Placement of Bicon SHORT® Implants after a Ridge Split, Uncovering of Two Bicon SHORT® Implants, and Placement of a Bicon SHORT® Implant Using an Internal Sinus Lift

Good evening Kiev! I’m Shadi Daher an Oral surgeon. Today we will be completing a case that we started with you a few months back and that is the uncovering of the implants in the upper left. And on the mandibular or the lower right we will be placing implants in a ridge split. And so when we make this incision, we will not open the flap to the buccal, only slightly to the lingual. We will find the crestal cut because we don’t open a very wide flap. If we need to see more, we will open it toward the lingual where the bone is still attached so it retains its circulation. And so in this case, what I’m trying to find out is if I can mobilize the bone flap with the curette. We’ll take retraction suture. And the retraction suture will just allow me to see a little bit better. And all we retract is of course the lingual tissues. So the idea is using the curved chisel allows us to avoid the interference of the maxilla. It requires a lot of patience to do this. Okay. Separate it in the anterior portion. Okay, you can hear the sound is a little different. And so what I will do now is place the implant. One way to be extra careful is you can use a slow speed pilot drill. If you feel that you are a little too close to the bone, don’t even need irrigation, but we will have good support. That helps separate. We will go back to high speed in just a minute. And you can do this with the Bicon pilot drill very easily because it’s very sharp. We will first check the location using paralleling pins, suction in the bed. We can’t make the initial pilot hole for the mesial implant too close to the tooth. It has to be more distal than you think because the cut in the bone will make the implant fall in the gap between the bone and the soft tissue. The gap between the soft tissue and the bone. Now I will use a periodontal probe to make sure that A) we have a floor to check the depth again and to make sure that we have an osteotomy that is below the lower cut in the bone. In this case, I will make it slightly deeper. It is okay in terms of depth, but I want it deeper a little bit. Whenever you use the mandibular ridge split technique, the bone on the outside loses roughly a millimeter or two because of the cut. So we always play, if possible, try to place the implants at least three millimeters or so below the crest. Right now we’re using the two point five millimeter reamer. We will collect the bone that comes out of the osteotomies. Okay, we are now at enough width to be able to get a curette in to make sure the walls of our osteotomies are still intact. And it’s very crucial to do that. What I start worrying about now is because we’re getting to the wider sizes is that the two implants don’t get too close together and the osteotomies are still well separated and that’s a good thing. Now to slow down the reaming speed, I went to a hand reamer which is mounted on the extender which makes it a latch type reamer. Once I find the bottom of the osteotomy, I can go faster. Now there is a little bit of a risk of having the edge of the reamer as it’s rotating clockwise, catch the edge of the bony flap because we’re close to it and peel it off of its attachment. So what I will do in this case, which is kind of unorthodox, is to reverse the spin. This will help us avoid that. It is still cut. You notice that the motor has a higher pitch. This is what it sounds like when you’re going in reverse. Now back to clockwise rotation. So if you look closely, see that I am moving the whole side as a unit. That’s the split. There we go. We will now grab that. We will use the seating point to seat them some more. So before today, this ridge was approximately three millimeters wide and now it is a little over seven and a half. Use the little bone that we’ve collected over the shoulder. Then, we take a Q tip. We will now use the collagen plug to just bridge a little bit of this void. As you see the nerve, the mental foramen is right here and the implant is pretty close to it but it’s not through it so it’s fine. The patient will be given a prescription for a steroid. This is what we had pre op. The two implants required a minor sinus lifting. This is the immediate post op as you may remember it for those of you who are with us at that webcast. That was on October twenty eighth of last year. That’s it. So as you can see there’s new bone formed have to engulf the implant. We will make a straight incision as much as possible. I’ll open it a little bit then we will do a little split thickness. We’re already seeing the black plug. The most critical part of the second stage procedure is the actual soft tissue development. What I’m unable to get because the opening is kind of small is to, just give me the needle holder. Okay, there we are. Now, lovely. We’ll use a plug remover. And the other. We’ll take now guide pins. We check integration. You can see, this is solid. I’m moving the whole head. We’re not going to take the impression today because we just did surgery on the mandible. The main thing that we have to ensure is that these abutments actually stay. I put it in my finger pressure and try to pull it out. Now we’re going to make these look like they’ve always had this gingiva around them and that’s by suturing the anterior edge first. What we will not do is suture in the middle because that will bring this, the papilla down. We don’t wanna bring it down. But what we will do is a vertical mattress suture in the anterior or the mesial papilla. Okay, we’re finished. We’re going to move on next door for placement of an implant in an internal sinus lift. Okay, we have the radiograph in front of you. The implant will be in the area of the maxillary right first molar. This depth of bone is approximately three millimeters. When we finish our osteotomy, we’ll be hitting the bone in this area and this area, which is about four-five millimeters in-depth. We will make a buccally based incision at a semilunar, turn to the left. We will use a hypodermic syringe. Then we will just simply peel back this tissue to expose the bone. We will use a retraction suture. So now you see the width of the crest. And we’re using the sharpness of the Bicon pilot drill to start the pilot hole. And what I’m drilling is to a depth of approximately three millimeters, no more. Verify the position with the paralleling pin this time. Bone is very soft. We are now at four millimeters. We’re starting to expand the buccal plate significantly. We’re at four point five. And for the five millimeters, I’m going to use the expander first, then the reamer, then the sinus floor osteotome. And again as you notice I am not twisting it at all toward the buccal plate, it’s just being pushed out by the back of the osteotome. Now we’ll take the sinus floor osteotome and the mallet and fracture the floor if possible. Now I’ll tap it a little harder, push hard. As you hear now the sound is a lot softer. And so this is the bone graft in the dappen dish and this is the blood that we collected and then we mix it. Okay so this is the bone graft we And you want to mix it as much as possible. Theoretically this helps it work faster. Before you start with the introduction of the graft into the osteotomy, you must have everything ready. So the first thing we have ready is the implant introduced onto or placed onto the inserter-retriever. Then using the Bicon metal syringe, we want to place most of the quarter gram of the graft very gently in the socket. Now to start really doing the sinus lift, we will use the four point five millimeter expander and we tap it very slightly. That will start introducing the graft. Now we will place the implant. Now the reason I am using this instrument to tap the implant in is because if we were to place the sinus lift abutment from the beginning and tap it with it, we risk locking the sinus lift abutment permanently. And then we will use one of the seating points, the two point five or the three to seat this implant fully. And then when it starts touching the bone you’ve got to keep tapping it slightly. All set. So as you can see the sinus lift abutment is flush with the bone on the top. You see that the sinus lift goes from about approximately six or seven millimeters posterior to the implant all the way up to the root that is mesial to the implant. So if you look closely, the floor of the sinus can be made out. This is the little piece of bone that we’ve lifted up. Thank you all for your help.