Placement of Bicon SHORT® Implants and Internal Sinus Lift using SynthoGraft™

Okay. Great. Tokyo and Hong Kong. Good evening to both again, from Boston. Thank you for joining us. Thank you, Dr. Morgan, for setting us up. We have we’ll be placing some short implants today. Can you see the X-ray? We will start on the maxillary right, the areas of numbers four and five, which would be numbers one four and one five in international speak, we will be placing six or five millimeter long implants, thereby avoiding any need for sinus manipulation altogether. We do have a second case after the after this one for you. Any questions before we start? Alright. So initial incision will be made in the crestal fashion, and we will develop sort of an envelope flap, but not over stretching it, protecting the papilla and staying more toward the palatal, especially in the area of the canine, brings us to the aesthetic zone. Okay? Just using a blunt dissection technique. Okay. This allows me to just open up the incision without too much trauma to the tissues. Controlled force allows us to peel open buccal. Okay? Now we will use a retraction suture both on the buccal and palatal. This is one of the compromises you do or you have to make for a crestal incision. When you have a crestal incision, it is very easy to develop. It’s very easy to dissect. You see very well with it. It also doesn’t compromise the circulation or really the aesthetics of the case. However, you need to retract both sides because you have essentially made two flaps. Essentially, if I can, I try to make a trapdoor flap? But in some cases, when you see that there is a weakness where the scar at the crest itself is pretty prominent, there could be a compromise of the circulation that could lead to a necrosis of one edge of the flap. And for that, we will have to go to a crestal incision. Okay? Which is okay. It just takes a couple of seconds extra. A crestal incision is not also appropriate for, placement of a, an internal sinus lift or a floor transport, as then the incision would be, right over a void, which can lead to its breakdown. And when you have the sinus cavity right under that void, you really don’t wanna risk that. But in this case, since we’re not planning a sinus lift, we can use this type of incision. And all we need is a little bit of an opening. I will retract it whenever I need it, but at least it’s it remains open. And then as for the palatal, we will just place a, sort of a weight retraction suture. And on the end of this suture, I will just dangle my instrument. And that way, way, we have good visibility. Alright? Because if you don’t see, you really can’t do. You know? Turn to the the the best way to really space them appropriately is to estimate roughly four millimeters from the distal ridge or the distal enamel of the canine, and we’ll just make a mark. Since we’re using a Bicon pilot bur, I will apply it first and start with my pilot hole. Okay. Alright. I will just make a six millimeter or so deep perforation. Take a paralleling pin to check the location, really. I haven’t determined the angulation much or the the length of the implant, but at least I know where it’s gotta go. And for that, I know I have roughly about three millimeters from the distal. So it’ll it’ll it’ll be allowed to to migrate a little bit distally. Alright? We will move it slightly. And this will help me now determine where the second bicuspid goes. And, again, like I said, because this is a Bicon pilot bur, the point is very sharp. So instead of using a high speed round, quarter round, or something like that, I can just use a little bit of pressure, and I can mark the spot where I want it to go. And here we go. And in this case as well, I will be placing okay. So I didn’t go in any significant depth, about three millimeters. So now I have a way to check the position, angulation, parallelism, etcetera, without having been committed to where it’s gonna go. Now we’ll go ahead and and finalize the depth, location, and angulation of the osteotomies. As you see now, I will use pumping action. They go to a depth of roughly seven to eight millimeters for placement of a six millimeter implant. Why not use the five, Shadi? Yeah. In the distal, we will. In the mesial, we’ll put a six since we have the depth. In here, we’ll put a five millimeter implant. So I only need to drill to roughly about six or seven millimeters. Thank you. OK. And here we are again. Good. So now we just reduce the speed to roughly about fifty RPMs, and we’ll just go ahead and finalize the osteotomies. And we progress just logically four and a half excuse me, from two and a half to three to three and a half, etcetera. And I’m going to a depth of about seven, eight on both. Alright. So now the bone is pretty soft, if you will, very porous. So I’ll go ahead and switch to a hand reamer, thereby transforming the character of the bone. K. So the hand reamer cuts a lot slower. It will also expand as it’s progressing in, and it as you can see, it collects quite a bit of bone. And slightly to the left, so show them a little bit more. Stay over. Alright. Now I’m going to selectively ream out from the palatal and distal only because I’m very thin on the buccal. What this does, it if it’s gonna do anything, it will expand slightly on the buccal and remove from the distal. Are you okay? A lot of pressure. I’m stretching your teeth, but there’s no pain. We are at four and a half now. Make sure that we have a floor, and we do. And we have four walls. And, again, in the in the posterior part, I don’t really need to worry about the thickness of the walls and the spacing, etcetera, etcetera. And so we went ahead to about six. We will do the same thing here by selectively removing bone from the palatal and distal only. So what we do is use the, hand reamer as a site expander by tapping it. Okay? Gotta get in position here. Suction right on the osteotome. A little bit of hammering like that. It doesn’t hurt. Just as noisy. Right? Yeah. Breathe. You’re okay. Good. You wanna make sure we have the appropriate depth. And, of course, with and we’ll take two five by fives because we can always finish up both. Good. Alright. Excellent. As we are preparing to place the implant into the osteotomy, we will always handle it right through the plastic bag that and keep it sterile on the inside. The, black plug and carrier come attached to the implant. You can use just that to place the implant, or you can use an inserter retriever. Retriever. We will I will show you both. For the posterior one, for the distal one, we will place it just using the inserter retriever. And that goes just press fit in there. He misspoke. What are you saying? He’s placing the distal on with polyethylene plug. Right. Did I say with the inserter retriever? I’m just gonna make sure you’re awake, Dr. Morgan. Don’t know if if our colleagues in Tokyo can hear Dr. Morgan’s comments. Always the colorful ones. Okay. Great. So you can remove and cut it outside the mouth. You can also leave it and cut it right in place. Either way, you gotta give it a little twist to lock it in place, and that’s one. Hold this. You will first remove the polyethylene plug. Secure it. Then take the inserter retriever. Engage it. And now you have a nice big handle. Handle. And then we’ll have you turn a little bit more to the left, if you don’t mind. And we go ahead and place the implant with the full depth of the osteotomy. And as you know, this is a friction fit fit implant. We can tap it into place to see that the final millimeter or so. Sorry. We will stop. We’ll just do this side. Okay? I won’t strain you for today. Just wanna make sure that we have the proper angulation of these implants because having ultra short implants, the and having them in a friction fit configuration or design, you have to be sure that they didn’t move as you’re kinda manipulating the black healing plugs, etcetera, etcetera. I’m gonna just tap the back one a little bit. It seems a little bit too shallow. You want these implants to be roughly two millimeters from the crest. Good. And what I don’t like about this one is that it didn’t go as deep as we had prepped it for. Okay. A bit of tapping. Yes. Thank you. So we check the angulation of this one. I like this one and of the posterior or distal one. Okay. Will these two implants work for you, Dr. Morgan? Fairly lift? Dr. Daher. So what I do is just cut the plug outside. Yes. The key is, however, to lock it in place using a twisting motion or a little bit of tapping. The key is to lock it in place because it can move. As you will see now, I’m showing you how to also cut the black healing plug in the mouth. And as you can see, that kinda squeezes it a little bit. And if you’re not careful, you could move the whole implant. So put the black healing plug cutter right on the crest of the bone and squeeze, and usually that cuts it like so. Alright. Good. We will take the bone that we secured from these two osteotomies, and they weren’t you know, remember, those were very small osteotomies, and it was a maxillary type four bone. And yet we still have enough bone to cover over the shoulder of the implants, which especially for coated implants, but for all Bicon implants, works very well to allow the entire integration of the surface of the implant right up to the very crest of the well. Take the bone and you sort of just squeeze it onto your curette. Okay? That kinda dries it out a little bit, but it makes it sticky. So it gives you a very easy vehicle to carry it into the mouth, pack it over the shoulder. It may hide the black healing plug temporarily. By the time we come to uncover it, the black healing plug will be visible again as the bone consolidates over the implant mainly. And, again, we are packing. This is unique among all the implant systems. This technique of harvesting the bone and using it immediately over the implant is a great advantage. One of the main reasons I have started started using Bicon thirteen, fourteen years ago, fifteen years ago, and I have stopped. So we remove the retraction suture. I will now take a dry gauze and gut suture. K. The closure will be through a continuous suture. Make sure you don’t overtighten the sutures. Retract, please. Okay. The next case will be slightly more, I’ll have the x-ray up, we will be performing an internal sinus lift. This case, even five years ago or even less than that, we would have been treated by a lateral sinus lift initially, and then an implant placement six to eight months later. With the Bicon short implant, with with the SynthoGraft, we can shorten the treatment time by up to eight months by placing the sinus lift and implant at the same time and using SynthoGraft, which coalesces in five months. So this patient will have an implant placed today that is five or six millimeters long with two-three millimeters sinus lift, which is all we need, and then we’ll have the restoration placed in as little as five months from today. Alright? So I’m going to go on to the next room and get started with anesthesia. I’ll answer questions as we are in the room, okay? K. The blood going on. So we’ll reflect the flap now. Okay. That’s it. I’ll take the syringe quickly, please. Now we will just collect the blood from this area. This will help us mix with the SynthoGraft without having to draw from anywhere else. SynthoGraft should only be mixed with patient’s blood. Because we are right over the sinus, I will try to not puncture through the mucosal surface. Take a retraction suture, the bite, from the thickness of the submucosal layer. Therefore, eliminating or reducing the chances of too many perforations and contamination, etc. We just retract it out of the way. If need be, we can always expand it, take the suture out. It takes no time at all. Now I have visibility and control. Okay. Great. Alrighty. The key now is to find the exact middle of this crest between the contact points. Because if you look at the bone, you sometimes will make a mistake. But look at the contact points and go through in the middle of an imaginary line that joins them. Okay. So, again, because this is a Bicon pilot bur, I will use its sharpness to mark my starting point. And this is a little too distal. This is better. And I’m gonna drill only about three or four millimeters because this really is a very shallow bone. Okay? You could go deeper and perforate the floor, that’s okay. But since we know for a fact this is a pretty wide crest, this will work. By leaving, by the way, this soft tissue, it has a quicker ability to seal over the area rather than going into the sulcus. And we’ll just go ahead and now, just use hand reamers for the whole process. Other than giving you cramps, it is relatively an easy process to know. Okay? And we will collect bone as well. And I’m reaming till about three or four millimeters. Okay. So again okay. I went from three to four. The bone is just that soft that I could actually expand it a little bit quicker, cut down on the waiting time. I’m seeing that k. Don’t suction now. Do not. Okay. So now we can apply a little bit more apical pressure. That will still shave off some of the floor of the osteotomy, but being careful. Okay? So now we’re at five. As you can see, we’re getting quite a bit of bone here. I want to see the osteotomies, walls, etcetera. So I can feel a pretty thick floor. Okay. Suction everything now? Suction everything. Good. And come out. We wanna make sure we have a palatal wall and mesial and distal walls. Excellent. K. Let me have the curette. Thank you. Collect all of that bone. Often the sides of the osteotomy are, than the sides of the floor are a little bit shallower and because these are the ones that we all have to fracture, we really want to be able to get to a proper depth so we don’t have to really do too much hammering to get the sinus lift complete. And as you can see, you know, in Hong Kong, there is a technique where you put the graft in and you grind it in there. And that’s all fine. I don’t have the patience that you all have. So I’d rather use significant amount of reaming and then use an osteotome, which was specifically designed for the Bicon implant that allows us to do what we need to do. So this is the osteotome. Okay? Has a rim that’s sharp. It’s got a a tip that’s six millimeters wide. Okay? And we’ll introduce that right to the floor of the osteotomy. A little bit of tapping now. Okay? And okay. Did you hear the difference? We just accomplished the fracture. See, we’ve moved in. Remember the osteotomy was just about four. Now the rim, or the markings at the rim of the bone is at six. So we don’t lift the sinus, we just fracture the floor. Take SynthoGraft, quarter gram, fine. We then mix it with the blood that we collected, which is now kind of clotted. Alright? The bone that we’ve collected is off to the side. I leave bone to be over the crest of the implant, the synthograph goes in the sinus. And the idea is to mix it till you get a putty like consistency. If it’s too wet, we’ll go ahead and use a Q tip or a gauze to dab some of the wetness away. But it is important to mix it enough to have a putty like consistency. We continue to kind of churn it together. If there’s extra wetness, we will don’t suction this socket, right? We will imbibe it. Okay. Now we will take a carrier. Four millimeters is the most popular size because it works for four point five, for five, and for six. You can buy wider, narrower would be kind of counterproductive because the granules start clogging it. We’ll go ahead and place the bone graft, And the bone graft needs to go in very slowly and sort of gingerly because it’s starting to lift and kind of ooze around that, floor and start dissecting the membrane itself. Okay? And as you see, a little bit of shaking and vibrating to try to give those granules a way of oozing past the floor onto the sides. And it was easier to do it the second time around as little surgical swelling sets in. We use a little Q tip to imbibe it, that way I can see the osteotomy, all the bone in there. Yeah. Okay. And then we take the implant that goes in. Spin it a little bit. This allows the granules to escape. I’ll take the mallet now, please. So that’s a six by five point seven, or six by five. A little bit more tapping. What happens now is there’s a little bit of the rim that has to be overcome because the true dimension of the actual osteotome is about a tenth or zero point one five of a millimeter narrower than six. So as we look in, we want to see how high can suction everything there. I want to seat this implant a little bit deeper, because if you the sinus lift abutment to tap the implant fully, we may lock in the sinus lift abutment a little bit too much. And that carries a little bit of risk. Now, one other thing you can do now, because this implant will be only partly in very solid bone, you can actually change this angulation again, but I like it this way. Alright? Why is my head always in the picture now? Hasn’t been all morning. Alright. Good. Alright. So I’m gonna tap it a little bit more. This will go in a little bit easier now. Suction right on it. Okay. Come on quickly. Okay. Good. Now I’ll disengage it. We’ll take the sinus lift abutment. You can carry it with a you can carry it with an abutment holder. You can carry it with a rongeur. Okay? The easiest way of carrying it right now we haven’t come up with anything easier, don’t think is with the suction tip. And the suction tip will go right there. And because the mesial and distal rims are higher, I’m going to orient it so that the narrower part this abutment has a wide, six point five, and a narrow side. I will make the wide side to go buccolingually. And that will allow us to seat it a lot better and more fully, if you will. And before I seat it fully, I will take the bone that we collected. We’ll pack that underneath it. Don’t worry. This will stay there. K. This is bone and a little bit of SynthoGraft. And put the, the green point on it, please. Okay. What I would like to do is put some on the palate as well. For that, I’ll use a curette, and I’ll take some of this bone. I got this. I got I’ll give it back to you. I promise. I know. Okay. No kidding. Getting bigger. Okay. This will allow us to secure bone right between those two. Not that it’s necessary, but I had all that bone and nothing to do with it. So I’ll take the point, the mallet. Hold this, please. So the abutment has a point in the center. Now you’re assured that that your implant won’t float into the sinus, but at the same time, it will be at exactly the right depth because this puts it at exactly two millimeters from the crest. All right. Now, you don’t have to have a very conservative flap, but bigger flaps, although you see more, but it takes a lot longer to close. Also, they’re associated with more pain, more risk of infection, risk of breakdown, etcetera, etcetera. So if you can perform the same procedure using a conservative flap, why not? It’s closed easily, patients have less discomfort. It all works to our advantage. And if you design them correctly, then if you need to go to a wider flap, it’s very easy to do. Okay, now we can unmute both sites, so we can hear comments and questions. Comment on the use of the sinus lift abutment that prevents the implant from going into the sinus. The diameter of the The sinus lift abutment acts like the the head of a screw or the head of a nail. It’s wider than the diameter of the of the implant at its widest dimension. So as we’re tapping it in, okay, it can’t go into the sinus because it’s wider than the osteotomy we have created. I saw you pack SynthoGraft in between the implant and the sinus lift abutment before you actually tap the abutment into place, right? Right. And will there be some bone graft material cut cut cut in between the two and and and will stop the abutment from fully seated in the implant? That’s a good point. I actually, I seated the abutment fully before I put the graft and then tapped the whole abutment implant assembly completely into the osteotomy. So what I placed the graft wasn’t really a synthograph. It was just a trace at the end. It was really all of that bone, and I placed that in between, right over the shoulder of the implant. You don’t need to do that. I just had all that bone and I didn’t want to waste it. So even if you left that area to fill with a blood clot, you wouldn’t wouldn’t have a problem. But the point that you’re asking about, if I did not seat the abutment first into the implant, then what you said would be true. But I did seat the abutment in the implant. Therefore, it will will have completely seated, but then the entire abutment and implant together were fully seated further later on. Have you ever had an experience of knowing, you you you dropped the implant into the sinus? Yes, just last week. No, of if you don’t do enough of those, you may have those kind of experiences. The idea is, okay, to be very careful and look for every step. When implant is lost a little bit, if you have paid attention, if you have maintained the integrity of the mucosa of the sinus, or if you’ve created a hole and yet was able to patch it with something like a collagen tape or some, Surgicel, then that implant won’t go too far and it’s easy to retrieve it. Okay? The fact is that if you think you are going to lose the implant either use the inserter-retriever or put the implant using the sinus lift abutment as the holder therefore or thereby you limit that risk okay? I have. But it hasn’t happened in a while. Shadi? How do you retrieve an implant if you’ve gone too far into the socket? I mean, if you’ve gone unexpectedly, too deep? Right. If I’ve gone ex unexpectedly too deep in the socket, because now the implant is really floating in the sinus, I will use the suction cannula and go in and bring it close to the surface. Okay? And then grab it with a rongeur and I may have to open the osteotomy a little bit more to be able to retrieve it out. Or if I could just reposition it in its place, hold it from the side with a curette and introduce an abutment into it, and secure it, then I’ll just leave it there. And we’ve had that. For those of you who have taken the course, the basic course, this is one of the cases that we show. When the implant went into the sinus, we lifted it up, and we just secured it in its place, and we left it back, and it’s integrated and restored and everything. The idea, you just wanna get it within three millimeters of the crest as long as it’s not moving. And usually within about two hours, you have a clot in there that will prevent it from going anywhere. That also is have a healthy sinus. So if when you retrieve it, do you put a wide implant in or what? You place the same implant in? Right. Just pull it out a bit and place it? If you can there are three options. Okay? If you had to remove a lot of bone, you may not have the option of putting a wider implant in there. Let’s say you started with a six millimeter wide implant. There is nothing wider. Number one. Number two, if you can’t she our patient will will say hello to you in just a minute. If you can, like, let’s say you place the five, then you go to a six, and that’s fine. But if you just bring it up close to the surface and you can secure it, that’s the third option. Now, one option is to, you know, and that’s in patients who have other compromises, is just to leave it for another one in. Shadi, comment on any sinus precautions that you’re concerned about? That’s a very important point. Thank you, Dr. Morgan. When the patient is discharged right now, dismissed, they are asked to avoid blowing the nose, especially in the immediate post op, three to five days. They are asked to avoid taking going on a plane, avoid sneezing with their mouth closed. Avoiding sort of pressure, positive or negative, on the mouth or nose are the general precautions. In this case, because we can see, as you can see, do they all see the X-ray now? We see that the sinus lift is well contained, which means we don’t have a perforation. Those precautions are extended for three days only. If we had perforation that we had repaired and what not, the precautions are five to ten days. Could you comment on the removal of the sinus lift abutment? Oh, well you could comment better than I can since you’ve removed more of them than I have. But it is because we did… More of the implants you mean. I’m not going there. But once you get to the second stage I know what you meant! But they didn’t. You didn’t have to go there. So the point here is that the sinus lift abutment is made of polished titanium. And as we uncover the area, if you see the entirety of its surface, you should be able to grab it with a rongeur or a holder of some sort. Just give it a slight wiggle and pull down. It should come out. If it doesn’t come out right away, then grab it and tap down. Don’t try to luxate it like you’re removing a tooth. Because if the implant is not integrated, it just needed a little extra time, you may remove the implant. Okay? So just take it very, very gingerly and it should come out. How far did you do the pilot drilling? How many millimeter right before the floor? I drill I pilot the pilot drill depth was was four millimeters. All of the osteotomy was four millimeters deep. Then it was about five millimeter total? Yes. We had about five millimeters. At the at the shallowest part, which is in the center. And when we get to six millimeters, the sides, mesial distal palatal buccal, it’s probably two millimeters left. So it’s probably six millimeter deep. So Thank you. Thank you, Taro, Mina, everyone in Tokyo. Appreciate your attention. Thanks.