bicon implant, virtually in a blood clot, like we today. So that stability is really dependent on how tight that bonding is, and that’s why, you know, a restorative dentist is doing it rather than the, oral surgeon. Oh, Shadi, don’t be modest. So practical matter, anyone can do it. As you saw, people always say that, our claims that it’s simple, but clearly it is simple. An MOD amalgam is far more difficult than what you saw my doing and putting two sleeves on and putting some restorative material. It’s it’s very straightforward. Your own experience will tell you that over over time. Do one or two or three of these and you’ll understand why we can speak so cavalierly about the restorations. There are nuances, but it’s straightforward dentistry. Always a chance of infection, always. That’s why the patient is pre medicated. But again, the oral cavity is, you know, it’s bathing in this bacterial broth. It deals with it very well. So what we do is help it along by reducing the bacterial titer in two ways: surgical prophylaxis with antibiotics and antiseptic mouthwash, which is started before the procedure is initiated. We would bond it to the adjacent teeth. In the case of a PFM, it’s very difficult in our hands to bond to porcelain. However, you can mechanically lock it in place. There are those dentists who tell us that they place and immediately load Bicon implants without splinting, and they claim they have excellent success. However, I have found that a patient is most likely noncompliant and will eat something hard or play with their tongue and orthodontically move it. So my preference is if I were to immediately load, I would bond it to the adjacent teeth or to an adjacent implant. In this particular case, making a two unit splint to an adjacent implant is foolproof, it’s just rigid. Having three or four implants in a row and putting a three unit splint in is equally valid. The problem is with a single unit non compliant patient, orthodontic movement with a tongue or food can be problematic. But yes, you can immediately load. We have been immediately loading for fifteen years very successfully. Is there a need to immediately load? I don’t think so. It does save you a second surgery, anesthesia, at the time of the impression, so it works. Choose it if you want, use two stage alternatively. We seldom use flippers or removable prostheses to temporize. If this were a two stage and we wanted to temporize it, we would temporize it with an indirect composite, making, if you will, a Maryland bridge that fits in place, and we find that to be much more effective both in time and cost and comfort for the patient is to use one of the indirect composites of which there are many to make a Maryland bridge. So there are many ways of achieving the same end. Absolutely, and that’s one of the benefits of the integrated abutment crown is the fact that if it were to, chip or break, it can be restored intraorally or, as you saw, easily removed and repaired outside the mouth. Once you get involved with the integrated abutment crown, you’ll come to appreciate they are stronger than PFMs. Yes, stronger. Additionally, unlike a porcelain fused metal restoration, you do not need the metal support. So the reality is the stronger the integrated abutment crown depends upon the bulk of the volume of the material. So if you further investigate that, that just allows you to have smaller abutments. The smaller the abutment, the more universal it is in its application. The longer the abutment, it limits the angulation and trajectory. So I would encourage those of you who are unfamiliar with it, investigate it for your own benefit and that of your patients. Very repairable. And more reliable than porcelain. By orders of magnitude, I might add. Can, as we mentioned, you can restore a Bicon implant with PFMs, all ceramic, CADCAM restorations, even screw retained restorations. I dare say the vast majority of Bicon implants are restored with PFMs. And most of them are restored with intraoral cementation. But, you can have extraoral cementation where you don’t have to worry about the extraneous cement being sub gingival. Six or eight. Any length that you can place anywhere else, can place in the anterior maxilla. If it works in the porous type of bone, the posterior maxilla, why wouldn’t it work in the anterior maxilla? You want to say about the torquing, well, eight millimeters has been in use and six millimeters have been in use for years and we have not seen any detrimental effect. So, any implant you would place anywhere else. The idea of using the Max two point five in the anterior maxilla is to provide a little added security for the eccentric loading in that particular part of the aesthetic zone. I think the question asked, our ideal implant length, I believe, is six millimeters. And contrary to what others believe and advocate, we believe shorter is clearly superior. And Doctor. Rainier Urdaneta has a publication this fall that will show that the shorter the implant, the more likely you’ll have bone increase. Yes, increase of bone with shorter length. He is comparing the longer length Bicons with the shorter length Bicons, and the shorter length are more likely statistically significantly to have increased bone over time. So we apologize for being at odds with the seemingly the rest of the world, but shorter is clearly superior. Because the entire the whole assembly of the handpiece and reamers, the drill, all of them are way too big for my hand to give me a proper finger rest that will allow me a proper parallel trajectory for every piece. By using a second hand, two handed technique, we have one hand that’s basically the driver and the other one is the motor or the wheels as well as the brakes. So one is pushing and one is pulling away and giving us that stability with a lot more travel distance. Because I can move my fingers of one hand a lot more than just that finger that’s also gripping the handpiece. Again, I thank you for your attention and for your support and I thank our audience here for being patient and hospitable, with us. Dr. Morgan? Thank you again. Good day, good night, good morning, as Shadi says. See you May fifth. See you May fifth.