Placement of a Bicon SHORT® Implant using an Internal Sinus Lift and SynthoGraft™

So Good afternoon everyone, it’s morning for us. This morning we have a maxillary right first molar. It was painful, it was becoming pretty symptomatic. The decision was to either root canal treat it or remove it. We did not do a site preservation because of the width of the opening and the shallowness of the sockets in the buccal. And this is today, the height of the residual bone is roughly four millimeters, maybe close to five. Let’s take some questions and we’ll get started. Okay. Shadi, the criteria for the the lift, the amount of lift again? From an internal sinus lift standpoint, it can be roughly, as a rule of thumb, roughly equal to the diameter of the implant osteotomy. So if it’s five millimeters, I can lift it comfortably about five millimeters. I can push it more, but that increases the risk of perforations and tears. Question to Shadi, how did you come to that empirical conclusion? Basically, many perforations. Well, you ask the question, you get the answer. The first thing I do when we are contemplating any grafting is as soon as we make our incision, we will collect some of the blood from the area. The flap will be wider than necessary for one implant. Before we continue, I’ll just open it ever so slightly. So we take just a a small tuberculin syringe or one cc, which we will use to mix with the graft. Any anticoagulant is the question. No. We we will we let it clot, and then we’ll break up the clot. It will congeal completely by the time I use it. Alright? So you see now the flap. Right in the center of that socket is where we intend to place the implant. Alright? So that’s a papilla preserving flap, buccally based and wide. So this little suture, just to help me retract this needs to be sharp. We will start our osteotomy with a small pilot hole at two millimeters under irrigation. And I only intend to make a a little notch. I’m not going to really make much of a pilot hole here. I’ll try to put a paralleling pin in there to give you an idea of where we are. And so this is a two point five millimeter hand reamer, three millimeters. As you all know, Bicon is very logical in sequence. You don’t have to guess. It goes in half millimeter increments all the time. So I’m at three point five. Four, my goal is to get as wide as I can without violating the the two millimeter zone near the adjacent tooth or the buccal or palatal cortices. We are at four point five millimeters. Before I go to it, I always check the osteotomy’s four walls and floor. OK? Now the profile of the five millimeter reamer, the tip of it is different from the other reamers. It matches the profile of the five by six millimeter implant. Again, a little bit of apical pressure. We’ve quickly reached the final size, in diameter that is. We still have to make sure that the depth of the osteotomy is adequate for us. That suction here for a minute. And the wet gauze, please. So you see, one of the most important aspects is to stay away from the mesial incision and to not destroy our buccal and palatal plates. This is the six millimeter trumpet osteotome. Okay. It has a rim, a sharp edge. Okay. Did you all see that? Just that second diffraction. Now I have no resistance, and it doesn’t ring anymore. So we have a SynthoGraft, fine grit of fifty to five hundred micron, half a gram of that. We will mix it with a little bit of bone that we got. Bone and blood. And the blood. Thank you. The idea of mixing it, at least theoretically, is that those little micro and nano porosities in the structure of the SynthoGraft will have a surface tension and the blood will not penetrate that and you end up with an area that’s resistant, or takes a long time to be resorbed. So, want to get to a of a putty. And so, first, we will use this metallic syringe, and we will then slowly, with a little bit of wiggling movement and twisting, start introducing the bone graft in there. And you feel quite a bit of resistance. I’m trying to lift the sinus here. If you find a lot of resistance, you may have to, kind of push a little bit of the the graft before you push the implant in, allowing the sinus mucosa to start lifting and relax a little bit to allow for the introduction of the implant. And I will use the implant insert and retriever. And believe it or not, tapping the implant in with the mallet is a lot gentler than trying to push it in by my body weight. It’s a lot less force used to tap it in. Now because we only have about two or three millimeters probably of contact since we will lose some of the bone contact because of the sloping shoulder, I will stop as soon as I get the top fin touching the bone. This is the sinus lift abutment. It’s a low profile. It’s about five and a half millimeters on the narrow end, about seven millimeters on the long end. It’s oblong with a little notch in the center. So we introduce it firmly. This top of the implant is going to have to sit flush with the bone. So I’m gonna twist it till I’m happy with the way it sits within the flat. We put this little seating tip that’s used for seating three millimeter implants. It sits right in that notch in the center, and we give it a couple of or a few taps until it is flat and flush with the bone. So this now is an added security for our ability to hold the implant from floating away into the sinus. How difficult is it to recover the temporary abutment? Very easy. We have a lot of footage. I I don’t know if it’s available online, but it’s really easy. We learned that if you if you take a very tight bone and you hammer it in there for, you know, seven or eight millimeters, you may engage the locking taper pretty solidly, then you’ll have to dig it out. But if you are careful and only seat the last two or three millimeters, we haven’t had that kind of a problem. How much how do you decide how much SynthoGraft to inject into the sinus? The fact is the SynthoGraft has an a function. It is not only as a bone graft. I usually inject something in the neighborhood of about a tenth or a fifth of a cc, something like that, and that’s very empirical. The idea is what and what you will see now is that you will have some SynthoGraft over the over the implant. Retracting. And, there might be some void right at the implant. As you all know, with the Bicon implant you don’t need to have that intimate bone adaptation a blood clot against the plateaus will work just fine. Shadi, last last year, you showed us the modified sinus internal sinus lift. Correct. Time, it is really a regular one. The the threshold is about four millimeters of native bone versus three millimeters or less. And in his case, if you had requested a floor transport sinus lift, we would have done the internal lift like just now and the floor transport posteriorly. You didn’t check whether there was a tear We didn’t seem to. Is it so confident? Question is, did you did you check whether there was a a tear? You didn’t you didn’t appear to. The problem was checking for any tears that I checked before I do the osteotomy, before I fracture the floor. But if you take a curette and you try to feel for any tears, after you get out the osteotomy, five you know, one out of two times, you will create a a tear. So by putting the graft in there, if I feel resistance, as I did, then that’s my sort of assurance that there has been no tears. And hopefully, the the radiograph will bear me out now. Shadi, thank you so much. That was wonderful, and it came across very well here. Great. It’s my pleasure. Great to work with you, Jeff and Clive, and everyone in the UK.