Placement of a Bicon SHORT® Implant using SynthoGraft™ and the Uncovering of Two Bicon SHORT® Implants

Hello and welcome to the latest edition of the Bicon webcast. What we will be sharing with you today is a procedure for the placement of a Bicon implant in the area of the maxillary right first bicuspid. The space is quite adequate for a Bicon short implant with a height of slightly over ten millimeters between the crest of the bone and the floor of the maxillary sinus. Mesiodistally at the narrowest, which is right at the crest of the bone, we do have a little over seven point five millimeters. Our intention is to place an implant that is within the confines of the crest. We will avoid the sinus floor. We will avoid the adjacent teeth. And if part of the implant is visible through the bone at the crest, will cover that with autogenous and possibly a SynthoGraft bone graft and use a membrane to control all of the graft and keep it in position. You see that there is a slight buccal defect. That’s easily visible. We will begin our incision by outlining the distal extent right at the crest. And we will go right up to the mucogingival junction. Then take a posterior turn. Okay. And we will extend this back up. It doesn’t need to go too far up. Make sure that the incision is through the periosteum. It’s a very loose mucosa. Okay? I want to make sure that this goes right against the bone. We will then turn it to preserve the papilla of the canine. And then continue on past the mucogingival junction. And then right up to give it the paddle shaped appearance. Okay. We’ll begin the dissection of the flap. We will be using SynthoGraft if we need to expand the volume. And the SynthoGraft needs to be mixed only with autogenous blood. This is the apex of the bicuspid. This is the apex of the canine. Our implant is going to sit somewhere in this neighborhood. Take a bite of the subepithelial layer. Okay. So we have the sinus floor at roughly this level, is, you know, consistent with what the radiograph showed us. And it is at the level of the apex of the second bicuspid. So we want to anchor our implant just before the floor of the sinus. Since we are gonna be placing an implant that is about six to eight millimeters in length, we will make our osteotomy, initial pilot osteotomy, to adapt first of six millimeters to make sure that our location and angulation is acceptable. Slightly angled mesially, we can easily rectify that since we haven’t committed to the full depth of it. You have to use a kind of a pumping action. We are at eight millimeters. The bands on the Bicon instrumentation are, between six and eight, and then between eleven and fourteen. So I don’t want to reach the, the second band because that will mean I’ve, gone into the sinus. And so we are now at roughly about nine millimeters or ten millimeters. We’ve corrected the angulation. This is two point five millimeters. We are at a depth of about eight millimeters and this is about nine. What we see again is the same marking. The first band begins at six. The second at eleven. The first band is between six and eight. The second is between eleven and fourteen. Are you okay? Okay. We’re starting to collect a little bit of blood, excuse me, bone. And this is a crucial reamer because this is the one that I use mostly to determine the actual bone density. Plus, it is probably the first size implant that I would, use, in case we want to stop reaming and just, place an implant. My goal is to use a four point five, certainly, at least a four millimeter, implant. We are now, at eight millimeter from the mesial and distal bone. We are now excuse me, at six. Now eight. Now just about ten. Okay. If you look closely, you see that the bone, although it’s still existent in the facial, it’s actually so thin as to be translucent. Before I continue, I will make sure that we do have a floor, and we do, and that we are weak only in the buccal, not on the palatal. I would rather have to graft the buccal and the buccal only. The palatal tissues are very hard to maneuver around and to control. So we will favor the palatal, keep it thicker. And if we’re going to dehisce through any portion, it would be through the buccal. Now, when you introduce the instrument, if you twist a lot, you will cut a lot. If you push a lot, you will expand more than cut. In this case, we really don’t have a lot to expand. So I am going to try to ream it. If the bone actually splinters, it’s okay. We will grasp it. That’s the whole idea of today’s exercise. We knew that it was going to splinter and we’re going to go to four and a half as a matter of fact. And you see that the bone is slightly, slightly moving. So as I design the positioning of the implant, I am taking into consideration that the shoulder of the implant will be placed within the crest. So the very top of the implant is going to be about two millimeters from the very top of the crestal bone. Okay. There is no opening in the sinus. The palatal wall is intact. The mesial wall is intact, it has a spongy feel to it. You know, a cancellous feel. Therefore, we are not violating the bone and getting into the root of the adjacent tooth. And the distal wall as well. We know that this is the apex of the adjacent bicuspid and we are well away from it. So we will engage the inserter-retriever, which also has markings as to the depth. You will see those when we zoom in a little closer. And these are at two and three millimeters. We want the implant to be between those two marks from the crest. So as you see now, I can maneuver this implant. It is not a screw, but it can be twisted in place. That gives it more stability. And if you look closely now, you see those two lines? The top of the crest from the mesial and distal, of course, is between those two. We’ll take advantage of the need for grafting to reinforce the buccal plate to create a better gingival profile. The blood that we had collected is a coagulum, but that’s not going to be an issue because we can break up the coagulant to moisten graft. And we mix it quite a bit. We want to break the surface tension at the mouth of all of these micro and nanoporosities so I can sort of have a reasonable expectation of the final bone graft to be thoroughly imbibed. And that will sit beautifully there. We will use a retention suture. And that’s a suture that will go from the palate into the surgical site. And then will go in the very depth of the surgical opening. We’ll take the autogenous bone, pack it over the shoulder of the implant, and immediately at the surface of the bone. This layering helps create an optimum Q tip, yes. Fill that again. We just lay it on top, it imbibes the excess fluid. We want to fill that gap right here. We want to create the root eminence again, if at all possible. At least fill it so that upon a high smile, we don’t have that dark shadow that defeats the purpose of all of the work that we are doing. Then I will take a chromic five-zero and four-zero chromic gut suture when the time comes to close it. First, I’ll take a little more of the graft. I want to try to get that there. We will overfill it. As always, you will overfill any graft area whenever you’re using autogenous or a synthetic grafting material. You want to overfill it. If you’re using a non resorbable membrane, the membrane must be a lot smaller to be away from the incision, or better yet, you make your flap a lot bigger. Slowly and methodically, you will position the suture so it becomes sort of a strap, a double strap on either side of the implant that will hold the membrane in place, as well as hold the graft underneath the membrane, positioned right around the implant. What I want to do is keep the head of this. It’s okay. Okay, here we go. Okay. Once we get one of them, I will reposition that. It’s the tedious part of the whole process, It’s this step, but it is crucial to be patient. It is crucial to do it properly. Otherwise, of the work will go to waste. Now the graft and the membrane are secure. And that basically is the whole purpose of this exercise. You don’t want to take your bite with the suture. It’s a pretty big suture. It’s four-zero. You don’t want to take it right at the very tip. It will choke it. So we take it slightly below at when it starts to widen up. And, there we are. We will use a figure of eight suture to strap it down in the center. Okay. And this is where we have it. It’s approximately two point five to three millimeters below the crest, well within the tolerances. That is the shadow of the graft that we placed in there. And as you see, it has a couple of millimeters away from the adjacent roots and it is away from the sinus. So we’ve achieved all of our goals. We did not compromise anything. Not the placement, not the positioning, not the angulation. We did not have to go into the sinus. We were able to regenerate the dental eminence for the aesthetic zone. What I will do for this case, we have, as you see in front of you, two also four point five by six millimeter implants placed in the area of the posterior left mandible and that had required coverage of the shoulder with a bone graft with membrane. They are placed exceedingly close to the posterior one, at least. Is very close to the mental foramen. However, there is no paresthesia or any neurological symptoms. So we will go ahead and uncover the two. As soon as they are uncovered, the integration is verified. We will then I’ll turn it over to Dr. Morgan, who will proceed to take the impression and shade and bite whatever is necessary for the final restoration of these two implants. I will try to avoid a complete severing of the attached gingiva right at the neck of the adjacent cuspid. Here is the top. Looking good. Looks real good. And just come right up, hugging the distal surface of this tooth. Good. And we now see the top of this implant and the top of this other implant. Okay. And we see that there is bone all around. Okay. We will, just remove a little bit of that excess bone. Very nice, thanks for making us look good. Alright, we’ll clean up. You want to see a perfect round circle of the black healing plug. Screw in there and that comes out. We will check the integration using the guide pins. They sit solidly within the well of the implant. We’ll check them. They don’t move. So what we will do is apply apical pressure and then twist. This is a five millimeter reamer that would allow us to sort of shape the crest to match the shape of the hemispherical base of the abutment that will eventually be used for the integrated abutment crown restoration. Or for the PFM restoration, you would still use a five millimeter diameter abutment since this is a bicuspid. And then we will do the same for the posterior one. I will now take a temporary or even an impression post, which I could put in, and then suture around it. Good. Good. And we will leave this part of the flap open. This will granulate in and we will have additional attached gingiva by secondary intention. Okay, Doctor. Morgan now is going to go through the exercise. I didn’t seat those fully and lock them into place of selecting different abutment types, different restoration and so on types. He will show you again how to take the impression. Thank you, Doctor. Daher. After taking the impression, the only portion that should come out into the impression material is the acrylic sleeve. Nothing could be simpler, it’s nothing more than a round peg in a round hole. As I have mentioned before, I have grandchildren that are learning to write, they’re teachers, in order to give them dexterity, We’ll give them square pegs to put into square holes, triangular pegs to put into triangular holes, and round pegs to put into round holes. And for a four or five year old child, what shape do you think is the easiest to, negotiate? Clearly, it’s a round peg in a round hole. And there it is. So, you can see the two impression posts are in the implants and only the acrylic sleeves have been removed. So, we’ll take a little GC resin and we’ll take just a minimum amount of acrylic on the acrylic sleeve. If it’s too high, we can trim the acrylic sleeve or alternatively just take the impression on the impression post. Close. Is that too high? Oh, yeah. Way too high. So, let’s just take it out, and once again, can take the impression right on the impression post. Close. Always remember that the technician does not have a TMJ, so we also only use full arch impression material, impressions. In fact, the Bicon laboratory will not accept quadrant trays or triple trays. Open. And we’ll replace the temporary healing abutments that Doctor. Daher had initially placed. So, the one suture that Doctor. Daher has placed will just hold that tissue in place near the canine. We could consider ridge splitting for the first case. The span mesiodistally is very tight. The other limitation is the way the curvature of the bone was. It comes up to a very thick root in the canine, and another one in the bicuspid. And the other limitation is, by the time we get to adequate width, we are in the sinus. So it would have had to be a combination of a ridge split and possibly a sinus lift. Doing that in a closed or a split thickness technique would have been technically much more difficult than the actual graft. At the same time, this allowed us a chance to preserve the papillae. A ridge split technique in the aesthetic zone, as you know, undermines the interdental papillae. So in this case I feel it was a better choice for the safety of the sinus and the protection of the dental papillae. Well as you see, the ridge itself was exceedingly thin when we placed it. When we placed those two implants, we had a ridge that was roughly three millimeters at the very crest. It was widening enough, but we couldn’t go any deeper because of the presence of the mental foramen. So we stopped at the mental foramen. We were left with about a third of the circumference of the shoulder and the first plateau outside of the bone. So instead, we elected to do a, again, a bone graft with a membrane. We used only autogenous bone and a resorbable membrane in there. Yep. Yes, we do try to achieve the widest diameter implant within reason. You have the latitude with the Bicon implant to get pretty close to the adjacent teeth. You get within one millimeter and you’re fine. You can get within even less than one millimeter from either cortex and you will be fine. You will have integration. The idea is that we want to increase the surface area without having to use a much longer implant. So we try to get to a wider implant. If the widest is four millimeters, so be it. If the widest is six millimeters, we will go after that diameter. Four point five by six is adequate for any molar, for any bicuspid. Five by six and five by five as well, and six by five and six by five point seven, all of them. Thank you again, and have a great rest of the day.