Placement of a Bicon SHORT® Implant and the Uncovering of Two Bicon SHORT® Implants

Welcome to the latest edition of the Bicon surgical webcasts. Today’s program for those of you joining us online will consist of two procedures. The first of which we will begin shortly and the second one will be the uncovering of implants. The first one will be placement. The panoramic film shows that the missing tooth space is quite wide as a first molar space should be, but also that the clearance above the mandibular canal is quite adequate. Now, that doesn’t mean we have to go and occupy this whole area, it may be or actually usually is a bit of an overkill. The other variable in cases like this one is the presence or lack of the depth of the mandibular fossa undercut and we can easily demonstrate that clinically. So our plan will be again for the placement of a wide bodied short or ultra short implant. So our incision now is going to have to obey what the anatomy of the site shows us. As you see, the socket has fully epithelialized and the margin, the facial margin seems to have the most undercut. So we will incorporate the facial margin in the incision, and we will do a slight release to open up the facial end. We will do a papilla sparing incision only because it makes it a little bit easier to close in the end, and it will be faster to heal. Okay? Open as wide as you can. Let’s turn it off. Uh-oh. Good answer. So and we will do a couple of back cuts to allow for the reflection of the crestal soft tissues on the facial. We’ll use a a regular curette to just elevate the flap. Do you feel any pain? Okay. The retraction suture will help us see better by just pulling the lingual flap out of the way. Okay. So initially, we will begin at a speed of about a thousand RPM or so, and I am now slipping over the remnants of that interseptal bone. Apparently, when the tooth was extracted, the interseptal bone was not removed, the interradicular bone. Bite down hard. Good. Okay. On the saliva management and control. So now we are at a depth of roughly eight millimeters from the crest, and we’re gonna go an an additional two or three millimeters and maybe slightly more only to be sure you are keyed in to the full depth. The implant will not be seated with that full depth. Alright. You’re not feeling pain, are you? Good answer. And we will verify our position once again. As you can see, the difference in speed. And this is fifty revolutions per minute. And we are down to a depth of roughly ten millimeters or so from the crest, the bony crest. Place it in. Check parallelism. And if we’re happy, we go with it. So in in this instance now, the mesial root and the osteotomy, the mesial root socket, excuse me, and the osteotomy have roughly the same diameter. Am I hurting you? Okay. So, again, as it bounces a little bit, you feel a little bit of pressure. Okay. Pressure is okay. And this is four. It’s gonna bounce a little bit with the irregularity of the socket. That’s normal. Just bite down hard. So we are now at a final potentially final size. So I just want to make sure that we have all of the the bone and all of it is, you know, well accounted for, protected, all the four walls and the floor. So the nice thing about using the Bicon system is if we need to, we can certainly use a six millimeter long implant and stay within the confines of our design. But luckily, we have enough room to go down as deep as we want. Okay. Step back. How am I doing? Okay? So as you see this, our assistant, Joanne, is is suctioning just in a time when the reamer is actually turned away from the facial. Okay? You alright? We’re almost there. Suction, please. Okay. Just that. Just one sec. Good. All done. Come out. Great. We want to make sure that we have bone on all four walls. Okay? And that we have a positive floor that is not a nerve. Okay? Most of this osteotomy is going into the mesial root and the interradicular bone. That’s it. So as you can see, this you can turn a little bit to me. This implant is now exactly in emerging in the center of the space. Okay? And we’ll take the cutter. We pack it on right there. We’ll take a gut suture. Okay. We have a ridge that was so wide that we went all the way up to six millimeters and we still had two to four millimeters on either side. We had a ridge that was so high that even below the apices of the adjacent teeth as evidenced by the radiograph preoperatively that we showed you, there were seven plus millimeters of additional bone. We had an undercut that was so posterior that just with an exam, you’re able to, or I was able anyway, to find that it’s too far posterior right underneath the apices of the second molar to make any issue of it, so why subject the patient to the added expense and radiation of a cone beam CT when all of the clinical and simple radiological evidence point to an adequate and if not superior amount of bone for any size implant for that area. We as you see now in front of you is the post op radiograph of the first case. And as you can see, as I told you before, we erred on the side of diverting into the mesial root as the distal root socket would be under the mesial ridge of the second molar. The implant that we chose for this to, in order for us to fit it within the confines of the basal bone as at the top would have been a little bit less stable seeing that this is all osteoid is an eight millimeter short implant because a six millimeter short would have been even lower. Now the position of the implant as you see relative to the lingual plate is slightly deeper, as you all saw clinically, the osteotomy was only to about ten millimeters or so. And so this implant is within two millimeters of the crest of the bone. Now mesiodistally, as you all know, with the healing of the molar socket, you will have a little dipping of the crestal bone. So this implant will end up exactly at the depth that we want it to be. And with, if you extrapolate this line, you will be able to see that emerges exactly in the center of this space. We will be uncovering two implants. One is a, both of them are short. One of them is in the area of the molar that was a one stage procedure and the second one is in the first bicuspid, both of them in the maxillary right quadrant. And we will begin by uncovering the first bicuspid, it’s a surgical process. This is a titanium abutment, this implant was placed in a one stage technique. In fact, some of you may have watched this being placed as it was done during a webcast. Do you feel this at all? Good. Now as you see, we will curve it inside the scar that was the area of the previous incision. The top and pulling it out. Come out now. Okay. So we place the because you want to make sure that it is in there because it doesn’t come out easily. You tug on it, it shouldn’t come out. And then I will try to move it. You see? I can move the whole head with it and it doesn’t move. Okay? And so now I know that this implant is integrated, grasp that healing abutment, give it a little bit of a twist and out it comes. Okay? So you see these little petechial bleeding is a sign of the intimate healing and soft tissue adaptation and near integration of the undersurface, the polished undersurface of this abutment. And you see I can bend the guide pin and I can’t move the implant. So Doctor. Morgan takes over. So what we’re going to be doing is taking an implant level impression and it’s simply a matter of introducing it into the well of the implant, introducing it into the well of the one stage uncovered implant. And that’s it. No screws, no torque drivers, simply round pegs, two round pegs into two round holes, finger pressure only and then it’s simply a matter of injecting impression material with a closed tray and end of story. It’s important, paramount, that the impression post remain in the well of the the implant and only the sleeves are removed. We will use a temporary abutment. The selection of an abutment is governed by the interdental papillae. So the abutment is in place. As you can see, the sleeve is too wide for the the space, so we’ll just polish the wings. It’s always best to use less than more. Week or so we’ll have two restorations. Our preference is the integrated abutment crown, although clearly the vast majority of Bicon implants are restored with porcelain fused to metal, because most dentists haven’t appreciated yet the merits of the hybrid composites. So we’ve placed a transitional abutment of PEEK material in the post area, which will hold the sulcus open. We fabricated very quickly a temporary restoration. It’s a very good question. The black plug itself will show a bit of a shadow even if you cover it with bone. Now if you uncover these implants at the prescribed three months to four months, no longer, it’ll be easy to just remove the excess bone with a sharp curette. If the patient disappears for any reason and comes back, let’s say seven, eight months later, that bone may become so well organized becomes cortical and you may have to actually drill a little bit and I would use a four round bur and just drill very gently based on your radiograph until you see the edge of the black plug and then you will widen it. Once you’ve widened it, you come from under the bone and flick it up. That’s why it is important to actually cut this plug flush with the crest because even if you pile the bone high above it, it will actually with the action of the muscles and the tissues and so on, it will shy away from it and by the end of integration, as you saw upon the uncovering of the prior case, or excuse me of the second case that in that black healing plug was well or is very visible right at the crest. The paper published by Rainier Urdaneta in this July/August issue of JOMI states that the Bicon implant can have a crown that is, five times as long as the implant. The perception of a one to one ratio is just, not applicable to the Bicon implant and there have been several publications, addressing that issue. John Schulte, University of Minnesota and his graduate students I have believe have two papers now three or four years duration. Urdaneta’s paper recently in July, it simply isn’t the case. Here we have had years and years of experience of having crowns that are five times and more longer than the implant. The impression post that used to be tapped in were the plastic impression post. With the metallic post and acrylic sleeve, there is no need. There is just a finger pressure. You could tap it, but there’s no need. As you saw, the impression post remained in the well of the implant upon removal of the impression. Thank you all for your attention. We’ll see you at the next webcast.