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

Good afternoon or good evening or good morning. My name is Shadi Daher. I will be performing the, procedure today. We do have over sixty seven countries, over seventeen hundred participants this evening. Some of you are here in the building. I appreciate your your sticking around. It’s been a very long afternoon for all of you. Also, we have, I think, six continents and, I think, forty five states. So I think we have probably reached a global audience as we’ll ever imagine. The fact is tonight we will be showing a live surgical procedure. This is unrehearsed. This will be uncut for you and what we will be trying to place a Bicon ultra short implant in a crestal approach through an internal sinus lift for the location of the maxillary left first molar. The radiological studies before are in this case limited to a periapical radiograph, to a panoramic radiograph and to a thorough exam and follow-up of the patient prior. If we can show the radiograph please. So on the radiograph you will see a translucency of a six millimeter wide, five point seven millimeter long implant. We will most likely not need this kind of length. We can place a six by five millimeter implant, which is what we will most likely place as it will strain the pressure placed on the floor of the sinus. We’ll reduce it slightly. What we have is a minimal amount of bone, roughly three millimeters. If you look at this translucency from the very crest to the top, this is no more than five point seven. So at the most, this is going to have about three millimeters of native depth. Even if we place the implant at the desired depth of two millimeters in this case, allowing us a better emergence profile for the aesthetic restoration, we will still have two of the plateaus or more in friction in the mesial and distal, but more in the buccal and palatal as the slopes of the bone allow us that luxury if you will. We will be using SynthoGraft mixed with the patient’s own bone and blood and that is a beta tricalcium phosphate. We will be using a fine granule size. So as you see the buccal part is nice and straight and narrow, and the palatal part is a little bit wider. There is a slight weakness at the center of the crest, which we will now incorporate in our flap so that we don’t end up with part of the flap being ill supplied with soft tissue. Can I have a Minnesota? And so we have now a we will use a fifteen c blade that will allow us to make a bucally based paddle shaped flap. The idea is although this is meant to be an internal lift, with this small amount of bone always one has to be prepared for any possible eventualities and for that we will hedge our bets and make a flap that could be utilized for a lateral sinus lift. Okay? So it is papilla sparing. We’ll open the flap ever so slightly. Now we’re using a straight curette. So what I will do is use a periosteal number 9 Molt and lift up the flap. Okay. So here is our flap open now. Okay. So we just need to collect enough of the blood even if it may congeal the plasma and the clot products will be enough to moisten all of the micro and nano porosities of the intended graft material, is the SynthoGraft. So we will just take a bite, and we will fasten the flap to the buccal mucosa. Thereby creating sort of an automatic perfect opening that we don’t need to worry about every time we carry an instrument in and out of the surgical site. We try to avoid making punctures right through the, surface of the gingiva, just to reduce the number of of entry points for any saliva or oral contents. So I take the bite from inside, the flap. So the first thing we’re gonna do now, we know that our depth is roughly three millimeters. So making a a drill, or a pilot drill osteotomy is probably not going to not going to give us too much more information. But what it does, because it’s spinning at a high speed, even if I drilled a millimeter or two, it will give us a positive marking of the center of this osteotomy. Okay? And it’s pretty soft. I can feel the bone. Now So I’m at about a depth of, oh, one and a half or two at the most. And as you can see, we’re pretty darn close to the center of that space. So look at the contact points. Imagine that line. We should be going right through the middle of it. Again. Now although this is nominally two and a half millimeter, but because it’s not getting to the full width of the parallel walls of the osteotomy, it really is acting more like a two millimeter. And so that’s why the pilot bur would not sit in there. We are now under prepping this osteotomy because if we were to leave only one or two millimeters, all we needed to drill really is about a millimeter. So we will see our implant migrating if we don’t pay attention toward the palatal, but that won’t affect the final placement because we will pay attention to it. Okay. One other way of using the, hand reamers is to actually put them on a latch adapter that goes into the handpiece. Because these latch reamers have a slight offset at the very tip, you can actually deepen the osteotomy. The Now we’re getting close to a possible size, which is a four and a half or five millimeter. Our intent is to use a six millimeter. However, a five millimeter would suffice if we had to stop then because, let’s say, of the ridge not being sufficient, etcetera. But let me verify the walls. Thank you. Okay. So now we are at five millimeter, and that’s important because five millimeter is a great sort of halfway size that gets us to a molar sized crown without any compromise whatsoever. Four and a half would be also in the same category. So what I will do now is selectively carve out the palatal plate and leave the as it’s thicker, and leave the buccal plate intact. So as you see, we can selectively go from one side to the next from the distal going to the palatal stopping on the mesial. So it’s a hundred and eighty degree rotation. Once I get into the full, depth, I will then be able to to turn three sixty degrees as well I would have expanded the buccal plate rather than splintered it. So now I will start really going after the floor as I left a considerable depth, not too much pressure. No. Don’t suction. Get the bone. Okay. So we’re getting all of that little bit of bone. Always, before you go to final size, verify that your walls, your floor are adequate and intact. One thing we have to make sure is our palatal. Great. Okay. So, again, now the buccal wall is actually about the same strength as the palatal, so it won’t favor either one. I’ll just go in circular fashion. And we are now at about a depth of roughly three and a half, four millimeters. So the center of our osteotomy, if you look if you could see closely, and I’ll try to show you, you can see already the little sheen of the green sheen of the sinus mucosal lining. We will use the sinus lift osteotome which is trumpet shaped and it’s also color coded. It’s green with the same tiger stripes. Now I try to use a straight if the mandible allows me. Now we will use an offset driver. I prefer a straight as I see better and I feel better with it. Okay, so again tapping with the mallet. Zoom out a little bit to show the mallet that we’re using. It’s a small five ounce surgical mallet. And just gently. Meanwhile, as you can see in the top left hand corner, the assistants, Janet, is pressing on the nose bridge stabilizing the facial skeleton so that the patient doesn’t feel like she’s getting a concussion at the same time as having a dental implant. So we tap gently but firmly. And it’s important to use many small taps. Don’t just whack it away like you’re nailing your deck screws. The idea is you are you okay? And now you can feel it. You can almost you hear the different tone and you can see it mobilizing. So we are now at roughly a depth of six millimeters which is well below that. This is the SynthoGraft, fifty to five hundred microns, zero point five grams, it comes in this handy vial. You see that after mixing the graft, on the corner here is the autogenous bone, some of it, which I will leave to seal over the implant and this is the graft. It comes to sort of this of putty stage. Zoom in a little bit more please. A little bit more and let me center on where your camera is. So if you look at it, you see that it’s kind of putty. We will use a graft carrier syringe, which has the same markings as the Bicon implants. You can see those three rings. Zoom in please. It’s at six, eight and eleven millimeters. Hopefully you won’t need to graft anything beyond that ever. The idea is the graft material will act as the way we dissect the mucosa off of the floor. So I’m using a little bit of wiggling action and we push it slowly. Alright but surely. We’ll use a sterilized cotton tipped applicator to just push it in and give it a, know, imbibe a little bit of the liquid out of it and slowly tapping it in place. Again, it may sound that we are hammer happy here but the fact is small taps of a very small mallet are a lot gentler than putting your body weight or your arm weight, which is a lot more than five ounces, and trying to force this very delicate area up and trying to dissect the mucosa. So this is sterile, if you want, if you’re that, peculiar about sterility, I’m able to handle it with my sterile gloves. And the little plastic bag in which the implant came, which was inside that little package, was also sterile. So now we’re going to place our, I’ll need a sinus lift abutment please. Okay, so we’re placing our implant and we will tap it to near full seating and it sounds like I’m using a jackhammer but I’m not. It’s just light taps but a lot of them. Right? Right Sheila? She’d rather be somewhere else I’m sure but nothing as nice as here I’m sure. So what’s going on? Why is it harder to tap the implant in than fracture the floor? Well we have a lot of friction now with all of this graft material. So what I will use now is a sinus lift abutment. The implant is not at full seating yet. So before I place it and seal it, I will put it in lightly and I think that in this direction it will be just within the flap and I think I’ll be happy with that. Now, because it’s a little wider than the implant, I can use this seating point that is obviously with no hold on the implant. Now, what I will do now is just tap it till it’s in the final seat. There we go. So now it just went in and now we’re going to stabilize it fully with the sinus lift temporary abutment. And this, the proof here that we’ve done our job, is when we close the flap, it should be perfectly flat. No need for releasing incisions or anything like that. Okay, now that looks great and that completes our surgery. We will now close the flap but you can see the flap now is closed absolutely tension free. There are not any sutures in there. That’s that. We will now suture it. We will close it. Now let’s take a look and see if I need more. That is what we have just placed. There is enough of a sinus lift to contain the implant. The implant is secure, it’s in the proper angulation location and at the proper depth for this restoration. The bone that you see on the mesial is mostly on the buccal side as I hope you saw from the flap. The, actual orientation matches where we we needed to go. As you, can see sometimes the top of the bone when using the sinus lift abutment will dictate where it goes a little bit more. However, the the total lift in this case was roughly six to seven millimeters from the floor of the sinus to the top of the dome of bone, which is roughly two and a half millimeters to three millimeters above the apex. This is a five millimeter long implant plus three, it’s obviously eight. We went to a depth of two from the crest. Remember, we started with two to three millimeters, so, excuse me, two plus, eight is ten. Started from three, so that gives us a lift of roughly seven millimeters. Now the Bicon implant will integrate that. You will have a, bone. This may remodel and drop down, but you will have enough bone to engulf this implant, heal it, and secure it in place. I’m an oral maxillofacial surgeon, I’m trained in oral and maxillofacial surgery at Boston University and Tufts University. I started using it back in ‘ninety three when I was still a resident. So I’ve, I’ve been placing Bicon implants in all shapes and forms, in all types of patients, in all types of locations for the past seventeen years or so. And I have used it on my own family and friends and obviously all of my patients. And I’ve used it again, like I said, in all locations of the mouth placed, I think several thousand now of these implants. And, you know, there’s nothing more I can say that they work, they just work, it’s not a headache, it’s a pleasure to see them work and integrate. The crown root ratio is not a concern, period. For those of you who are with us tonight, for those of you who have seen the Bicon short implant lecture around country and around the world, you know the science behind it. The evidence basis for the crown to implant ratio being of actually no detrimental, which is the one absolutely true statement, it doesn’t have detrimental effect on neither the survival nor the health and longevity of the implant or the prosthetics of the Bicon implants. And what we expect to show in the near future is that it possibly, in cases, will have an actual effect of increasing bone height even. But it does not reduce the likelihood of survival or it doesn’t increase statistically the chance of any complications with the implant at restoration or long term afterwards. In this case, four and five months, no more. We’ve uncovered them when we’ve had a little more of the implant in the native bone in as little as four months. Sixteen weeks, we’re uncovering them. But in this case, this entire implant is in, grafted bone. So we need to give it time to get replaced and get consolidated. The questions that, basically are confusing is basically when you see that the implant has all these ridges, it looks like it has threads. And when I placed it in, I twisted it a little bit, but I didn’t twist it in one direction. Wiggled it, you know, clockwise and counterclockwise. Basically what we’re trying to do is trying to sneak those parallel plateaus past the soft tissues. And although it looks like we’re ******** it into this, the bone, we’re not. It is a friction fit implant. After the soft tissues had been, passed, bypassed, we’re able to tap it with impunity. And as you saw, it was mostly tapping the implant. It’s mostly by friction fit, pressure. The implant is a friction fit implant. The osteotomy is prepped to the full width of the implant. There is no undercut for biting of threads, etc. The floor transport technique requires that we have narrower contact, excuse me, narrower space between the palatal slope and the buccal slope. Because what you’re doing is, and those of you who were here earlier, forgive me, I’m repeating that. What you’re doing is you’re removing all mesial and distal contact. You’re relying only on the buccal and palatal. In this case, the, first of all, the space is very tight. So in order for us to be able to have any semblance, I already, you know, just putting the osteotomy itself, we’ve occupied all of the space if we were to protect the papillae, which is what we did. So, in this case, to have more stability, we actually got some of the friction in the mesial and distal, and as you can see, the walls were higher in that area. So, at what point, if I have a bigger expanse, anteroposteriori or mesiodistally, so that I can, you know, create that rectangle of scored bone, mobilize the rectangle, and then go on to the implant placement, provided that the two walls are narrow together. In this case also, the palatal slope, the palatal vault was slightly shallower and I thought that the inside of the sinus, though I can’t say for sure, but it didn’t seem to me that the wall on the inside was very, very high and tight and so we just placed the implant through an internal lift and that works okay and works very predictably. Correct, absolutely. The implant is part of the whole. The implant becomes a surgical tool. What it does initially, sinus lift graft is placed, it fills the osteotomy. Then as you start pushing the implant, much like, as I said before as well, much like the sealer cement in a root canal treatment, the cones will start forcing that sealer and it will start oozing out to the sides. In the case of the sinus lift, the internal lift, the implant itself would start squeezing these particles off to the side, helping you dissect blindly but bluntly this mucosa off of the floor. The flat top of the implant will actually lock against these particles and will lift the floor. Now, don’t be fooled, you know, sometimes the top of that implant is only three and a half millimeters if you’re using a four point five millimeter diameter implant. So it’s not that flat and it’s not that big. And the widest, the widest apex of the Bicon implants, even this, the six point five, the very top fin has a diameter of no more than about four point three millimeters. So it’s not that flat. It’s not like you’re just putting this brick and pushing it up. It still has a point, but it is flat. It is not, you know, rounded and it’s not pointy. It is flatter than most other implants. There is maybe a bit of time and skill involved but we’re able to lift the sinus membrane distances of eight, even ten millimeters, right through the crest. The key is taking the time and selecting the cases properly. For instance, a case where the tooth was removed relatively recently, where the previous or the tooth that was removed was infected creating some adhesions in the floor or neighboring teeth have some pathology, etc, then this membrane will be more tethered and you will have a higher risk of tears. But to have a mature sinus where the teeth are healthy, the sinus bone on radiographs, plain film radiographs, smooth and all, we can, with a little bit of time, a lot of patience, lift the sinus, floor up to, I think we’ve lifted, the most I have done through internal two in tandem, was, about twelve millimeters. But as a rule of thumb, however, your best odds is to lift it no more than about a distance equal, plus or minus one millimeter to the diameter of your, osteotomy. So in this case for instance, we had a six millimeter wide osteotomy, we lifted it seven millimeters. It’s what I found to be the safe, kind of normal way of pushing that kind of envelope, okay? Of course, that’s why you have all kinds of safeguards. It starts from your design of the incision. Remember when we looked at the patient in the beginning, if you joined us a little bit late, what we did is looked at the crest, looked at the flap where it can be incised and then reflected it as if we were going to do a lateral lift, just didn’t complete the incision, reflected it partially and now had we had a problem and gone into the sinus, we would be able to retrieve it. So that’s step one. Step two, we will drill, we’ll under drill, leaving a millimeter or more of the floor intact, then we will fracture that. Now if we need to go a little bit deeper, we go with the hand reamers. So now we’ve protected ourselves from having perforations in the first place. Then what we do is use the graft in there. The graft serves the purpose of dissecting the mucosa and being the sinus lift graft, but at the same time, it’s like the little pebbles, they’ll stop a truck from rolling. So it gives us more friction and as we’re tapping it in, we have, as you saw, more friction. It required quite a bit of energy to mobilize that short implant into the sinus. So I had placed it by hand about three millimeters to get it the remainder, five millimeters or so, it took quite a few, taps of the surgical mallet. And the taps of the surgical mallet, believe it or not, are a lot gentler than trying to just push it with your body weight. I’ve done it, the mallet is better, try it, you will be able. So and then, at the very end, the last millimeter or so, we put the sinus lift abutment, which is bigger. It’s wider than six millimeters at its longest dimension. So now you have an added, you know, assurance. If you want something bigger, there is even a bigger one. In this case, the flap was very conservative and I’ve found little use for the very large ones, but this is what we normally would do and that’s your final frontier, you will, your last line of defense. Because if you push this baby in with sinus lift abutment attached to it, you know, there is nothing that I’m gonna be able to teach you online to stop you from doing it. Be gentle, be careful, and when you see it flat with the bone, stop. Don’t keep hammering, although it may be tempting. Well, let me answer the second part, first. If you have a little damage to the membrane and you stop the procedure, I mean, you can’t justify what you’ve done to the patient. So yes, we continue. We do check it. We check it basically by, first by feel and by sound. Now, if I had placed, you know, for those of you who have watched, if I had placed the osteotomy and it just went right up unhindered, unimpeded into the sinus, then that is a dead giveaway that we have basically no floor. And so for that, we need to contain the graft. Remember, if the sinus, if we selected the case properly and the sinus and the patient are healthy, Then the sinus mucosal lining is an epithelium, it will migrate very quickly. All we need to deal with is containment of the graft as it is placed in the sinus. For that, we will use a pouch like kind of configuration of either a barrier membrane or a containment membrane like a collagen tape. And then we will place our graft after moistening it, and we place it into the osteotomy. Part of it has to touch the implant and that’s not a detriment because the implant will still integrate. Okay, it does integrate because it will become part of the clot, these resorb very quickly. And so, the biggest danger is when you have such a perforation and you have, you know, green and yellow stuff leaking out of that osteotomy, then you have to make a decision, do you treat the sinus and place the implant at the same time, or do you treat them, because that’s an indication of a diseased sinus, or do you treat the sinus, which we probably should have done earlier, and wait? And so, you know, we need to make all of these, basically knowledge before action is a diagnosis, knowledge after the action is excuse. So now we start making excuses, well you had an infection. We should have known that beforehand. So the short answer that is yes, we proceed and and with patching. It just prevented me from tapping that implant right into the sinus first. And then because it stabilized at the top, it actually provided extra stability for the implant by creating this wider pedestal at the crest. If, if you go online, you will see some of those cases with the sinus lift abutment being removed. When you open the flap, it will be a crestal incision. You will elevate the mucosa slightly toward, the, buccal and slightly toward the palatal. You will then be able to engage a, bone rongeur, but a fine tipped bone rongeur on the edges of the long part of the abutment. Once you grab, the edges are thin, the blunt and the end cutting bone rongeurs will slip under. As soon as you feel that kind of click underneath, you give it about a five degree twist either way and you pull it out. It comes out very easily. Absolutely. That’s that’s also for those of you who were here earlier, you know, I’ll be repeating myself, but when you reduce the number of days waiting for a graft to heal, number of procedures, reentry, incidences, all of that, it factors into the patient’s kind of calculations. How many times do I come back? How many anesthetics? How many surgeries? How many times am I stitched up? So absolutely, without a question, we have a significant increase in case acceptance and case flexibility as well. And the ability of many practitioners to be able to offer this service when in you know, for other types of implants, for longer implants, you will have had to go through a step of major grafting. Yes. We use surgical guides, but one one implant. It was bad enough to let you see what I’m doing without a guide. You imagine if I had to put the guide in there and try to drill right through it? The fact is yes. If you have two teeth on either, you know, one on either side with the contact point and all of that, the surgical guide will do very little for you than to use your actual observation. Especially if you’re using only the pilot drill level surgical guide. When you start going into reaming, the bone is going to dictate to you where it’s going to go. So you have to pay attention, there is no substitute to that. And as you saw, we switched the technique. We went into a hand reaming technique whenever we needed to sort of control where the bone goes. So using a surgical guide does not guarantee you that you will have an implant placed in the proper space, assuming that the guide was done perfectly in the first place. Secondly, if you have a surgical guide, your best surgical guide will probably be with CT assistance and that have all of the sizes. So you don’t just guide one drill, you guide all of them, then fine, that you can use for all of them. But then it comes to a point of risk versus benefit or return on investment, if you will, in this case. And so is it worth spending hundreds of dollars on a CT and hundreds of dollars on a scan, excuse me, on a guide for one implant like this one? So we do use surgical guides, for all of you who have seen our lectures or see our cases on the Bicon dot com website, you see that the large cases, you know, multiple implants, definitely have surgical guides. We use, you need to know where they need to go, you can’t imagine them right on the fly. This has to be worked up and the surgical guide should be used not only for placement, even for the flap, the incision and flap development. But if it’s just one implant, between teeth, you can easily make a case for just using the landmarks that you have right in front of you. When you have implants in the sinus, the short answer is yes, but there’s a little bit more nuance to it. If you take an impression, and you have all of these nooks and crannies and surgical crevices and so on, and a little bit of your polyether or whatever poly something that you use, a little bit of it breaks and it’s left behind, it is going to have a serious detrimental effect on healing, granulation, tissues, all kinds of rejection reaction. So, for the sake of conservatism, I would say in cases where you had to open a flap or you have a sinus open, I would not do an immediate impression. You can can get it soon after that. Of course I use it. You can’t have an implant practice if you refuse to do the anterior teeth. Mean that’s what people come in the first place. And I’ve noticed that the patients who have Bicon implants have the good looking papillae, I don’t worry about the actual aesthetics of the case if we have preserved the papillae in the first place, if we’ve left them room to breathe and grow and stay alive. And then the key however remains the occlusion, the occlusion, the occlusion. These implants have an all or abutments have an all or non response. They have to be spot on, they can’t have eccentric loading, they can’t have excursive interferences, and they can’t have exceedingly tight contacts. They have to have the right, the occlusion is absolutely paramount in the anterior maxilla, not so much in the anterior mandible. If you place them, I usually try to go to two point five millimeter diameter three millimeter diameter wells so that we have a larger friction kind of area with the abutment post and the implant well. We make sure that all of the basics of the Bicon implant, the engagement of the locking taper, the locking, etcetera, etcetera, are all done properly and I really have, it’s part of my practice, everyday practice. After an extraction, what we do is we just contain the clot and the graft with a collagen material and just instead of doing a sliding buccal flap to, you know, close the area, which can destroy the gingival architecture, we just place the implant, allow a clot to form, we pack some bone over the shoulder as an added layer of protection and over that bone we will place a collagen plug which we will secure in place with an inverted figure of eight suture, taking care not to create craze lines that will then result in, unaesthetic, suture and scar lines. When you put the graft in, you take a radiograph, it should have a smooth, kind of round dome like appearance on the radiograph. The only exception is when you are using autogenous bone, it doesn’t have very good radiographic appearance. But if you use a graft, should have a nice smooth kind of shape to it and for that you will, you know, you’ll see it on a radiograph. If you see that the implant is just sitting there and there is no graft around it, or the graft is kind of trailing off like a cloud in one direction, then you have a perforation. Then you probably will have felt it, saw like little bubbles of blood coming out the osteotomy as the patient is breathing, or you would have felt no resistance. One of the key factors actually is when you place the graft into the socket, into the osteotomy, it filled up. There was actual pushback. And as you saw, I used an expander and I tapped, and that even had pushback and resistance. So all of these factors should give you indication that you have some sort of resistance in there And that you don’t have a tear. Well, that’s a good question. If you have the whole implant, like in this case, you have the whole implant, invested in that graft, you take a, keep a close watch on it, okay? And if you take a radiograph a week later and there is absolutely no bone around it, okay, and the patient is having some sinus symptoms, you have to remove it. If on the other hand you take another radiograph and you see that some of the graft, you know the graft has come down a little bit but it’s not entirely gone, then odds are you lost some of the granules but you had the natural seal and you have, you’re going to have integration. And that’s, the second scenario is more common, especially if you selected your cases and the sinus is healthy. Patients are placed on, Amoxicillin, if they are not allergic to Penicillin, zero to thirty minutes before incision and then they carry on afterwards for at least a day and preferably a couple of days, but they’re given a prescription for up to a week in case something happens, they are already, you know, they already have the prescription to continue, for, you know, up to a week. But usually it’s the first twenty four to forty eight hours that I believe are critical. We don’t start them the day before, though. Our patients are, are, given, if there are no contraindication, you know, from bleeding or ulcer or anything like that, they are given a prescription for or dispensed six hundred milligrams of Ibuprofen to be taken every eight hours as needed for pain. They are given sixteen tablets. Some of them may require, something, light like a Tylenol with codeine, Tylenol number three, or, Vicodin, you know, hydrocodone. I think, hydrocodone is probably the heaviest type of analgesic that we’ve used for those. But usually it’s not for one implant. And I will tell you, for one or two implants, it is more common that our patients take maybe one of the ibuprofens, if any, and that’s it. It’s a very atraumatic technique. The key is to keep your flaps small. Yes, If, in this case, the buccal plate was two point five to three millimeters, so you couldn’t see it, you couldn’t feel it. But when you get close to one point five or so millimeters, you, will feel it flex with hand reamers and with latch reamers. And that’s part of the features. That’s why I like using the implant because it’s kept me out of trouble. You know, I feel it before I break it. So, thank you again.