Placement of a Bicon SHORT® Implant using a Floor Transport Technique

Hello and welcome to the latest episode of the Surgical Webcasts. What we will try to do today with the use of the Ultra Short Bicon implants is the placement of such an implant at the same time as the internal sinus lifting. However, for this case, because of the extreme atrophy of the native bone and the hypertrophy of the sinus, we will begin by elevating the floor via a floor transport technique. This technique will allow us to mobilize and lift the sinus before we attempt the osteotomy giving us a little bit more access and a lot more visibility and certainly a lot more control. The design of the incision is going to be a trap door with the beginning of a paddle shape that will come from the facial encompassing all of the crest and going all the way onto the crestal-palatal corner, right onto the palatal slope ever so slightly, then we will turn around and complete it. Turn a little bit more to me please. And finish it off with a nice wide base on the facial. And so now using a Woodson, we will elevate the flap carefully and cautiously until we have full exposure. Before we continue, because we obviously anticipate using a bone graft, we will collect some blood from the site, which is a mixed arteriovenous blood of course. Alternatively, you can do a venipuncture and collect a little bit of blood to moisten your SynthoGraft. The SynthoGraft, like all beta beta-tricalcium phosphate, needs to be imbibed with blood. We will be able to just take a sub epithelial bite if possible. That will then allow us to tether it to the cheek mucosa. Okay. I’m gonna because I wanna use a wider implant, I’m just going to make a mark. Okay. This is a ridge split bi bevel chisel. It’s pretty sharp. This is five millimeters in diameter. So when I make the window I want the window to be no wider than this chisel. So I’m going to mark the anterior and posterior extent of this window. And you only need to score it. I don’t need to cut it. Alright. Very good. Okay. Again, we’re scoring that rectangle. You see the corner here has been joined for both. We need to do the palatal end now. Right on the ridge. Good. A very small window indeed, but it’s going to allow us to mobilize the floor of the sinus within, with full view which will then work to permit the placement of the implant. And I’m going more by the sound of it as when we are tapping, if it’s getting close to the bottom, you will hear more of a kind of a fracturing rather than a sort of a nailing type of a sound. Especially on the palatal where the presence of the mandible obviously forces us to go in the more buccal palatal direction. Now we’ll take a flat osteotome and we start tapping to mobilize. Initially all you will have is a compression of the bony window. Okay. Okay? How are we doing? Yeah? You having any pain? Good. Sometimes if the mandible is really getting in the way, you may have to use an offset driver. And of course because the three-dimensional character of the floor of the sinus, we can never know if you need to score more or that you’ve done enough. So all we have to do is sort of trial and error. So far we have not mobilized it as well as I’d like to see it moving. Okay. So this part, I’m almost positive. We have scored it deeply enough. This part is the questionable part. Can you open any wider? Good. This part here as well. It’s a little bit questionable. I think it’s better now. Okay. I’m gonna go back over the facial again. And then for those of you who’ve watched these webcasts before, you know that sometimes it takes quite a bit of doing to get us to the final mobilization. Now there are some advantages to using a piezo surgery. However, I found that using the osteotomes saves us from any loss of bone except that it is very loud, especially if you are the patient. Right? All right, good. Okay. And again, we’ll mobilize it some more. And you can hear the sound is slightly different now. Okay, we start to seeing it mobilizing into the, there we go. It just mobilized on the distal which is thinner. We’re going to quickly and surely mobilize the anterior portion. Do you see it? I just want to make sure we have it all mobilized. I’m using a sinus lift curette. This area is a little bit wedged in the mesial part. And we will keep mobilizing it. Alright, good. Alright, we’re gonna switch to a thinner site expander because I want to be able to exert some pressure more on the mesial as it’s not mobilizing as fast as I want it to. Here we go. Make sure that we are underneath the sinus mucosa and we are. There we go. Good. K. We are now up to four and a half, but the bone is pretty solid. Going to be reamed. Alright? So because please open a little bit wider, if you don’t mind. Because this ridge is so wide, I will go a little bit wider. I’ll go to six millimeters in diameter. Okay. And I have a nice wide palatal excuse me, buccal shelf, so I will favor it in my reaming. I’ll take more of it. So all of this bone was shaved off of the buccal shelf. This is the side expander. So now we know that we will have mobilized, we have mobilized the sinus. What I want to know now whether I mobilized air or actually the sinus floor. So we will take a curette and gently feel that we have something resisting my pressure. I feel it on the mesial, on the palatal, on the facial and I think more importantly, do I have it on the distal? That’s the question. Are you okay? Now I’ll take the Surgicel and we’ll just lay it across. Take this from you. And we’ll let it get a little bit of blood moistening it. I want it to stay somewhat spread, but I want it to go into the posterior part, the rear of this osteotomy. I’m going keep putting it in there. I’m really using this just to have a better view and to isolate if there is a little perforation this will act a little bit to isolate the implant. Then we’ll take a five point five millimeters site expander which is going to go right in the mesial, the anterior portion of our osteotomy allowing us to mobilize and pack. Okay, there is a bit of a hydrostatic pressure. We’re going to seat it a little bit shallow and then we will use a sinus lift abutment. Okay. Now let’s take some of this here. At the center of it and give it gentle tapping. You feel okay? I think you’ve had enough tapping for one day, right? Almost there. Much gentler tapping than before, very carefully, allowing it to get in to the full depth. The top, here we go, the top of the sinus lift abutment will lock against the crest. That’s it. Done. Okay, that’s it. There we are. Good. Alright, it is very tempting when we have a little bit of bleeding to make the suture extremely tight but that is really asking for trouble. That will cause necrosis of the flap or breakdown of the incision of the suture. So we will close and then reassess where we are and put additional sutures if need be. So, the testament that we have done the floor transport correctly using sinus lift abutment is that our flap is laying completely flat like when we opened it. And on the radiograph, as you can see, we have the implant placed within the crest by no more than two millimeters as the sinus lift abutment positions it. Do you see the sinus lift? Do you see the native bone? So this implant is mainly and practically only in contact with the sinus lift newly placed graft. But as a testament to the plateau designed implant, this one will integrate at the same time as the bone is turning over. There was most likely no perforation, however, we do have a bunch of surgery cells that will become part of the scar and we will have integration. Thank you again and goodbye.