Placement of Two Bicon SHORT® Implants, One with an Internal Sinus Lift Using SynthoGraft™

Good evening. We’re coming to you live from Boston. Welcome, we have over forty countries, about forty three countries and a couple of dozen states. So welcome everybody to the first live webcast of the Bicon surgical placement of two implants. We will be placing two implants, one in the area of number fourteen that will require a minor internal sinus lift, and the second in the area of number fifteen, which is the upper left second molar, that will not require a sinus lift because of the use of the Bicon Ultra Short Implant. Now in the area or location of number thirteen, the upper left second bicuspid, we have a previously placed and restored Bicon implant that is restored with an integrated abutment crown. For visibility’s sake and as a demonstration, we will remove the integrated abutment crown in the beginning of the procedure and we will replace it at the end. That way both you and I will see better throughout the process. That will also demonstrate the retrievability and versatility of this restoration. Our patient is anesthetized and ready to go. Last week in Dallas, we had the question about how do we remove an abutment and a crown if they are placed there permanently. We’re using just plain old one hundred fifty universal upper forceps. And if you don’t make them slip, you can then quickly give it a quick little twist, like so, and it comes out. We will use a temporary abutment in the area. I will use a trapdoor type of a flap that is buckally based, widely based. First take scissors to open the flap. Before completing the dissection, we will collect about roughly a cc of blood to mix with our bone graft. We will take a periosteal elevator. What we need to do just to expedite matters is to keep the flap open. And for that we will use a suture that’s placed through the inside of the flap to the cheek mucosa thereby maintaining the flap open and limiting the amount of trauma we cause the flap by reflecting it repeatedly. Open as wide as you can. This is the only step in the Bicon protocol that requires irrigation. So we will be using a twist drill, two millimeters pilot drill. We will place now the pilot hole for the second molar implant. And as we can assess the parallelism very well now. Okay, so I’m happy with the depth and with the angulation. Now we’ll go on to the osteotomy itself, widening it. This is a two point five millimeter reamer. It’s like a double cannon bur. And it’s spinning at this is the top speed. It’s about fifty RPM. So by varying the pressure on the rheostat, you can reduce the speed. But you cannot increase it more than fifty. And for that, we’re able to avoid any irrigation. So again, we verify the parallelism. And as you see, the osteotomy in the first molar is a little bit shallower to protect the floor of the sinus. The bone is very soft, so I will soon revert to hand reamers or expanders. And this is the three millimeter reamer. So what I will use now are site expanders. And we will go to a three point five millimeter site expander. Because the bone is so soft, I’m able to compress it just by pressure. As well as in the area of the maxillary tuberosity. So what we will alternate between hand reamers and site expanders. That was a site expander. This now is a hand reamer. This is four millimeters. You could probably see that. The one thing that the hand reamer affords you that the latch reamer or the expander don’t is selective reaming. I can now selectively ream out the palatal plate while expanding the buccal plate. As you can see, I will cut only a half a turn. And as you see, the buccal plate is now pretty thin and it’s kind of bowing out. We’ll go now to the first molar and we will also carve out on the palatal. Because of the shape of the hand reamer, you’re able to expand with the side that is not cutting. So as you can see, we can collect some bone. Okay. So the bone in the tuberosity area has been very soft so the best way to change the nature of that bone is instead of carving it or reaming it out, I am expanding it. Okay. Open wider please. We’ve expanded it now. We will use the sinus floor osteotome. One of the advantages of having an intracrestally placed implant is the ability of placing it deeper within the crest. So as you can see, the osteotome has now moved up to the eight millimeter depth and I’m just continuing to do it ever so slightly to allow the mucosa to lift itself off of the floor of the sinus. We will collect some more blood. This time we’re going take it from the osteotomy. That will give us a little bit of bone marrow elements in it which is the best type of blood to mix with. This is SynthoGraft mixed with the blood that we collected just now and before. So we mix it until it comes to about a putty consistency. By mixing it vigorously using the thinner end of a Pritchard, we are breaking the surface tension of the micro and nano porosities of the granules of the bone graft and filling them with the patient’s autologous, obviously, blood and blood elements. That expedites the healing in our experience. Then we will use a metal syringe. We will pull the plunger back a little bit and then we will start introducing the graft. You should always check that you do have a floor. We’ll place the the metal syringe, and using sort of a pumping action, backing. Try not to move your jaw. Okay. Alright. That’s starting to lift the sinus. Okay. We will open the sterile plastic bag or cut it. Never handle the implant except through that bag and let it only touch the bone. We’ll remove the carrier and plug. We will then replace that with the insert or retriever. And we will then place our implant. Open wider. Great. A little more tapping. A lot more tapping actually. So as you see, even a short implant and a little bit of bone with the bone graft has a lot of friction. So for those of you who are worried about a friction implant being placed in the sinus, this is proof positive that it’s easy, it’s predictable, and it’s safe. By twisting the closer handle counter clockwise and that disengages it, It actually forced the implant off and left it in place. The osteotomy of the second molar was done now, completed about ten minutes ago. That may cause it to have bounced back. So before I go back in and try to reintroduce the implant, I just want to push it back to its size that we had prepared. And I’m just using the expander again. Okay. Little tap tap. That’s good. So now the implant is placed. Those lines on the that you see right there, those are at two millimeters and three millimeters. So all I want to do now is just twist counter clockwise. And it’s disengaged. So now, let’s look at our positioning of the two implants. So as you can see, they’re pretty parallel. They’re at the right spot the way we want them. This is incidentally an inserting tip that allows us to tap without friction against the walls of the well of the implant. So now what we will do is put our customizable cover plug, if you will, or healing plug. And that is placed and then cut to the crest. And as you can see, it’s flush with the top of the crest. That makes it easy to uncover when the time comes. And we just put bone over it. That just covers the shoulder of the implant, allows it to predictably regenerate bone over the shoulder. I’m going to remove the retraction suture. So what I’m using now is a continuous suture with 4-0 chromic gut on a FS2 needle, reverse cutting. Whenever we have a graft in the sinus, we wait a minimum of five months, four to five months, excuse me. In this case, it’s a very small graft, so this will be ready for loading in four months. Now, we’re finished with the surgical part. I will reinsert the IAC. That’s nice contact. So we now have the patient bite to engage the locking taper, and that will do it. Bite down, please. First, the first molar, a small sinus lift, and you see the parallelism, the spacing, the second molar with no sinus lift, and that you will see is the majority of your cases where the the use of the ultra short implant allows you to pretty much avoid the sinus most of the time. Recognizing that you’ve had a tear is probably not as easy as it may sound if you first forget to palpate or you go a little bit too aggressive with the mallet, etcetera. Now if you recognize it, now you need to know what kind of a perforation you have. First, if it’s just the puncture in the center and there is no air bubbling, etcetera, from the center of your osteotomy, you’re probably okay by the time you get to the final size. And so then you will just place some graft and the graft will serve as a plug and that’s all you need to do. If you have, however, a tear on the edge, and that happens when the floor is slanted. If you do have a tear then, you need to control that. And the best way to control it is using a resorbable barrier of some sort, mostly a containment device such as a collagen tape, collagen membrane. We’ve even used Surgicel, okay, or a Vicryl mesh. Something that’s resorable that has some tensile strength, which you will make it three or four times the size of the osteotomy, that you will wet it with a neutral, like a normal saline solution. You will drape it into the osteotomy, making sure that when you put your implant or first your graft in it, and then your implant, it will remain in contact with the osteotomy and the implant, sort of acting as a purse, as like a little bag of a graft over it. And that will contain it, and that is enough for you to allow the sinus mucosa to migrate over and heal it in place. Absolutely. One of the features of the plateau configuration, the plateau implant design, is that it is made to heal in healing bone. It doesn’t need mature bone to implant and intimate mature bone to implant contact to integrate. So it is actually the best way to have a graft heal against an implant is to have a plateau configuration implant. And therefore, had we had a dehiscence or a perforation of the buccal plate or any plate for that matter, we would have easily grafted over it, put a membrane over it if need be, or just use the membrane for containment. Because the name of the game is not just putting the implant and the graft, it’s keeping the graft over the implant. And sometimes a membrane is necessary, not so much for the barrier function, but rather as a containment function. And we will tack it in place or suture it in place or put a retention suture over it. In a healthy individual, in a healthy sinus, you do not need to do anything. Just make sure you have enough graft to contain the implant, because any granule that is actually lost into the sinus, the cilia and the normal function of the sinus will take care of it and the next day the patient may call you and say, You know, I’ve been blowing my nose and I’m getting pebbles coming out of my nose. Hopefully you will never have a situation like this, but if you do, bring the patient back, first reassure them, and take a radiograph. You want to see that you still have enough graft around the implant. If you have a situation where you’ve lost all of the covering around the implant and so on, you may consider redoing the procedure, but allowing some healing time. Most of the time, however, we go back to the initial question, is, you know, how do you correct the perforation? So recognize the perforation and therefore avoid displacing particles into the sinus. And you don’t have to face these kind of dilemmas. Yes, in a case like this one, which was two stage, will require anesthesia and an incision, removal of the healing plug, and then we will put a temporary abutment or a healing abutment. At that point, the restoring dentist, after two weeks or so of healing, if they choose to take the impression at the implant level or not, they do not need to lay another flap. I will do everything I can to give them a final kind of gingival contour that they will then fabricate the final restoration, whether it be serum omental or integrated abutment crown. Now for those of you, and I know many of you, if not most, are doing both phases, you may find that you can take an implant level impression at the time of uncovering and then have the lab with your help then fabricate the best emergence profile possible for that restoration. If you do that, first thing is to just always use the insert or retriever. So if you lose sort of the floor, you will end up retrievability of the implant with the insert or retriever, hence the name. If you were to displace it and it’s somewhere where it’s floating right up in the sinus, you may have to use Caldwell lock procedure to get it. And it’s beyond the purposes of today’s webcast to go into that in great detail. But suffice it to say, an ounce of protection, just do everything you can. Now, there is one other thing that we can use is the sinus lift abutment. If you are afraid that you don’t have full control of that, then substitute the black healing plug with the sinus lift abutment, which you will see on the Bicon website, and use that as the carrier, as the holder for the implant. Place the implant that gives you a wider top, almost like a nail head, so that you won’t have that risk. And it comes in two sizes. If you want a lot more protection, you can have a much larger one. Just remember to make your flaps a little bit bigger so that they cover over all of the head of the implant. Very good question. As you saw, had we continued in the original course because the buccal plate was deficient right from the get go, would have completely blown out the buccal plate, And yet we expanded to full five millimeters and were able to maintain the implant in the osteotomy by carving out on the palatal plate only. Now remember that sometimes you can go the other way because the palatal plate also can be weak enough that you can, you know, cause a dehiscence there and that’s a lot harder to repair. So find the happy medium. In this case, I would rather see a little bit of thin buckle plate that I can control, I can graft over, etcetera, rather than have a weaker palatal plate. And so the short answer is yes, we can control, we can start carving out completely on the palatal from the three millimeter size on. I try to use the patient’s own bone on the very crest because that’s where I want the fastest remodeling. So if I have a small amount of bone, I will save it. If I am, let’s say, doing a graft and I have some harvested bone that’s not enough to continue or to complete the entire graft, then I will layer it as the autogenous bone comes in a layer against the implant immediately and then on top of that the SynthoGraft or whatever graft you choose to use. Not because it makes any difference from the standpoint of the success of the SynthoGraft, I think, but rather I feel that autogenous bone against the body of the implant has the best chance at turning over the fastest. And the rest of the bone, which will be closer to the soft tissues, can then be a bone graft material. So as we conclude our first live webcast, I want to thank all of you for logging on, for giving us some of your time, and I hope that you can join us again in our future webcast. It’s been fun. Thank you again. Good night.