Placement of Bicon SHORT® Implants

So the the case that we’ve selected for this afternoon Is for the placement of two implants in the areas of the maxillary left premolars. The area of twenty four has adequate bone on the X-ray, both panoramic, which is in the upper left corner. Excuse me. Periapical in the upper left and panoramic in the lower left left corners. And the area of the twenty five has a limited amount of available native bone. That area will receive an implant as well, however, through a sinus lift by trans alveolar floor transport. And what we will be using for graft material is SynthoGraft, and the intended implant sizes will be six millimeter in length. Four and a half or five. This is a sinus lift osteotome that’s five millimeter at the top. So I can place two five millimeter implants with a good separation between the two. This is just the marker for sort of a final measurement. This is the. Those implant is a. And this allows us to also design our flap more appropriately. You see the the soft tissue here has a bit of a ridge, and that’s from the long term use of the bridge. Okay. To also not limit ourselves, we will make the incision intrasulcular. And we will make it also on the palatal slope. But we need to give ourselves a wide wide berth because of the sinus proximity. Before we start doing too much suction, please, we will collect some of the blood from the area which will serve us to mix with our bone graft. Suction for now. Any pain? About a quarter or a third of a cc is adequate. Okay. The best way to elevate this tissue is to lift it up. The retraction suture allows us to keep the flap open without traumatizing it too much. We’ll take a bite. Actually, I don’t want one. So you wanna keep your eye on this here. Okay? Can’t have much of that. Sorry. I didn’t need to gag you. Can I keep that to your eye there? Okay. Okay. Let me have local, please. Whatever you Now for the placement of the implant. In the first bicuspid, twenty four. Turn more to me. Over the lip. OK. So before we proceed too far, I will estimate the location of the implant first. Implant. The intended implant will be between five and four and a half millimeter. And so when I start with two millimeter pilot bur, I just need to extend that another two millimeters, so a millimeter to the mesial. We will check our position. Our position. Okay. I will go ahead and continue now. The handpiece before was eighteen to one. This one is four hundred to one. This now reduces the speed to fifty RPM. The original speed of the 18:1 was about one thousand one hundred. Before we continue now, we wanna make sure that we still have a floor. And we always use this is a pretty sharp periodontal probe. OK? And it looks like from the periodont the periodontium? We have it. The bone is pretty thin and soft. So when I if I find it too soft, I will switch to the basic hand reamers. And with the slow speed, you see that the bone is harvested in the reamers. No irrigation is necessary. Now we are at three point five millimeter diameter. Very slow progression. That way, we protect the bone completely. Now we will use the hand reamers because this is pretty soft bone. And the nice thing about the hand reamers, number one, they are really readily available. You can use them in a circular fashion. Or semicircular fashion. That way you can expand one side and protect the other. Oh. Like the like this. And, again, we can harvest bone because the reaming is very slow. Now always a good practice to go before the last size and check that all the walls are intact. Go all around and make sure that you still have a floor, and we have all of these prerequisites satisfied. And this is four point five millimeter reamer. This will be our final size. K? Okay. Okay. And, again, we can see that we have four walls and the floor, and I will verify that one more time. K. It’s important to verify that you have bone on the buccal wall suction right here. You see it right there? It’s still it’s still there. And I can feel it. You can feel that it’s not moving the soft tissues above it. Okay? Alright. Now we will check the depth that we made sure that we have adequate depth for the placement of the implant. And this is the depth gauge. Okay. We will see that on the mesial, it is at about eight millimeter. Millimeters. On the distal buccal, it’s about six millimeters. That is easily deepened a little bit because we have depth by using the hand reamer a few times with a little bit of pressure. That makes it slightly deeper. That’s all we need. The ideal depth of the implant in the ridge should be approximately two to three millimeters from the crest of the bone. Okay. So we have about eight now from the distal buccal and about nine from the mesial palatal. So the placement of the Bicon implant now follows. We will take a four and a half by six millimeter implant. We are using coated implant. You can use uncoated as well. However, you would need to wait a little bit longer for the integration. The Bicon implant, it comes in a doubly sterile package. Okay. This is the inside, and the outside is a is another pack that’s sterile. The this bag is sterile on the inside and outside, so you can handle it. So the best way to handle it is to just cut the bag while holding the implant. Like that. And then you use the instrument. You lift up the carrier outside. And you take it out of the bag. Okay. And we will use a little retraction. And we place our implant. K. The implant is now in position. We can now is now positional. If you twist the implant, it will lock in place, allowing you to remove the black healing plug. Because this is a friction fit implant, we wanna make sure that the full depth is engaged and the implant is fully seated. We will now tap the implant in place. A little bit of tapping. We will use Batello implant in position. Okay. You wanna make sure that it is at a good depth from the distal buccal, which is the shallower part. Chin up a little bit more. Okay? So now this implant is in ideal position, and we can verify that with a guide pin. It’s okay. This is a position I didn’t check. Okay? Alright. Now we will turn our attention to the closure. If we were just using displacing this one simple implant, we would put the black healing plug like so. We will take the plug cutter. Okay. Then you cut the plug right at the level of the crest of the bone. Suction right on the plug. Trying to leave room for the camera. Okay. Now if you possible camera. If you don’t like the top because it may be a little bit not very smooth or something, you can always shave it to make it ideal and perfect for you. Make sure you suction those pieces. Okay. So that’s a simple Bicon placement. It’s an opposition insertion during implanted Bicon, normal conventional. Alright. Now we will turn our attention to go on to the X-ray. To the distal location. Position of twenty five. Position of implant and numero vinte cinco. What we will do in this case is mobilize the sinus lift excuse me, the sinus floor and membrane, then expand the tissue. And if you look closely at the shape of the ridge, you see that it is pretty narrow. Chin up a little bit. Turn to the left a little bit. So what we will do now is we’ll take the entire crest posterior to the implant. We’ll move it up first, and then we will expand between the two cortices and place the implant. This is a very tight area. However, we are able to do that. Now I’m using a chisel, an osteotome. This one is three millimeters wide only. Okay. And you don’t have to go or you should not go through the full thickness. You need to leave a little bit so you can fracture it. This is only scoring. The headache. Okay? And I already feel it giving away. So now, we take very very small flat osteotomes that could be used for sinus lift. Okay. So the idea is to be very, very careful and not try to do everything at once. The most important instrument for this procedure is your patience. And we go in sequence back and forth. Doing alright? So, again, slowly, we continue continue to elevate the entire crest through the alveolus To elevate the floor of the sign the sinus through the crest. What happened? K. Now that it’s starting to mobilize, you can feel it. Alright. That’s all. Good. Are you okay? We’ll use a little slightly wider osteotome. Okay. And right now, there’s no need to a lot of tapping. But what we wanna make sure is that the membrane is still intact. We can verify that with the curette. Good. I like it. Okay. Now we will go to this the implant placement. We will use site dilator or expanders because these will bend the bone out, allowing friction between the buccal plate and the palatal plate to hold the implant. Not the fold. The to bend. To bend. And what’s happening is the front part is not mobilized as much. So we’ll take a little moment, and we will mobilize the front mesial part. There you go. You can see it moving now. We really like it. Now we will push the limit a little bit here. That almost and it’s very important to be patient and slow in this because as you proceed slowly, the sinus mucosal lining will develop a little bit of swelling, and the swelling will allow it to separate from the bone easier. You you would re you reduce the risk of tears. Okay? And, also, you need to sort of read what the what the bone is is showing you. In this case, we have a lot of the bone bowing out on the buccal. You can see it. So now instead of just expanding it, I’m gonna shave a little bit of the palatal. K. A little bit, and then expand the rest. Great. We could also use the reamer to five millimeters. That allows a little bit of expansion, and then we’ll finish it up. Okay. Good. And this is the final size here. Five with cinco millimeters. I won’t finish it because if you do it too too soon, you will end up with a quarter is fine. Half is fine. Either one. Give give me the the half. We will be using SynthoGraft. Zoom out a little bit. SynthoGraft. It’s a synthetic beta tricalcium phosphate. And beta tricalcium phosphate? It’s fifty to five hundred microns, grit size. Microns? Put it in a silicone dapping dish. Okay. And then we’ll mix it with the blood that we collected earlier. The blood now is coagulant, but that coagulant will give us a good way of wetting it. So instead of spending a lot of money on PRP machines using blood with SynthoGraft is all we need. Can you show a little bit better to the camera, please? Now it’s wet. Yeah. K. It’s a little bit too wet, so I had reserved some of the dry not a lot, but a little bit. Try to make it drier. If you find it too wet, you can. So you wanna get to a sort of a putty? We will take our bone graft. We will use a syringe. And we will gently place it inside. And we could take this the depth gauge that we used before, we will use it like a plug, as an amalgam plugger. Push it in a little bit. Again, you wanna be very slow, deliberate in doing all of that. We’ll put a little bit more since we already have it. Okay. Now we will take our implant. I’ll ask for emblemostro implant. K. And we’ll use a little Q tip so I can see the edges where I’m going. Now it, please. As it progresses, the gently the the most gentle way of placing the implant is actually with very gentle small taps. And this is how you take it off of the insert or retriever by twisting this knob counterclockwise. And it comes out. Yeah. It’s sacral de implante. Now we will place the sinus lift abutment. Because this abutment will act to prevent the implant from falling into the sinus. It also serve to stabilize it against the crest. And it will place the implant at exactly two millimeters from the crest. Implant implanted those millimeters crest. Okay. And, again, the gentlest way of doing that, the implant needs to go another three millimeters in the bone, is by gentle tapping. Okay. So now we will take the excess bone in the flap. Okay. And we wanna make sure that it is sitting inside the bone, flat against the soft excuse me, the crest of the bone. Now when we close the flap over it, I’ll show you how that will go. So we will take the flap and try it over the implants, and it should close with no tension at all. If you have any tension, we will do releasing incisions. And since we made it all the way on the palate, there is a little bit of expansion of the bone right here. So we will need to do a little bit of release, or we can just close it away, and that should be okay too. It retracts. It will reflect a little bit. And and you want to make an incision at the depth of the vestibule so that the area that was expanded will still get blood supply, and the incision will be closed. Suction the area very well. Okay. So we go you you don’t wanna cut the mucosa. Just the periosteum. Do you see the incision? No. Can you see it? If you can’t see it, they can’t see it. They can see it. Okay. Good. This is called a horizontal releasing incision. Bürger’s. Dr. Bürger. Bürger’s incision. And we put this is the little bit of autogenous bone we got. We saved it aside from the bone graft for the sinus lift, no suction. And we will pack it over tightly. That will help protect the crest of the implant. And whatever a little bit, we don’t waste it. We will put it all around. Not that you need it anyway. So now we’ll take a suture. Okay. Alright. Perfect. Thank you. Okay. Now we will go ahead and and finish suturing. Start from one corner. This is a three o or four o? The suture is chromic gut. Must have had a Chromic gut suture. Yeah. You got chromical? Chromico. And we will use a continuous suture to obtain a watertight closure. Okay. K. Which is the minimum weight of a bone you need to make this technique? The technique itself can be applied even when you have almost less than a millimeter of crestal bone. The key to the technique is more the presence of the alveolar process, buccal and palatal plates. The buccal plate and the palatal plates will hold the implant. We will move, you know, anything from zero millimeters or half a millimeter of crestal thickness. I I want to know this. The three. Thickness. The width. The width. K. The width of the the crest should be whatever width of implants you intend to use. Okay? Plus two millimeters. Now if if the bone is very is very flexible, you can use it, you know, and and expand it like we did here. The bone in this case was roughly about six six millimeters. We pushed it out, so we got obtained a total thickness of about seven and a half millimeters. Thank you your answer, but my question was not very good translated until. My question is not weight of the bone. My question is the height of the bone from the periosteum, from the crest to sinus. Right. What height we can use, we need for use six millimeters implants and what height we need for do lymph sinus with your method. This method can be applied from zero point five millimeters up to three millimeters or four millimeters. You can use this technique. If you have more than four millimeters, you can use a normal or or a a an internal sinus lift without a a floor transport. Yes. Thank you. Another question I have personal is Turn to me. If you can use a normal sinus lift, internal sinus lift technique, you prefer that to elevate the floor? There’s no it’s not a question of what I prefer. It’s what I can use. At four millimeters or so, I will use an internal lift. It’s a little bit quicker. You I don’t have to make the cuts with the chisels first. So yeah. I mean, if I can use it, I will use that. But it’s not a matter of preference. It’s whatever is available. Do you want to translate that, Tony? Or Yeah. I translate it. And your the minimum for internal sinus lift for you is four? Four millimeters to five. I mean, we’ve done less than that, but for specific cases, not for all, you know, across the board. Okay. I just didn’t know. Okay. Sorry. Okay. And in these cases that you use this technique with half millimeter, one millimeter of residual bone, how do you assure the stability of the implant? Because sometimes it could be a little difficult, no, to stabilize it. Very good. Very good question. So when we use the the floor transport technique, the bone, the two plates of bone will hold the implant in between them. That’s the first stabilizer. Okay. And then we use the sinus lift abutment that comes on top of the crest and holds it in place so that it it’s like a pedestal. It doesn’t move. That’s where the stability also comes from. Does that make sense? So, yeah. No. I’m sorry. That release, it helps a lot, this this kind of abutment. Yes. We couldn’t do this technique without the abutment. The abutment is specially designed for this. It has a specific shape as well. Okay. Thank you. Using the osteotomes. I noticed that you you incline the osteotomes to mesial and distal. Is there any particular reason for that? You know, the the only reason is that the crest was curved. I can’t come right down at it without slipping to one side or the other. So I have to come a little bit against it. But in the end, it all fractures flat. I have another question. Okay. How how you take it out? It’s easy to take it out the the sinus abutment? Yes. It looks very flat. There is special trick for that? No. You use a soft tissue pointed rongeur, and the soft tissue pointed rongeur will grab it just right, and you can remove it that way. You know? It gives gives it a little bit of a a twist and comes out. And you you don’t wanna use bone rongeurs because you don’t wanna break the bone. You do that always under anesthesia. Yes. This question? Yes. Yes. Okay. You can see it. Any questions? Comments? Is that exactly a point? For his face, it didn’t convince him that much. Oh, okay. Well, we will show you cases, but when you don’t need to have it longer yeah. It’s not necessary. But if he if he feels he wants to place it longer, he’ll need to do a an internal lift. However, if he needs to take another, Yeah. Consequences implanted. Tell them where where when is the paper coming out? Okay. And basically says it. It says the says this. I could have said that in English. I mean, that’s why you’re here. The question is, how do we control or protect against tears of the membrane when we’re using this technique. Is that correct? How you control not to tear and how you check if you tear? Okay. First, the first way you control is by being careful not to cut through the bone. Second, once you’ve finished scoring the bone, you start tapping in all of the direction, in all of the surface of the rectangle. If it’s a bigger rectangle than I could do this afternoon, you start in the corners. Rectangle Because the the corners, the angle is where you can have tears. If they lift up too quickly, they can tear the membrane. So you start on them very slowly. So you’re lift all four together. Second thirdly, once you’ve mobilized the bone rectangle into the crest, you check the sides. You can easily feel them or you can see them with good light. And then if you’re not sure if one side is lifted or not, you can do what I just did before and take a curette and clean out the side or the wall, moving or removing the membrane up so it’s freed up. Now, once you’ve done that, also, as it’s progressing slowly, the membrane and all of the tissues will have some swelling, which will allow them to lift off of the sides of the sinus a lot easier. And then finally, the the best protection in the end is having the bone graft particles cushion the implant as it’s going in. Now the other part of the question is what happens if you have a tear? Recognize it as early as possible. Okay. First, you can see it. If you can’t see it, you can have the patient blow their nose very gently. And pinch the nose. And if you see air coming out, you know you have a tear. And in that case, you take piece of collagen tape or Surgicel. The collagen tape or Surgicel. That’s at least three to four times as wide as the tear. And you make it wet with either blood or saline. And you put it in and put the bone graft in it and then put the implant. You to to go to or see collagen tape. And this is disposable in here, disposal in implant. The idea is you just want to contain the graft. The mucosa of the sinus will migrate over it and seal the tear in a matter of days, two or three days. Yes. Yes. We we not only we we have experience with it. We also have statistics about it. Our statistics show that irrespective of whether it is in a post extraction or in a healed site, a six millimeter implant of varying widths, if it is placed as a two stage technique, like the ones you show you saw today, it heals and it succeeds and it’s restored in over ninety five percent of the time, which is comparable to all other sizes. Ninety four percent to ninety five point seven percent. Okay. Okay? No more questions? That it would be two stage. Two step surgery. Yes. Okay. Okay. So thank you very much. Thank you. It’s been a pleasure to have you here today. And I wanna thank also Thomas and all the people behind you that has been preparing all this transmission. Transmission is really excellent. And thank you, and thank you also Dr. Urdaneta.