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

Today’s case will be the removal of the maxillary right first bicuspid, that’s tooth number five in American speak and tooth number fourteen in international speak. The tooth has had a long term gold or acrylic fused to gold crown. The crown is compromised and the tooth has a cervical decay, which I will show you in a minute. The plan is to remove the tooth and place an implant immediately. So this is the tooth in question. It is not actively infected. It is not tender. And so there is no acute abscess in the area. So the first step of an atraumatic extraction begins by severing as much as possible of the periodontal ligament. For that, we will use a periotome. We will repeat the same step on the palatal surface, as well as the mesial palatal and the distal palatal. We will now use a luxator. So we introduce these forceps that have serrations, vertical serrations inside the beaks. And we give it a three-dimensional luxation, sort of like a figure of eight until it loosens up. And we give it slowly. Keep moving it slowly but surely. Alright. And so we can hear it now. So basically the biggest instrument in atraumatic extraction is patience. The teeth will have a tendency to loosen up if you give them time. Now, when using the pilot drill, when we’re placing in the area of a single tooth where the mesial and distal adjacent teeth are present, we will use the contact points as our guide. We’ll imagine a line going from one to the next and go through the center of that line. Okay. And that’s where we will go. All I’m going to drill here is roughly two or three millimeters. So just give me a positive seat. This is at about a thousand RPM. And all we want to do is begin this osteotomy. Okay. At about two or three millimeters. Now even if you went deeper you do not have to seat the implant deeper. And start the osteotomy. So this is a three millimeter. This has the same markings as the pilot drill. And so if we’re intending to place an eight millimeter short implant, we would want it to be about two millimeters below the crest. And since the depth of the socket is roughly thirteen millimeters, that means that we want to drill to the full depth of the socket. That the thirteen millimeters is from the soft tissue. It is ten millimeters from the edge of the buccal bone, buccal plate of bone. The all of the instrumentation is color coded and it carries through the entire kit. And this is a three and a half millimeter. For those of you who have seen the placement video on the Styrofoam model, you can draw the parallels between the two. You see how it just is going in the same sequence. And again, go in the same axis. And the nice thing about it is that you have full control. So if you want to ream mostly from the mesial, you could do that. You want to ream mostly from the palatal you could do that. Okay. We are now at roughly thirteen millimeters from the top of the soft tissue, which puts us at ten millimeters from the top of the buccal bone. And what I want is to feel right at the edge of where the osteotomy starts. So a four and a half by eight would be perfect. This is the implant going in. All right. It’s on an inserter-retriever that provides us with a handle onto the implant. We will introduce it. And although this is not a threaded implant, by twisting it in place, the vertical anti rotational slots of the implant will then act as tapping device and you can tap and mill the implant into place. And of course, no surgery is complete without the mallet, my favorite instrument. We’ll go ahead and tap it to full seat. Okay. Now we turn the short knob counterclockwise until it pushes the implant off and we withdraw it, leaving the implant behind. Before I close it, I will show you the position of this implant. And we can now at least be sure before we complete the case that the implant is in a restorable position. Go ahead, suction that. Okay. And we’ll take a good old perio probe. Okay. And we will pop it in there. Seat it fully. Then what we’ll do is we take all of that bone that we’ve collected and squeeze it over onto the back of a periosteal or a Pritchard. Now it’s easily controllable and pack it in place. I’ll take a Q tip. We’ll pack it in place with a sterile cotton tipped applicator. We’ll take the collagen plug, which will just bridge the gap between the edges of socket, excuse me. And that will just hold the bone and will hold the blood clot. We will use a crossover horizontal mattress or an upside down figure of eight suture. Correct. And, again, just a square surgeon’s knot will secure this. This is a 4-0 chromic gut suture on an FS2 needle. And plain and simple, we are now finished. The patient will either have a temporary bonded or a flipper made. As you see, this implant, as you can tell, mesiodistally, it’s within about three millimeters on the buccal right here. It’s about two millimeters below the crest. Exactly where we wanted it to be, it’s in good position. And we will uncover this implant in three months. So the next case will be the uncovering of these two short implants. So this is pre op, this is at placement a minor internal sinus lift. These are five millimeter wide six millimeter long implants. And this one is today’s film. As you see how the bone has remodeled all over, and so the patient is already anesthetized. So as you can see, we will now proceed with making a crestal incision. There happens to be a very convenient divot right at the crest allowing us to leave all of this attached gingiva toward the buccal of our implants. And here we go. And we use the scissors to just spread the incision. In order for us to see a little bit more, as you can see, there’s the scar from the surgery, we can mimic the release right at that scar. We need to give ourselves a little bit more of an ability to dissect toward the buccal. So as you can see, what you’ve just saw me do before, what you’ve just seen me do before is cut the black healing plug so that will be flush with the crest. Can you see where it is now? And the mesial one is right here as well. So we will now take them out. This one has a bit of bone overgrowing one of its edges. So for that I will use the fifteen blade. You need to see there is a small void that is introduced into the black healing plug in the manufacturing process. This has to go in it. It will then engage and you remove it. What I’m doing is I’m moving the whole head and the implant is solid. The second implant also is solid. This is a two component, the titanium post and the green disposable sleeve. We will put the posterior one first. Since we don’t really need to get a lot of detail of anything but where these lock and the edge of the soft tissue, we will have the lab make us an ideal emergence and that will still be able to fit in. Open wide. Okay. And so both of these are placed with finger pressure. We will place two small undersized healing abutments, allowing the soft tissue to heal and stay high. We will give it a couple of taps with a mallet. Okay. Okay. Good. First of all, the bone that we pack on top is not only trabecular. It’s a mixture of cortical and trabecular bone and cancellous bone. It is a mixture of hard tissue and soft tissue, the bone marrow elements. That’s packed over the shoulder of the implant. It is packed where the black healing plug is still going to be sticking through it. So it’s at the top of it. So I think what you’re getting at in your question is that I am covering the implant so much that I can’t even see it. And that’s simply not the case. A, I didn’t have that much bone. I wish I did, but I didn’t. And B, the black healing plug prevents it from happening. C, the collagen plug creates a circumstance where soft tissue comes up but not bone. So, you know, if I had a ton of bone and I grafted it all and it’s so deep and everything is on top, yeah, you may spend a few minutes digging for that implant. But in reality that doesn’t that is not an issue, especially not in this case. Why do I need it? I’m not saying I need it, but I have it so I won’t waste it. Secondly, the bone, the implant itself, if I can have it isolated from everything else, doesn’t need anything but just the circulation around it. But it is in the oral environment. Okay? When the implant is in the osteotomy, it’s going to be imbibed and thoroughly saturated with blood. And that becomes a blood clot. As we talked about today, it will become bone. But in the oral cavity, the shoulder itself is the part that’s most accessible, especially after an extraction. So putting the bone on top of it is actually a layer on top of the blood clot. Then on top of that we put the collagen plug, or you can choose to use a sliding buccal flap or any other type of closure. So what you’re doing is just giving yourself, your implant, more and more protection against the detrimental effects of the saliva in terms of contamination and mechanically washing away what you want to stick around. So do I need it? No. Do I like to have it? Yes. Will I work at getting it? Of course. Yes. There are a couple of prerequisites. The short answer is yes. The long answer is very nuanced. First of all, you want to have healthy bone, no infection, etc. Second, you want to be able to place this implant with a good expectation of, again, being able to protect the shoulder so it keeps that blood clot so it has new bone forming. Thirdly, you want to be able to have primary stability. You don’t want an implant that when the patient trips on the way out, it tips into the osteotomy because it’s just floating in a blood clot. So you want to have these prerequisites. They’re very easy to satisfy. I will tell you, if the area is not infected and we don’t need to do any major sinus work and so on, Our preference is to place the implant immediately at the time of extraction, no matter what the socket. Because we can get all the way out to six millimeter in diameter, which will give you a significant area to contact the facial and lingual or palatal bones and get primary stability. If we have a significant number of implants together, if we have a very solid adjacent teeth where we can bond it so it does not move, And if the I do not particularly like to load immediate extraction and place implants. I prefer to do those as a delayed immediate or as a delayed, especially if we’re going to immediately load them. I also, for the ultra short implants, if I want to sort of stack the deck in my favor, I prefer to do them as a two stage. The impression posts are not meant to be tapped in. They are meant to lock precisely with finger pressure. And they lock at the same level precisely. The lab analogs will lock at the same level precisely. So that will give you a very accurate impression. Those new this is the system that we’ve been using for a couple of years now. It’s the titanium. It’s very precise. So, you know, why theoretically you can make a case, well, you have to take an x-ray and this and that and the other thing. There are no positive plateaus, you know, the platforms, two disks that fit together that you want to see them fitting together. You take an x-ray to see that. The fact is, if it’s not seated, it is not locked. If you push it in and you pull it, it doesn’t come out, that is all you need for that. The previous system, we used to tap them in and that again gave you a positive seat. It’s all or none. It’s either seated or it is not. If you put it in and it doesn’t come out, that’s all you need to know. The anterior maxilla for any implant presents a challenge for any implant, whether it would become prosthetic loosening or abutment screw loosening, etc. It presents a challenge. Most other implant systems would advocate having crowns joined together. With the Bicon implant, we have recently begun using in the implant dentistry center, and it’s available for everyone, the MAX 2.5, which are implants that have two point five millimeter wells where the taper is not three degrees, but rather two degrees. And the dissociation strength between the abutment post and the implant in those is so strong that we haven’t had the problems of dislocation. Now, if you think of it from another angle, the ability of an eccentric load or an ill fitting restoration or a restoration that’s being traumatized by the excursive movement that are eccentric interferences, instead of fracturing the restorative material, causing bone loss or causing fracture of screws, etc, it’s actually loosening the abutment that’s easy to re tap back in place and gain the same strength of association and dissociation. So in reality, it acts as a stress breaker and gives you another shot or two or three or four until you get the occlusion right and it won’t come out again. Thank you very much for your attention. Thank you all who are with us online. It was a pleasure to have you all.