Placement of a Bicon SHORT® Implant using a Floor Transport Technique and the Uncovering of Two Bicon SHORT® Implants

This afternoon program will start with the placement of an ultra short implant in the posterior maxillary ridge. The plan is to do an internal sinus lift. The residual bone, the native bone that is still in there underneath the crest, excuse me, the floor of the sinus is roughly three millimeters. The encouraging sign is that this area has been edentulous for a number of years, meaning the risk of adhesions is reduced. So that allows us for an actual lifting of the sinus floor that is equal or slightly more, very slightly more than the diameter of an osteotomy that we would make. And so if we look closely at this radiograph, we’ll see that approximately three to four millimeters of the implant will be sticking inside the sinus necessitating a sinus lift of approximately five to six millimeters as two additional millimeters have to be apical to the implant itself. So that certainly puts us within the realm of possibilities, whether it be by a sinus, an internal sinus lift procedure, or a floor transport procedure. Our patient has been patiently waiting and has been anesthetized with local anesthetic, no sedation. Okay. So our flap will encompass roughly the area of the first molar and some of the second molar location. We will leave the papilla at the second bicuspid protected and hopefully completely intact. Okay. So that’s our mesial incision. It will be buccally based. I just need to join these two lines. And that’s it. Okay. We will collect some of this liquid. It will help us moisten our graft. We’ll use a retraction suture. So we will score a rectangle. And the key and the operative word here is that we are scoring it. A little bit of tapping. Okay, that is the anterior extent. Pretty hard bone, that’s good. Okay, and this will be the posterior extent. Okay. I’m scoring it now. It’s pretty hard bone, which is a good thing. Okay. The idea is to score it. In other words, to weaken bone so when you start tapping to move it, it will break where exactly you want it to go. Okay. Go over the corners. Okay. And now, we’ll tap this to start mobilizing it into, telescoping it into the ridge. Sometimes you will find that the block of bone is kind of locked in place. That’s mostly because of the access that you have where the cuts make a trapezoid, where the top, the crestal surface of the rectangle is actually wider than the sinus side. So, it’s a little bit kind of hard to remove it or to mobilize it. But, you’ve got to be patient and methodical and go all around the edges, favoring, of course, the corners. And I can see it already moving up. Can if you listen closely, you can hear that the sound is not so much of an intact bone, but rather of a mobilizing, moving bone that is only tethered to soft tissue. And you’ve got to be extra careful as not to move one side significantly more than the other of this rectangle. So what I’m doing now is doing the sinus lift at the same appointment, but before I do the implant osteotomy. So now you can see that as we proceed very slowly, very cautiously, we are making sure that this sinus floor is moved out of the way. The surface area is certainly more than it would have been through just an osteotomy. Okay, that’s it. Now we’re finished with the lifting. Okay? These are kind of bullet shaped osteotomes that will just expand, dilate the bone. So, as you see, now I have to make a decision. Do we go to six or do we stop at five? And we’ve introduced this all the way down to a depth. And I’m going to do it in two areas just to make sure it’s all mobilized. Good. We’ll go with hand reaming. The palatal wall is a little thicker, so I will favor it. I will actually take more of it. Alright. That’s it. All I want is friction at the top. All I want here is to take these little shavings of bone that may get wedged and prevent us from seating or cause trauma to the bone as we’re seating them. Okay. And we will expand it to the final size right now. So notice how much pressure and energy is required to actually introduce this very smooth expander. So you can only imagine that the implant will have even more friction. Okay? So we will now mix our SynthoGraft, the quarter gram. We will use the syringe, a metal syringe. We’ll now take as much of that graft and gently introduce it there. And that’s it. Now, we’ll take our implant. By doing a little bit of a twisting motion, you allow some of the particles to sneak into the implant plateaus. Now we will seat it fully. As soon as the shoulder is at or slightly below the very crest, I will stop the tapping or here we are. Okay. Taking the suction tip. Okay? Doesn’t slip. And you position it exactly where you want it to go. Okay? Now, we will seat it to the final seat by tapping right in that central depression. Don’t worry, it’s gonna become flat again because as it moves in, the top Okay? Of the crest will dictate where it sits. Be careful. This is only slightly bigger than the implant. That’s it. We have a little bit of that bone graft. So instead of just throwing it out, we could put it back on. Totally optional. It is not necessary, but since we have it, we won’t waste it. My rule of thumb is you can lift the sinus roughly an amount equal to the diameter of the implant you’re placing. With a little bit of patience and experience, you probably can add another millimeter or two to that, but not much more. So the maximum we’ve lifted internally is roughly six to seven millimeters. Okay. Okay, so as you see, it’s actually textbook. If you look closely, as I told you, we would leave a generous amount of bone between the two. The implant is sitting mainly in a sinus lift. Its stability is from the friction against the buccal and palatal walls. Also, if you look at the difference between the posterior area where we concentrated our sinus lift graft and our anterior area where there is no sinus lift graft. If you look closely, there is the outline of the actual sinus mucosa. And the key feature that you want to look for and you want to see after such a procedure is the complete containment of the graft. As for the slight angulation, it’s roughly about ten degrees from this implant. That is well within restorative tolerances. In fact, this will bring the abutment closer to the adjacent tooth. So that actually helped us avoid the thicker part. This is about six millimeters of bone. So if we had moved the window more anteriorly, we would have had a very difficult time in mobilizing the floor. This was a floor transport technique for two actually, posterior was through a floor transport technique and the anterior, the mesial, was through an internal lift. The combination of the two formed for what would be the equivalent of a lateral lift amount of a volume. So if you look closely, you will see the black shadow right there and there. Okay? So what we will do is basically recruit some of the palatal tissues, move them up to the buccal. Now we’ll make our incision right here. Do you feel anything? Yeah. This thankfully is outside of the aesthetic zone. So we won’t worry too much about preserving too many, too much papilla height, but we still want to preserve a healthy papilla. And as you see just where the shadow was is where the black healing plug is. And now we will just uncover these, suction right on it. There’s one. And here’s the other. Okay. Good. Okay. So you see those two implants, one and then the other. Let us remove some of the intervening bone, the bone that’s over the black healing plugs. That’s solid. And when the bone is kind of thick and well organized, you may have to either ream it out a little bit, suction, or cut it away. I usually use, something like a blade, a fifteen or a fifteen c blade. Okay. Okay, solid. These are both molars, so they will require a wide abutment. We will use a six point five or a five. So we will just ream out a little amount here, a small amount by five millimeters. See how that bone that was intervening over the mesial part because of the slope? So now I will, before I turn it over to Dr. Morgan for the restorative component, I will place a couple of abutments and then suture around them. He can then remove them and do whatever he pleases in terms of restorative technique. Good. Okay, so now we’ll turn it over to Dr. Morgan, who will demonstrate the possibilities that the restorative aspects provide us. Good afternoon. We’ll take an impression with an implant level transfer impression. Place it in with finger pressure. Take the second, and that’s it. Okay. The two and a half minutes has gone by, and we’re going to remove the the tray. Only the sleeve should come out in the impression material. If the impression post were to come out, you’d have to retake the impression. And the bite registration will be done by putting the sleeve onto the post, making sure there’s clearance. Close. There’s the second. Close. You’re hitting that, I think. Yeah. So he’s hitting that tooth so open. We can in fact close. We can in fact not use the sleeve and just let it and just put the the GC resin right onto the post. Close. That’s it. Open. And that’s it. Whenever the residual bone between the floor of the sinus and the crest is about three to four millimeters or less, the risk of perforating and having a mishap whereby an implant is dislodged inadvertently and the sinus is somewhat increased. We are really pushing it, as you see, from the final result. So, for that, we may have to go and open a lateral window to access it for a Caldwell-Luc procedure. And for that, we want the flap to be able, or for us to be able to widen that flap and have that access. And for those cases, we will base the flap on the buccal. So we flap it toward the buccal. We will then suture it out of the way toward the cheek, towards the buccal. If, on the other hand, you have a significant depth of bone, then the more aesthetic flap would be the one that is made, the incision that’s made within the free gingival margins outlined, and that is based on the palatal that is reflected toward the palatal and retracted by the weight of a needle holder you know, dangling from a suture, that keeps it open because the risk is far reduced. And therefore, it makes the opening easier. It makes the incision more aesthetic. It makes, certainly, the suturing and the closing a lot faster, more efficient. And it causes less pain. That’s why, whenever I can, I favor the palatally based flap, like the finger or trapdoor flap? I’m able to then see what I need to, perform the procedure that I want to without having to do a big opening and a lot of sutures at the end. Okay? If there were any problem to be had from a normal, uncomplicated, regular sinus lift procedure, we wouldn’t be able to perform the technique so often as to perfect it like we do now. The fact is, in the vast majority of the cases, it is practically a nonevent for the patient. The amount of postoperative pain, the amount of postoperative complications is minimal. It is not any higher than any other implant procedure. Also, what we do for all of our patients, and certainly for the patients who are undergoing any sinus lifting of any kind, they are premedicated with a surgical prophylaxis dose antibiotic, I. E, one gram of amoxicillin if they’re not allergic to penicillin, and clindamycin, three hundred milligrams if they are. So we do stack the deck in our favor, but statistically speaking, the odds of having any untoward sequelae from an internal lift or any sinus manipulation, barring obviously the tears or any other unusual circumstances, are minimal. The postoperative instructions are kind of uniformly given to the patient. First, they are instructed to kind of avoid chewing with, you know, over the area. The usual stuff, you know, from icing to beginning the rinsing with Peridex, or at least scrubbing the area twenty four hours post operatively. They are instructed to continue the antibiotic for a period of three to five days minimally, post operatively. But with specifically the sinus lift patients, we ask them to avoid any positive or negative pressure on the mouth or nose. So, they are instructed to avoid blowing their nose, or if they must sneeze, not to stifle a sneeze where an increase, a paroxysmal increase in pressure, may force the membrane that may be unsupported, the sinus lining that is, or any other things to be paroxysmally forced out and can create other problems. So you create it as a weak spot for about five to ten days. They’re also instructed to avoid plane rides as the change in the pressure can be pretty significant. If they must travel, we ask them to use a decongestant, preferably a topical nasal decongestant, that they use a couple of puffs, especially in the nostril on the side of the surgery, so that any balancing of the pressure will not be at the expense of the internal pressure in the sinus. It will be the same in and out of the sinus, and in and out of the mouth. It will all be equal, and therefore minimizing the untoward effect. So those are, in a nutshell. Basically, any time you extract a maxillary molar that’s very close to the sinus, you would give the patient the same instructions. Instructions. And this is not very much different. I appreciate your attention. Thank you all very much.