Placement of a Bicon SHORT® Implant, Uncovering of a Bicon SHORT® Implant, and Insertion of an Integrated Abutment Crown™

Good afternoon and, good morning, good evening. Welcome again to another Bicon webcast. Today’s program is going to take you through the journey that will get us from an edentulous space to a restored tooth. Granted they won’t be on the same patient obviously, but it will be showing us how we place an implant, in this case it will be a one stage implant. The tooth, as you, will see shortly on the radiograph as well as clinically, has been removed about six, weeks ago. So there isn’t complete bone formation however, there is epithelialization of the area. After the placement of the implant we will carry to an uncovering of an implant. The uncovering will be reminiscent of the implant that we did at our last webcast on February eighteenth, which you can also see online at bicon dot com. At that webcast we placed a Bicon six by five millimeter implant. And finally, we’ll be inserting the restoration. So again, welcome, and let me introduce Dr. Vincent Morgan, a general dentist, and, my name is Shadi Daher, I’m an oral surgeon, and we together will provide you with today’s, program. Can we please have the, radiograph? You see that, the, two bicuspids are present. The molar, as you can see, it’s the shadow of the socket still remaining, and if you look closely, without really reading too much into the radiograph, the shadow of the soft tissue is obviously a little bit irregular. And this will be actually, will translate clinically. And so we will be placing a Bicon short implant with a one stage technique. In other words, a part, a healing abutment will be visible through the gingiva, will allow for healing, and it will make the second procedure of taking the impression much faster and to be also easy on the patient in that rarely will you need a local anesthetic for the area. You can easily see the kind of defect we are dealing with. And as you can all imagine, we have basically no grafting in the area. The sinus, as you recall from the radiograph, is not near the area. We’ll make an incision that will allow us to close over should we decide that a one stage procedure is not, optimal at this point. However, because of the lack of complete epithelialization and because we can see easily that the socket and the bone should be adequate for all intents and purposes, what I’m going to do is of adjust the core, akin to a punch flap. Now since we don’t have full epithelialization, this will be considered an immediate placement. We waited not enough time for either bone regeneration or full epithelialization. So we will consider this an immediate post extraction placement. Okay. So we take a soft tissue rongeur after having made the incision sort of circular around the perimeter of the socket. And we will remove all of this friable, pre epithelium type of soft tissue or and not completely keratinized epithelium. And we will go ahead and remove any remnants that may be too mobile because what we ultimately wanna feel is a, kind of bone contact. You see? You can see now how we sort of freshened the the socket. We have made it, circular. That will be, a lot easier to fit with a, healing abutment. So in the Bicon system you can have a comprehensive surgical kit or an advanced surgical kit. So, the advanced surgical kit will contain a lot of instruments, however, the instrument that we have available in that kit are all essential for the placement of different techniques of the Bicon implant. So if you intend to use the Bicon implant to its fullest, I think this kit is absolutely essential. Now looking in rows you see the coloring and the banding of these instruments. First the color carries through and we will have the standard length two point five all the way up to six and the banding, the black color, is between six and eight for the first band and eleven and fourteen for the second band. These are latch type reamers. The colors, the gold or light blue, dark blue, pink, etc, are also carried through the kit. So whenever you have a two point five millimeters instrument you will have the same colouring. Whenever it’s a four, again the same pink colouring, etc. So the other instruments at the top of the screen are the handles. These allow you to use hand instrumentation, which is one of the big features of the implant and the implant kit because right with any implant, as you will see, we have that possibility which gives you greater control and more meticulous reaming to obey what the bone is telling you. And so looking at the pilot drill, when we rotate at eleven hundred rpm or so, you can easily see those bands. Now, because we are rotating at such a high speed, we will obviously risk trauma, thermal trauma to the bone, so we do irrigate. So if we were to go in this direction, okay, if we had to use hand reamers, we wouldn’t be able to because they would come in a direct collision course with the mandible. So for that reason, and because the implant allows us that latitude, we’re able to angle ever so slightly, roughly ten degrees or so, and we’re able to then, because of that angulation, we’re still within the confines of the occlusion and the crowns of the intended teeth, but at the same time, we’re able to avoid the interference of the mandible. The other pilot drill is slightly longer now. When we’re engaging the bone, irrigation and suction please, we may sometimes have interference from the crown of a tooth or when able, I like to use the longer one because it gives me a better indication of my direction. Placement of the pilot drill. Let’s talk about the depth of placement for a moment. The Bicon implant needs to be at the very least within the bone. So first we need to know where the bone is. And so when we look and we use a perio probe and we can measure the depth of the bone, and in this case it’s roughly five millimeters, or almost six, on the palatal, slightly higher on the distal buccal, and of course a lot higher on the mesial. Now, if we were to place this implant at the crest of the bone on the palatal aspect, it will put it within two or three millimeters on the other sides of this osteotomy, which is perfectly acceptable. Now we will look at our pilot hole. Now you can see the position. Okay? So this was angled and yet looking right down at it, it doesn’t look so angled. Okay? The other aspect of Bicon technique is the use of very slow reaming. The reason we use slow reaming is that we will then avoid the need for irrigation. We certainly will avoid, thermal trauma since this is well below the threshold for that, it’s about fifty RPM. And as you can see with these, they are marked at the same banding as the pilot drill, six to eight and eleven to fourteen. Okay? So what I’ll do is I’ll find the mouth of the osteotomy and then I’ll push it in. Okay, in this case we are not gonna find a lot of bone, we didn’t expect that, but it will help us now as we get wider, we will get to the proper level. Okay? And again, one by one we will carry our osteotomy to the proper depth. Keeping the index finger against the buccal plate allows you to have a tactile sense of where your implant is going. The initial, when I penetrated with this reamer, the initial start went into the socket of the buccal root and I’m going into the pyramidal bone between the three roots. Now, that gives me better stability and I’m starting to see a little bit of bone even at three millimeter diameter level. And again you see at very slow speed, start before you engage the bone and then k, you can also palpate the palatal and that’s one other advantage of the slow reaming is that by palpating you get a significant warning of about a millimeter before you penetrate or perforate. You can see that there is some bone shavings or maybe remnants of the osteoid or the scar forming in the socket. Okay, so we will remove that. Again, we will continue. It still has a tendency to want to slip into one of the sockets more than the osteotomy. So always pay attention. Once we reach the four to four point five, this will be a lot less likely. And the reamers have the added advantage in that they do not drill. They bottom out in the osteotomy and unless the bone is extremely soft or you have a bottomless osteotomy or you’re touching a soft tissue of some sort, you will be stopped. This is a four point five millimeter reamer. Now you see it’s engaging more walls, it’s wobbling for a little bit until it engages the full parallel wall of the osteotomy. Okay, again we are getting bone. We’re going to make sure that our walls are intact, and they are. And some because of also the spaces in the extraction socket, we have to go fishing for a little bit of the escaped bone. So, this is a hand reamer, this is a five millimeters, has the gold coloring of another, you know, latch reamer. Maybe, okay you can see them but they are reflecting the light a little bit too much. But the only difference is the hand reamer cuts on only one side. So if you look right down the barrel of the reamer so to speak, you will see that it only cuts in one surface. There is another advantage in that the reamer has a little offset at the tip. That offset allows you with a bit of pressure to deepen your osteotomy if you have any need. But more importantly it allows you to make it deeper very very slowly. So let’s say you’re working near the sinus mucosa and or near the mandibular canal, you can get very close to either of those two structures. Now, if you zoom out, can see how we’re able to use this reamer by hand. Okay. I will show you the osteotomy in a minute. Turn slightly to the left, and we get to the full depth that we wanna and this actually compresses the bone so when it cuts it, it cuts a significant amount. So we’ll go to five point five millimeter reamer, And again, we’ll do that by hand. You gotta find the mouth of the osteotomy, engage it, and start. Now you’ll feel there’s a little bit or a lot more resistance. It’s a heavier contact. It is a wider diameter, it is also going to be traveling although it’s the same speed, my turning of my hand is the same angular speed, but it’s a bigger distance, slightly but significantly nevertheless. Okay, and you notice how much bone we are collecting. We’re collecting all of the bone out of these flutes so we empty it out into this silicone dappen dish. Check for any weaknesses before you go to the final size as you can cause a problem just trying to finish up your osteotomy. We’re collecting quite a bit of bone. This is the Bicon depth gauge, it comes also with the kit. It has a flat and sharp bottom so you slide it, down the wall, either buccal, palatal, whichever one you want to measure. In this case because the palatal was the shallowest of them, I’m most interested in the depth of the osteotomy there. The first line is at six millimeters, the second line is at eight millimeters, then eleven, then fourteen. Right on the palatal tissues we’re right about fourteen, Okay, and that’s where we want the implant to be within the bone. This is the crucial step where we want to have integrity of the walls and we push. If you twist only or twist and push very little you will be carving out all of the walls. If you push harder and twist slowly you will be expanding the weaker walls which is the best way to protect when you don’t have a widely open flap you see. So as I’m pushing, I’m twisting kind of slowly and I’m pushing pretty hard. You know, our patient can probably attest to that. So, we are now finished with the osteotomy. That’s our osteotomy. You can see the walls almost. It’s actually better than I can see them. The implant that’s going to go into this osteotomy is a six millimeters x eight millimeters short implant. The Bicon implant comes triply sterilized. The package that you see on the screen now comes the cardboard and the blister pack are packed in a plastic bag. The cardboard and the blister pack are sterilized. The blister pack further contains a bag that contains the implant. That is also sterilized, as well as the, implant. So, what we would like to now look at are some abutments, and what we would like to use is an abutment that allows us flexibility in the placement depth and it has the size. If you remember, the soft tissue depth on the palatal is five millimeters. So we have these options. We either place it below the soft tissue or above the soft tissue. My preference is to go with the longer one because the soft tissues on the buccal are slightly higher. And a difference of about a millimeter to a millimeter and a half, as long as we instruct our patients not to play with the abutment with their tongue or chew on it, it will give us primary stability, will not cause macro movement of the implant and we’re able to do it that way. Couple, the abutment and the implant, make them as one unit, carry the both of them together, place them and seat them fully, thereby creating a sort of a one stage implant with a healing abutment. Now we have an implant that is one stage and you may have to use a little bit of twisting in there to just make sure it goes in the proper osteotomy. Now it’s a friction fit implant so we will push it to seat as much as possible. We will use a seating tip that is as wide as the top of this abutment or actually this is slightly narrower but it will still work. And that comes also in the kit, we can take this, now the osseointegration is going to guide it in, so we’ll just give it a couple of taps, because we want it to be just and you can hear the difference in tone. The post op radiograph, as you can see this is a one stage implant filling our osteotomy with primary stability and plenty of bone contact This is an implant that was placed with an internal lift and it was six millimeters wide, five millimeters long and it’s placed as a two stage implant, however it does have a metal abutment and that’s called a sinus lift temporary abutment, which is covered with the soft tissues entirely. Now, obviously you want to preserve the buccal soft tissues, and we initially start with just a crestal incision. Now the retractor always gets in the way of making this incision with protection of the papilla, however, it is not going to be at all crucial. So, it will be curved appropriately. Before we proceed, the best way to open a crestal incision is with Dean scissors and using a blunt dissection technique. So, we will introduce the scissors into the incision and spread them and then close them outside and then push back in until we’ve expanded the whole incision. I will show you now how that works. You can see it actually. So now using a Pritchard, periosteal elevator, we’ll use the narrower end so we can also elevate more of the soft tissues to get around the entirety of the sinus lift abutment, and we can now take a good view of it. My preference is to always maintain as small a flap as possible. It causes less pain. And that’s the abutment. We will take a guide pin which will fit snugly in the implant well. We will place it and check integration. I’m moving the entire head with that, there is no micro movement, there is no perceptible movement of this implant, which has correlated in our clinic with appropriate numbers on the periot test In this case, what we will do is take an implant level impression and that’s very simple to do Now because there will be an impression taken, I will place a buried suture. Basically the knot is inside the tissues. So instead of going from the buccal to the center and then from the center to the palatal, we’ll go from the center to the palatal, then from the buccal to the center, or to the incision, and then we will tie the knot. When we release and cut the knot, it will pull into the incision space. I will now turn it over to doctor Morgan who’s a general dentist who will now restore it. Thank you, doctor Daher. And that’s it. Although you can take impressions of the Bicon implant directly on an abutment if it were tapped in, Alternatively, with an acrylic sleeve snapped onto the abutment. However, our preference is the implant level impression. I would advise all of you that it is probably the most effective way and certainly the most cost effective way of doing it because the dentist needn’t have an inventory of components. Impression is just about set or remove it. The acrylic sleeve should remain in the impression and to remove the green color three millimeter impression post simply remove it and now since it’s a non aesthetic area we’re not concerned about restoring it at this time. We’ll simply put in a white healing abutment. It’s nothing more than a round peg into a round hole. Slight tap. What you want to be cognizant of in placing these abutments is that you allow sufficient room for the interproximal papilla. It’s better to err the side of a smaller diameter abutment than a larger. You do not want to encroach upon the space of the papilla and additionally you do not want to have it too far facially or bucally. So if you’re going to err the side of a smaller abutment. So there’s a short Bicon abutment, implant rather. Patient has anesthesia, now it’s just a matter of locating the well of the implant. I’m going to use the backside of a guide pin. It’s clearly there. The post is cleaned with alcohol and if all goes well it will be just a matter of inserting it and being done with it. We will most likely use a relieving incision since the soft tissue has closed in on us. Close, right down. Open. Close. Bite down. Close firmly. You can see the blanching of the tissues. Open. Which is oddly enough not interfering. So we contact at present mesially, contact at present distally. First thing we will do is check the occlusion on the opposing side, make sure that it is in occlusion. Close. There’s contact on the opposing side, open. Now let’s see if it is in fact in occlusion or whether it’s hypo occlusion. Close. Tap. Tap, tap, tap. Open. Probably a little heavy because it’s on that palatal cusp. It was still blanching because of the fact that there was no temporary abutment in place. We may make a little relieving incision. That’s it. Maxillary anteriors you’d want to tap. However in the posterior just having your patient close on a Q tip is sufficient. There it is. How does that feel? A little high. A little high? Okay. Then, let’s check and see if it’s closed. They’re closed. It can’t be too high so we’ll make a little adjustment. And the beauty of these indirect composites is the fact that you can adjust them and polish them completely in the mouth. Close. Tap, tap, tap. Open. Feel better? Still uncomfortable? No, it’s okay. It’s okay. Let’s just polish that little adjustment that we made with a finishing bur. Okay. The key to the integrated abutment crown radiographically to evaluate it is that it has a hemispherical base. As you can see, the hemispherical base, the titanium, is in contact with the bone and not the indirect composite. My comments on that is, if you don’t see, open a wider flap. Whenever in doubt, there’s nothing better than so called cold steel and sunshine. You gotta open it. You gotta see it. You gotta do what is absolutely necessary. Basically, since we are not drilling at high speed, we are not afraid of having traumatized bone and sequestra of bone left behind, we don’t irrigate the area. The only irrigant that’s used is sterile water at the time of the pilot drill. Beside or beyond that, we do not irrigate the area. We curette it, we remove all lodged debris as they may interfere with the seating. However, it is not, it’s not needed at all. In fact, it may be detrimental. That is an osteotomy that has been placed with no, irrigation whatsoever. It’s been placed atraumatically, all of the cells in there, we dared think, are vital and viable why irrigate we’re washing them away it is not necessary the answer in short is why not Why not? You saw the middle case where we had an area where a millimeter of native bone initially was expanded with an internal sinus lift. We placed a six by five millimeter implant and we’re going to place a molar tooth on that. And it works in that, it’s all grafted bone. Why wouldn’t it work in native bone then? And clearly we have the case after case after case, we have the statistics, we have the research, there are papers published on that. The real question or the answer is why not. If it works in the worst type of bone, this is even better, it will work in that as well. The fact is all the research, all of our experience, and we are talking here, thousands of implants, we’re talking two decades we have implants, that are eight millimeters in length and those put us usually in crown to implant ratio at best of, one, and a half to one, which is clearly in violation of all of what we were taught in prosthodontics. And it has not affected our longevity, long term success, crestal bone maintenance, etcetera, etcetera. And the paper the literature is available online if you go to bicon dot com. What we are using are short implants for all our patients. The longest implant we are using is eight millimeter, and that’s short implant by everybody’s standard. And beyond that we use five point seven, we use six, we use five millimeter long implants. So we use them in all situations, whether we have eighteen millimeters of bone or eight millimeters of bone. And so, what we are doing, what we are researching, what we are finding success, and even in these uncertain times, is the short implant goes anywhere there is bone. A lot of bone, or a little bone, we’re able to serve our patients. Well, I’d like to refer you to the previous webcast where we did quite a few sinus procedures. Also, I’d like to invite you to come to our short implant seminars that are going on frequently around the country and the world. The short answer is we’ve placed implants in as little as one millimeter of bone with select internal or crestal lifting techniques. Short of going into a whole lecture on the topic, which I can’t right now, I couldn’t go into greater detail. But the short answer is one millimeter, select cases, experience, the appropriate wide implant, a plateau design implant, the Bicon implant will allow you to do that. Well, this is an abutment that’s used exclusively for sinus lift to stabilize the, implant with the crestal bone. It is placed there not permanently but rather temporarily, hence the name: sinus lift temporary abutment. The key is, to think of the one stage surgery as the uncovering procedure for the implant. So, if you have an implant placed and you have the attached gingiva, you look at your attached gingiva, what you need is an aesthetic buccal, especially in the aesthetic zone. Buccal, keratinized, attached gingiva. So, the decision tree after that becomes a little simpler. If you’re making an opening to uncover an implant, preserve your attached gingiva, and that is the same flap that we use. Now, if you place that incision and open the flap and there are ends that are loose. They have to be sutured because they cause bleeding, they cause pain, they pump the saliva and oral flora in and around the implant, etc, etc. So suturing is not a boogeyman, it’s not scary. However, if you have a lot of attached gingiva, you can use a punch. My preference is to use a fifteen or a 15C blade and create a sort of elliptical incision, therefore creating weaker spots at the mesial and distal, and when stretching it, don’t cause tears in the buccal and palatal areas. And that will allow you to avoid suturing. First of all, the implant is not a polished cylindrical piece of metal. It has ridges, it has vertical slots cut in these plateaus so that you will be able to get an irregular fit between the implant and the osteotomy. Secondly, the bone is not granite, it’s not marble, it is not metal. The bone is a living, organ. It will flex away as we’re reaming it, especially if it’s the proper type two or three bone. It will bend out of the way with the use of the proper Bicon reamers. And so as you remove your last reamer, that minute or two or three it takes you to get to the next reamer, let’s say, or usually to the implant, the bone actually bows back in, kind of flexes back. And when we introduce our implant, especially as you saw in this last one, or the first case, excuse me, we had to actually tap the implant to seat it into that bone. That is how tight the osteotomy is against the implant. So we don’t need to thread it. We have not needed to thread it. It is the way it has been designed. The tips of the plateaus contact the bone, it may bend into the plateau space ever so slightly. The blood clots in the plateau spaces will over time become ossified by callus formation. It’s fast, it’s predictable, and it gives the best type of bone, which is the lamellar type, cortical type of bone. And again, we’ll refer you to the website or to our lectures going around the country and the world. Short answer is no. In fact, even in this case, although we went toward the palatal, it was really more central. We went, we sort of split the difference between the buccal plate and the palatal plate. The palatal root is obviously bigger, so you will have more of your osteotomy within the confines of the palatal root. Well, it’s a very different scenario. Second bicuspids, the majority, if you remember from endo, majority of them have a single root. First bicuspids, that’s about the maxilla, of course. First bicuspids have a higher, likelihood of having two roots, a palatal and a, buccal. And so, in both of these, my preference is to go in between the roots. And my preference is to do it immediately after extraction if I can, ensure there is no infective agents left in the socket, and that we have the proper provisional, etcetera. As for the molar, my preference if there is adequate bone in the inter radicular space to place the implant in that area, parts of the, implant may, sort of bulge into or burst into the root sockets, that is not an issue. The fact is now you decide either to place it as a single stage implant whereby the titanium of your abutment will obliterate the rest of the socket opening, or you place it as a two stage implant whereby you place some bone or little bone and some hemostatic agent over usually a collagen plug. That will close over the area, it will get migration of the soft tissues, obviously healing by secondary intention in a few days. Now, do we always go into the palatal? No. Sometimes you have to go slightly palatal. I demonstrated why that is the case. So there’s nothing wrong with that. You just don’t have an excuse to try to go thirty degrees toward the palatal, or twenty five degrees. You stay within ten degrees, it has no effect, no bearing on the restoration, either from a restorative, purely restorative standpoint or from an aesthetic standpoint. On behalf of all of our staff here, Dr. Morgan, and all of our patients, I thank you for your attention and I, welcome you to our coming, upcoming, webcasts. Also feel free to, go on the Bicon dot com website so that you may send us any further questions and or comments. We always depend on your ability to feedback so we can improve our programs to you. Anything to add Dr. Morgan? No, other than the fact that the Bicon website is a wealth of information even on the ridge splitting techniques. Whatever you want to know about Bicon, I think you can find on bicon dot com. Thank you very much. Thank you, and good night.