Placement of Three Bicon SHORT® Implants using Internal Sinus Lifts and the Insertion of an Integrated Abutment Crown™

This morning’s plan is for the placement of three ultra short implants in the maxillary left for the second bicuspid, first and second molars. As you see in the area of the first and second molars, especially in the area of the first molar, the floor of the sinus is very close to the crest within two to three millimeters. For that area, we will perform a conservative and small internal sinus lift. The area beyond that will also require an even smaller sinus lift. We’ll perform the two in tandem and we will be able to place these three implants today. The recent extraction of the second bicuspid has left a slight area with the weakness of the top of the crest. The other extractions, although they have been missing for quite some time, these for quite some time, these two teeth have left a kind of an imprint, a little divot right at the crest. And so for that, we cannot really go beyond them by a long distance, a millimeter or two, but we have to lap a little bit over the crest for us to have access and visibility and also to be able to close the crest over these implants. Our incision will be curvilinear and we’ll start from the posterior. We’re using a 15C blade. Open as wide as you can now please. And we’re gonna hug the palatal slope of the crest and continue the incision. So right to the edge of the healing socket or healed socket of the expected second bicuspid. We will then make a releasing incision which we will extend slightly just past the mucogingival junction to allow us better mobilization of the entire flap. In order to lift this flap, the best way to do that is using a pivot, your thumb as a pivot, and your index as a protector so we don’t over dissect. And we’ll just go over that area and quickly elevate this. Because we are planning grafting in the form of sinus lift, we will collect some of this liquid and use it to moisten our graft particles. We intend to use of course the synthetic beta tricalcium phosphate synthograph, the purest form of the beta tricalcium phosphate available to us. We will use a retraction suture. The retraction suture will allow us to work slightly more efficiently and certainly will protect this flap from continuing to be dissected every time we search for its end and reflect it. Okay, so you see how this will help us see quickly free up one hand or at least expedite the retraction. Okay, we’re using a high speed with a sharp pilot drill. We will create our pilot hole, at least the beginning of it. We’ll take a paralleling pin. First we’ll look at it. We want to be sure that from an occlusal standpoint, this osteotomy is started in the right proximity. It seems to me that it might be slightly distal. What I would like to do with this one is to move the osteotomy slightly, mesially and slightly, palatally as I’m seeing that the edge of the, let me see if I can show you that. The edge of our buccal extent of the bone is a little bit too close for comfort. And to do so, just will tow it in a little bit and we’ll go in roughly about six millimeters to seven millimeters or so. So as you can see now, this is a little bit more reasonable position. We will use that as a guide for the next pilot hole, which will be significantly shallower since we will be getting very close to the sinus. I wanna drill just about three millimeters and we will stop. Because the floor of the sinus was at a slope, the edge of this initial pilot hole might be encountering it already. Before we proceed, I will take a perio probe and make sure that I have not created an inadvertent perforation. And I don’t have a perforation. And I know the osteotomy is at about four millimeters of depth in one end and three at the posterior end, which is a good thing. Again, checking the parallelism of the two, I think is acceptable. And again, I’m gonna go about four millimeters. This one sounds a little softer. And these are our three pilot holes. As you see, these kind of gingerly penetrate the area. Again, I’m going to a pretty shallow depth. It’s a little bit, you know, very little bone so I’m just going to go ahead and do two osteotomies without shaving the tops or saving the shavings. And we will now complete the osteotomy for the bicuspid as I intend to place a four by five millimeter implant in there. And I want to place the implant at roughly two millimeters from the top of the crest. So we drill to seven millimeters, which is in the middle of the first band. And my intent for this one is to go to five millimeter implant, five by five. Now, the hand reamers have the added advantage of being able to actually change the depth because of an offset at the very tip. The third osteotomy, which is for the second molar, we have a lot of width. In this one I will try to go to a six by five and therefore in this one case we will show you the use of all five millimeter long implants available. K. Careful. I like to get to as wide an implant as possible. The length is not as much of an issue, the width is not so much of an issue but if you can get it wider, why not? And this is the five. I’m gonna apply a little bit more pressure, I want to shave the bottom a little bit more. You okay? What you want to be sure is not to miss any edge of the bone that may be pretty thin. So what I’m trying to do is shave mostly from the buccal distal in this corner right here. And the one important thing also about the hand reamers is that they are reaming so slowly, so gently that, excuse me, if we were to remove all of the bone from underneath the sinus mucosa lining, that lining will not likely be torn because it’s just a significant width and diameter that is not going to exert a pinpoint pressure that has a higher likelihood of tearing the mucosa. Okay. And this is the sixth and final size. And now we will perform the sinus lift in the first and second molars. You want to make sure you still have a floor and I do. And in the second molar, we also do. And it’s a bony floor. The reason for having this kind of flare at the top is because I can enter the osteotomy, okay, and then angle it. I know that the mesial part of the osteotomy has to be thicker so I will hit it harder. Okay, a little bit of tapping. Okay, stop the suction again. A little bit of tapping. Okay? They can, I know it’s okay as can be expected, right? What also happens is the mesial, excuse me, the buccal and palatal slopes can get involved because the ridge is not so wide. So you’re not just fracturing a piece of floor, you may be compressing the bone first. So you give it a moment to sort of rest and then we come back for it in just a minute. So what we have is a tighter floor now. What’s happened is it’s kind of compressed. So what we can do is shave it down a little bit and then come back to this. What this is going to do is because of the offset at the very top of the reamers, it will take some of that bone that has been just compacted in the floor and shave it up. As you can see, this is the same size that we had. The osteotomy is still five millimeters wide, but yet we’re getting some bone. This is all from the floor and the slope leading to the floor. I think now it’s starting to sort of yield a little bit and continue. A little bit of tapping again. Here we go. You can hear the noise now, the sound is a lot softer, it’s no longer resonant. That means we just fractured that floor. Retract a little bit more Janet so they see how far we’ve gone. I want to mobilize it by about, excuse me, about four millimeters, which means I have to reach the top of the first mark. And that’s why I’m still tapping while I know it’s fractured. But that allows me to make sure that all of the sides of that osteotomy are freed up. And here we are, done. Okay, we take it out, we switch to the wider osteotome, is the six millimeter. That was there. Now what’ll happen is the back slope of this one is going to be tighter. But I think all in all, this will give a little bit faster. Okay, he needs a break. Sorry about that, you alright? The back slope again needs to be thinned out. I still feel a bony floor of course. I’m going to get those out because what happens these will become packed against the floor and start dampening the force. Okay. There we go. I just saw it just move right now. And again, I wanna move it to just above this top line. That means it’s about four millimeters, it’s mobilized. Now we will take it out. Mallet please. You want to seat it fully. Okay. You could see that either using, this is called the inserter retriever. You can insert and retrieve with it. I have the rongeur. Actually, I got it. Never mind. Save the autogenous bone off to one side. I don’t want to mix it in with the SynthoGraft. Coagulant that we had saved from before, as you see we will exude it all. We will then use a bone grafting syringe and we go in very gingerly, very slowly. And again, we inject the graft ever so deliberately, ever so gently because the idea is to sort of fill the osteotomy and allow this to sneak in and start mobilizing the floor of the sinus. We want to make sure that the graft has gone in the floor. We will use a smaller expander. This is four point five and we start tapping it. We probably will be secure without having to resort to a sinus lift abutment, but we will see. And I can gauge that with the amount of resistance I’m getting to the tapping. That’s pretty tight. But if you feel, you know, kind of nervous about putting it without some kind of safety net, then you will put the sinus lift abutment open wider please. And the nice thing about these very short implants is that you can adjust a little bit of that angulation before you close it. Let me see. It’s a little bit shallow still. I will push it down some more. I do like to place the implants at roughly two millimeters below the crest. This allows for a better circulatory access to get the bone to heal over the shoulder. Let alone it makes the aesthetics a lot easier to achieve. Again, same thing. You’re gonna gingerly and very gently and slowly inject the bone graft. And this is a bigger osteotomy. It will require a lot more graft. And you see there’s kind of a little bit of a pumping action. It’s just sort of I inject a little bit of the bone and then pack it a little bit and so on. Alright, now again we will pack the bone and start lifting the sinus floor and this is a site expander. Now we will tap it in. Now I know that the bone has gotten in there. Open wider. Okay. Okay, you can twist it a little bit and that allows some of the particles to escape. Go ahead and suction, it’s okay. Step out now. And again we seat it. Okay, I’m happy with that seating. There. So we will double check the angulation before we seal them. And that is by using these guide pins which are designed to give us access and indication as to where the implant is upon uncovering. But we use them now because this is the last chance I will get to control these implants before I turn them over to, you know, after they heal. So as you see, the second molar, keep retracting please. Second molar implant, I’ll take the… It’s slightly angled but that’s okay. We can fix it. Let’s have the suction. I can change the angulation ever so slightly and that’s easy in soft bone and in this case this is the softest of bone. And same here. So I will estimate the depth about two millimeters from the top of the implant. If you look closely, there’s a little bit of a ridge, a little bit of a mark that’s made by the implant having been packaged with this healing plug. So it makes a little mark enough for me to know how high the implant is and I cut about two millimeters above that. Then to seat it in place there is a little a bit of a hole right inside the center of this healing plug. We’ll introduce a perio probe. Okay. That’s it. First with the first molar. Open wider please. Okay. Okay. Now both of these appear a little bit longer than I want them to be, So you can adjust them intra orally using the cutter. And this one. Now we just will pack the autogenous bone since we’ve used practically all of the graft. We’ll pack that over the implants. So as you see now, we have this really biologically active bone over the shoulder that’s going to create this favorable environment for the shoulder to receive new bone. First we will release the retraction suture. Did you feel this? No, good. Okay, now we’ll cut the short end. Always try to close these releasing incisions so they don’t have a wide open appearance that will create an unsightly scar. Although this is at the far end of the aesthetic zone. And we’ll put one just in the center. We placed three implants that are all five millimeters in length. We placed two of them with internal lifts. We placed one, obviously, without. But as you see, the three implants are exactly where we want them. And you see that this is a pretty significant sinus lift. Now, the sinus lift allowed us to go. If you look strictly between the two implants, you will see that the sinus floor is actually right at the first fin of both implants. The mesial and distal side of these implants are in native bone up to the fourth or fifth fin. I’ll turn it over now to Dr. Urdaneta. Hello, I’m Rainier Urdaneta. I’m a prosthodontist. We’re going to begin by showing the radiograph. We uncover this implant and the day of uncovering, I placed a five millimeter wide by ten millimeter long non shouldered abutment. Then I temporized it with a composite directly built up on top of the abutment. We’re going to remove the abutment and we’re going to then insert the, crown. This is an integrated abutment crown ready to be inserted. As you can see, it has, the abutment is the crown material is baked directly on top of the abutment so there is no need for screws or cement. We’re going to begin first by removing the temporary restoration. So you can grab it with a crown removal forceps, this one with a flat surface I really like. And then just grab the crown and pull. Sometimes the abutment comes out with the crown, sometimes it doesn’t. But I’m glad in this case it didn’t because I’m going to then show you how to remove an abutment. So you grab both sides, and at this point in time, you can tap onto the instrument with a hammer, I’m gonna be showing to you. Stop right here. Okay. That’s one way of doing it. Alternatively, you just rotate on the abutment and you pull. Okay. You don’t wanna torque. Okay? But you just want to rotate slightly and pull. We begin cleaning the post with alcohol, and we’re going to go to the mouth, and we’re going to then clean the well. This is not absolutely necessary in a posterior area. We mainly do it in the anteriors to obtain the best adaptation of the metal of the abutment in the well. What we’re gonna do here just to show you this, three millimeter cotton swab has the exact same size as the implant well, so it cleans out perfectly down there. We’re gonna remove that, and we’re gonna insert the crown. One, two, three. And go with the crown and the abutment. So we press it. Okay. And we rotate. Then we’re gonna check interproximal contact. The distal one, it’s tight, whereas the mesial one, it’s open. So I am going to then rotate the crown. K? This you can do manually, or you can just use the same instrument. Now I have a mesial contact as well as a distal contact. Okay? It seems to be pretty good. I like to show you anyway the way you would adjust interproximal contacts. Let’s say this distal contact was too tight. The way you’re going to do it is, or the way my preference is, grab the crown, remove it, then you’re going to place a articulating paper in between the surface and you’re going to slide the crown down. Right? Remove the articulating paper and that will leave a mark that then you can adjust with a silicone wheel. Okay? With the silicone wheel, you can adjust it. Okay? And then you can insert it. I’m gonna clean again the crown with alcohol. Remove all the excess of the powder, and then I am going to insert it again in the mouth. That is if the contact is not too too tight and the crown is going down again. I have a mesial and I have a distal interproximal contact. The distal seems a little tight, but not too bad. Now I’m going to tap lightly on the crown to sit the crown down. For this, you have different ways. Doctor Morgan’s preferred way is you ask the patient to bite down into bite down, please. Into the crown with a cotton swab open, and that seats the restoration. Okay? I prefer giving a little bit of taps because I love a hammer. So I’m just gonna tap on this, A couple of this in each cusp. That was the facial cusp. This is the lingual cusp. Alright? Then I’m going to check interproximal contacts one more time. The distal remains a little tight. I have a perfect mesial contact. So the next way you can adjust interproximal contacts is with the use of a diamond strip. Very nice. This is I like the ones that are yellow diamond strips. They’re really they’re really fine diamond strips. Okay? And I’m going to place it in the distal area. Get it in, and then I’m going to move it. Okay? Around the interproximal contact. This particular yellow one is so thin that you can actually use it many, many times and it doesn’t really remove the interproximal contact. It just makes it perfect. Okay? So you can You have to make sure you protect the patient’s lips because this diamond strip loves to cut lips, and I’ve done it many times. Okay? A little bit more. Okay? And then we’re gonna check the proximal contact one more time. It remains a little tight, so I’m going to go a little bit more with that. And as you can see, it’s it’s very easy. Can do it as many times as needed until you get the perfect interproximal contact. Okay. Check one more time. Perfect. I like that contact. Now we’re gonna tap a little bit more just to make sure, just in case interproximal contacts being tight didn’t allow the crown to go down all the way down. I’m just going to tap one final time. And now I’m going to check occlusion. You can ask the patient, does it feel a little high? Is it comfortable? It’s pretty good. It’s pretty good. We have contact there on all the adjacent teeth as well as in the crown. I will prefer the contact in the crown to be just slightly little lower, so I’m and I do not like this sliding contact in the lingual cusp, so I’m going to adjust that. Since this is a restoration that is poly ceramic and not porcelain, it is very easy to adjust. So we go, adjust that sliding contact in the lingual, and lighten a little bit that distal marginal ridge contact. Then we’re going to check occlusion one more time. Bite down. Open. That’s perfect. Now bite down. Now you’re gonna grind left, right, front, back. Open. Just wanna see if the tooth is guiding it’s guiding slightly towards the distal facial, so I am going to grind it a little bit there because I don’t wanna guide in context. I don’t think it will create many problems. It’s obvious that this tooth is guiding with the adjacent ones, but so it’s obviously group function. But in any case, I wanna just adjust it there. Open a little wider. Now I’m gonna polish again with finish with a wheel, polishing wheel. It’s a really highly polishable composite resin. It has ten percent of composite. It’s a polyceramic with a highly polishable surface. As you can see, you achieve polishing very, very nicely. Even though it’s definitively seated, you could remove this crown. And I’m just going to illustrate for you what you would do in that You’re going to use a, the same crown removal forceps, grab the crown, and then you can tap on it with a hammer, or you can rotate a little bit and pull at the same time, Then you’ll be able to remove it. That’s one of the most, one of my most favorite features of this is the ability to being able to remove the crown if I need to in the future for adding contacts because it broke or whatever necessary adjustment. Okay? As you can see there isn’t any metal showing but if there was any metal showing in the abutment I could remove the crown, send it back to the lab or to add a little bit more composite in that metal area and have it repaired so there is no need for any problems with that. Alright? So this is all set. We’re going to take a radiograph. I know that the, crown is inserted all the way down because there is two threads of the implant, left, you know, two threads of space left at the end of the well, it tells me that, you know, within a framework, you know, this is definitely seated down. Basically, the best way to treat a perforation is not to have one in the first place. So, measure twice, or three, or four times. Do whatever it takes to avoid that. If you have a perforation, the second thing you have to do is know that you have a perforation. So, before you proceed, you’ve got to look at all the signs of perforation. Excessive bleeding, bubbling from there. If you have a big tear, your membrane, you can feel that there is no resistance. As you introduce your graft, if your graft just flies in, and it just keeps going, and it’s not giving you any resistance, that’s a dead giveaway that you have a tear. And so once you’ve recognized that, what you need to do is take out anything that you have in the socket, graft and otherwise, cut a resorbable, either containment membrane, such as a collagen tape, or a resorbable collagen membrane, a barrier membrane. Cut it three to four fold the size of your osteotomy. Moisten it so it’s very pliable. Introduce it in the osteotomy. Then introduce your graft in it. Then introduce your implant in the graft. So it’s sort of a layered approach. You want to have it big enough that it still is touching the side of the osteotomy. And you put it in, and you secure implant and your membrane together that way. Okay? The implant doesn’t have threads. These are not spiral threads. So screwing it in there allows you to sort of mobilize it a little bit, but it’s not meant to be seated by twisting it. It is meant to be pressed in. Pressed either gently, or with a little bit of tapping. Now, the question really is, why did I tap, and not just push it in? Well, tapping with a very light mallet, like the surgical mallet that we’re using, is a lot gentler than putting your upper body weight behind it, which can force it in very abruptly and very forcefully. And you end up with the implant in the sinus. So when in doubt, just use a very light tapping, with a very light mallet, with a very sort of deliberate progression. Okay? But the implant is not a screw implant. Those that you see are plateaus, that are parallel. They are meant to go in by friction, not by screwing it. I actually over trim it on purpose most of the time. I would much rather have the black plug be sort of just slightly within the confines of the crest of the bone. It is then less likely to allow for permucosal loading of the implant, or in case of thin mucosa, to cause it to wear through too early in sort of an inopportune spot that would deprive the implant from attached gingiva as we uncover it. So, no, I if I were using the black plug, want it to be spot on or shorter than the crest of the bone. Now, over trimming it so much that it’s lost inside the well, I mean, that’s not going to help you because it will make uncovering that implant extremely risky to the implant and to the patient in particular. So we ask you to keep it above the implant, and preferably right at, ever so slightly below the bone. Crown to root ratio is not a risk factor, for crestal bone loss or a risk factor for implant or crown failure. We demonstrated this in a manuscript that we published last month in the International Journal of Oral and Maxillofacial Implants, where we demonstrated that increased crown to implant ratios up to four point nine five, that is almost five times the length of the implant within the bone, did not have a statistically significant effect on crown implant failures or in crestal bone loss. What we have actually learned with our own experience is that, bone likes to be loaded. Okay? So one of the reasons we believe strongly nowadays that we lose bone around implants is because we have been using implants that are too long and implants that are splinted. So the bone simply is, dies away or is resorbed, as a result of, disuse atrophy. Bone likes to be loaded so a short implant, per thread will distribute much more forces to the bone than a longer implant. Thus the effects that you’re going to see for a longer, crown to implant ratio in those biological responses like crestal bone response is, are beneficial. I can tell you from my own research that if a Bicon implant is five millimeters wide, if it is eleven millimeters long it’s significantly more likely to lose bone than if it is eight millimeters long. And we hypothesize in a manuscript that we have, right now under review that it is the length that for a five millimeter wide implant eleven millimeters is simply too long. I basically just bonded a temporary crown to the adjacent teeth. Had a porcelain crown on one side and a tooth on the other. So using silane couplers on one side and then just regular bonding procedures on the other, we just made it regular temporary. We try to avoid doing flippers. We try to avoid. I haven’t found one patient that likes them. So if we can, only area we found limited clinical success is when we have two adjacent porcelain crowns and it’s a very tight occlusion. It just doesn’t work. In those cases, it’s fair to treatment plan for a flipper, for an interim removable partial denture. So thank you all for your attention, and thank you to all our colleagues who’ve been patiently with us online, and to our friends and colleagues in Tver.