Sinus Lift Techniques

Our young patient has missing what you call the one five one six, which are really number three and four. The area of number four has been grafted by a previous dentist, and we are assuming that the graft material was either autogenous or banked bone. Needless to say, you can actually see right on the radiograph here. If I can zoom in a little bit right there. This is a six by five point seven millimeter implant template, and you can see that it is barely fitting within the confines of the available native bone. So our plan is to perform a small internal sinus lift, but the real fun happens in the more posterior area where the bone is between two and three millimeters at the widest in the most mesial part of that. And in this area, the crest, as you will see clinically in a minute, is actually narrow. So the plan is to perform a floor transport sinus lift, taking advantage of the narrowness of the crest and placing the sinus lift at the same time as the implant. So as you can see, it’s relatively wide. There is, however, a scar right right there. And this is the area of the socket of number four or one five. Okay? And the intent is to expose the crest going from the palatal slope all the way to the full buccal slope. I will use a papilla sparing technique. However, in the distal, I may not only because the space is so tight. Okay? I favor as continuous a an incision as possible. Don’t like angles and connecting and lines. Gotta move it in a minute. Use a little blunt dissection. To see where the flap is lifting or or not, then I’ll take a periosteal elevator and sort of peel it back. Yeah. You alright? Good. And I’ll take a retraction suture next. So this graft is definitely not banked bone. This is more could be neoss, could be whatever. Take this off. Some of it is incorporated. Some of it is sloughing off. Either way, we should have enough to place our implant. The way I’m going to proceed just for your, basically, understanding is to first collect a little bit of blood from the surgical site, which we will use in the graft. That way avoiding a venipuncture, which is obviously not a big deal, but that way you can see how easy it is to collect what you need. We don’t need a lot, but we collect as much as possible. And this will be left aside until we mix it with the SynthoGraft. SynthoGraft. Do you stop the blood clotting? Oh, I don’t. I don’t. It’s gonna clot eventually. Right? We let it clot, and then we will break up the clot into the the bone excuse me, the the bone graft. This, I think, creates sort of a a favorable environment to stimulate more inflammatory response in the area, which I think enhances the the healing. Usually, however, you know, we we work relatively quickly. Usually. You know, you don’t have a completely congealed clot. However, in this case, because I am talking, we’ll and we’re filming, we’re gonna have a seriously congealed clot. We will add some more blood in the in the end. You can suction it. So we’re using a retraction suture for sort of convenience and visibility. Good. Then move it. So first of all, I take a straight curette. I wanna see how much of the graft has coalesced and how much hasn’t. So I’ll take a straight curette, we will try to dig out all of the loose bone. It looks alright. So now, for the placement of the initial pilot hole. The the Bicon pilot bur, as you know, is a twist drill. It’s okay. I can move it. It goes at eleven hundred RPM or so, and it’s done under irrigation. So we will advance very slowly. I am now at six millimeters. I expect to be another maybe millimeter or so before I get into but because I’m angling palatally, I may stay get some more. So before we commit to the final size suction, take a paralleling pin, And we check the angulation. The camera. Is there anything Okay. Let’s see. Turn more to the left, please. Turn more to the left. Thank you very much. Okay. So the ring at the top of the oh, excuse me. In the middle of the paralleling pin is actually slightly over three millimeters, about three and a half. So if this fits, odds are we would be able to get an implant in there. Okay? I’m gonna continue now with the pilot Okay. Drill. Action. I’m feeling resistance. I am almost at eight, about seven. And just at eight. Water. Okay. I am good now. I think I just hold on. I just lost resistance. Okay? And there was a bit of a step. So we double check our position as every time you you use the pilot hole, you can change it, and it’s still unchanged. So we will continue now. We’ll switch the handpiece, and I’m gonna step back. I won’t ream beyond about seven millimeters. Yeah. Medium is good. And we are using the medium length latch reamers. I’m at six and just beyond that. Okay. As you see, not much bone coming out yet. What’s gonna happen now because the socket is mostly very loose osteoid and bone graft, the osteotomy is gonna be transposed distally. So where where our pilot hole was is actually not the center of the implant. It’s gonna be the mesial edge of the implant, which works out fine. Either way will be okay, but this way actually will give us a good spacing from the mesial tooth, from number five or one four. I have to translate for you. See, it’s such a special occasion. We’re getting all new reamers for you guys. I hope you appreciate the beautiful colors. So there’s really not much to it. You can ask Pete what what the reamer feels as it’s going in and dragging itself in Yeah. To the osteotomy. We are at four and a half now, and the the goal is to get to five diameter implants. Now before I go to the final size, I’ll take a straight and finish it up by hand. Take a straight curette first, then I’ll take the hand reamer to finish off the osteotomy. And what I’m yeah. Fire. Fire. Suction this. So I still have a floor. It’s always a good thing. And we wanna remove all of this excess bone. We don’t wanna compact it against the bottom if we don’t need to. Do we have the the beveled sinus floor, osteotome? Yes. You might need to use that. Arthur, are you okay? No pain. Right? No. No. K. Good. So finishing up by hand. Yeah. Option, please. K? So this is a hand reamer, obviously, using it by hand. And the the reason why we’re we’re although it appears that I could probably go even wider is that the bone here is all grafted, and it’s starting to to break a little bit to open up. So I don’t wanna strain it. Five five by six or five by eight will be fantastic. So, again, before we go to the sinus lift, we will verify that our floor is is still intact. No holes, perforations, or otherwise. Then when I will start using the osteotomes for the sinus floor osteotome that is, Janet or Alyssa will be supporting the facial skeleton by bracing the nose. Alright. So, incidentally, this is the new the Bicon so called trumpet osteotome. K. We designed this about, oh, I think two years ago or so. It is five millimeter at the top, just under five, maybe four point nine or so. But it’s a it’s wider at the tip, which allows me two things, to spread the energy of the tapping to create sort of a manhole cover at the top or the bottom of the osteotomy that would be wider, which would allow which limits the possibility of tears or reduces it anyway. And, also, I can direct it one way or another to favor one side. So in this case, because the mesial bone is a little thicker, I’m going to tap till we get into the floor, and I should be hitting the floor or just above the floor at about six, which is exactly where we are. And then I’m gonna aim a little bit distally, so that way I tap more against the the mesial and palatal. You hear the difference in the sound? I hope you did. Because now already we’ve created the little fracture. Okay? So now what I’m going to do is take my bone graft it’s a half a gram. Okay? How much bone did we get from there? Okay. So this is the little bit of clot with a little bit of bone that we collected from the osteotomy so far. We will expand this with half a gram of SynthoGraft fine. Now what I will do is mix them all together to create a putty like grafting substance and mix it quite a bit. And the one decision I wanna make is do I use a five by eight or a five by six in there? And I think to show you the the sinus lift better, five by six will will need a slighter a smaller five internal lift. But to show you the internal lift more, I’ll use a five by eight. It will show the possibility. So let me have a five by eight, please. So please understand that a five by six is adequate, but it will a five by eight will be will show the lift a little bit more. So would you please mix this some more, Janet? Shadi? Yes? Shadi, how do you know you haven’t got a tear in that membrane? I prayed before I came in this morning. Why don’t you invest in a little loupe with a five or six times magnification and a five optic light and look in there? Do you have the money? Actually I’m sure I’ll buy one. We’ll take donations from South Africa, diamonds will be preferred. Now let’s be serious, you don’t know there isn’t a What I do is I look in there. Once I’ve done that tapping, I look to see that there’s no tear. Okay. Well, you could you could check it several ways. Okay? First of all, I could go with the curette very gently and feel it. So when I feel it there. Okay? That’s one. Okay? The other way, we can ask our patient. I’ll pinch his nose, and I’ll ask him to blow slightly. If we see bubbles of, you know, red bubbles, that’s it. Arthur, blow your nose very, very, very slightly. No. Just a little bit. Just a little bit. Okay? K. No bubbles. No air coming out. So, yeah, there’s no tear. Are you satisfied with that? Yes. Okay. And it’s and it’s free. And it’s free. Okay. So now to place the the graft in there, we will turn our attention. Actually, what I’m gonna do only because I don’t wanna traumatize the area too much is go ahead and and put the graft and the implant in. Now you could do it two ways. You could put you can wait, do the osteotomy for the other implant, and then finish up the two together placing the implants. This is a four millimeter tip carrier. It’s usually these are used for amalgams, but we never use it for amalgam. We always use it to carry bone grafting when I need it. So what I will do as a rule of thumb is fill this osteotomy. Okay? But before I do that, I get to the bottom and wiggle it and push the graft in. The graft itself will start oozing into the sinus right beside the floor, the the little floor a sort of a manhole cover as I like to call it. And that will start the sinus lift. Okay. Okay? And now that’s enough, I think. Put quite a bit in there, almost. Now I put the implant in, and using an inserter-retriever is the most predictable and easiest way. Okay. So the implant is now going to be placed on the inserter-retriever. Okay? And, initially, I’ll thread it in Wow. Just by twisting and pushing. And this gentle twisting and pushing can be very effective. However, the final seat will be gentler if done with slight tapping with a surgical mallet mallet. He certainly woke you up this morning. Right? He says I know. Okay. So now that it is in the right position. Okay? About two millimeters or so, I probably wanna do it a little bit more. I will take the inserting point. Now I wouldn’t do this if I don’t have good friction. And since we have a quite a bit of bone, I could use this tip, and this will allow me to see where the implant is seated. K. And I want the bevel, this point stop focusing on the bevel to be right about the level of the bone, mesial, distally, at least. Okay? So it is fine on the mesial. It needs to go just a little bit more, maybe a millimeter on the distal and here we go. Okay? I’m happy with the placement of the implant now. We will place our black healing plug. You can place it in and cut it, or you can cut it outside. The reason I like to cut it outside is it’s less likely to fall into the patient’s throat, But and we can also aim at the assistant. Okay. And so using just a standard periodontal probe, there is a little hole in the black healing plug, and we pop it in. So the first one is finished. That’s good question. Shadi? Yes? Shadi, we have a question. The the make of the the plastic tip is not actually plastic. I think it’s Teflon, isn’t it? The it’s poly it’s carbon filled polyethylene, which is not Teflon. No. It’s carbon filled polyethylene. Biocompatible. Biocompatible. It is biocompatible indefinitely by the FDA. Any more questions? Everybody’s gone silent. Now what I need to do is do a a floor window for the floor transport osteotomy And for that, I need my ridge split osteotomes. Now the idea is to place a six millimeter wide implant. So for that, we have to make the sides of the window, the narrower sides of the rectangle, you will, the width of the rectangle, less than six, obviously. And and the easiest way to do that for me is to use an osteotome, a chisel, that is less than six. So I use the width of this osteotome to make the rectangle. Okay? So I might need you to retract a little bit more this one. Okay. That’s nice. Okay. Good. And your hand is out of the way. Okay. K. Suction. The other important aspect of it is to leave myself enough room away from the implant and also away from the tooth and away from the flap. So you got a bit of a sort of juggling act here. So distally, I’m gonna leave myself just about two millimeters from the edge of the flap and a little bit of tapping, Arthur. Okay? And you’re really not doing a lot of, you know, cutting. You’re scoring that bone. Alright? And now with the mesial end. So I’m gonna do the narrower sides and try to get as big a rectangle as possible. Okay. And it’s pretty soft. The bone is pretty soft now. So now these, I don’t wanna be outside of the confines or the length of my osteotome, which is five. That way I can guarantee that the flap now that the window is And the main reason this technique works is because of the plateau design of the Bicon implant where a blood clot and bone graft will heal just as fast and give us a predictable osseointegration as would another type of implant in fully healed mature bone. So that’s the reason why we’re able to use this kind of technique. Now that I’ve made all the cuts, I’ve just gotta make sure the media the front one suction here, the anterior cut is redeveloped. And this is the one that’s coming against the anterior slope if you remember from the X-ray. Okay. Now I will go with a flat top osteotome, which we normally use for the sinus floor elevation anyway. And this is a three millimeter one, and I wanna aim at the corners because these are the ones that are hardest to mobilize. And we start tapping, and we see what happens. We may need to refine or redefine our cuts. Takes a bit of work. So for this technique, suction more, patience is absolutely essential. You gotta stay out of my way there. Okay. Suction here. She’s moving your elbow, not your wrist. Look. Are you okay, Arthur? A lot of banging, but you should be okay. But there’s a lot of banging going on. Sorry? Yes. Well, you you with the Bicon system, you don’t get screwed — you get hammered. I love it. When I tell old joke to new people, it’s like, you know, it’s a new joke to me. Right? So, again, we go back and refreshen our cuts. Okay. And, again, we go back. And it’s starting to mobilize in the posterior edge, so I gotta freshen up the anterior cut. Here we go. Can you see it? Can you see the can you get a little more light in the distal? You see how the rectangle just started moving into the sinus or really the alveolar process, which has been occupied by the sinus expansion. So it is key to wait a little bit because what happens now, there’s a little bit of, you know, swelling and inflammation happening from the lifting of the sinus membrane, a little bit of bleeding. Give it time to sort of release and relax, and then we will start putting pushing it up. What I will use next is the five millimeter or maybe even the four millimeter floor transport or or sinus floor osteotome. And tap this up just a little bit more. Again, a lot of patience. Take your time. But now I have enough movement away, enough enough room for for being able to start the actual osteotomy. That’s okay. So now I will just use a slightly wider osteot or reamer. Okay? This is a four and a half, and we will start just carrying it in there. Not much happening yet. The five millimeter hand reamer again. My vision for this is to have the hand reamers. Oh, he’s not calling it my head anymore, only my hair. Sorry about that. Well, exactly. I’m I’m happy to hear that I still have hair to get in the way. Okay. So the procedure now will expand the walls, the palatal and buccal wall. We’ll use the site dilator of five and a half. Okay? So this is implant site expander, five point five millimeters. Need some more tapping. Okay. So that’s pretty tight, which is exactly what I want. Okay. Don’t suction too far in there. I’ll take the six millimeter hand reamer, then I’ll six millimeter dilator. So, again, now I’m gonna switch between hand reamers and site dilators. Basically, there is no real rule. You do what you feel the bone needs. Sometimes you need to cut a little bit. Sometimes you gotta do a combination of both, cutting and expansion. And in this case, just needed to cut a little bit on the top, and then I’m gonna expand the rest, then I’ll take a six by five point seven. So the benefit of the floor transport technique is that I move the floor of the sinus under control with full vision rather than through a small hole. And I can mobilize it as much as I want, and then I will still use the sides of the bone to hold our implant. And at this point, I’m gonna also use a a little bit of bone graft and the site the implant insert or retriever and finish it off with the Bicon sinus lift abutment. The question from the live audience was, does the buccal plate ever fracture? Yes. If you’re not careful, you can fracture anything. But the key here is to read what you’ve got and not to strain it. What is this? Shadi? Yes, sir. Can can you hear me, Shah I do. I can. There’s been a there’s a question that’s about why you use the square technique instead of a trephine. I I think that they’re both the same, but a trephine will be cutting with a higher speed, and it’s a saw, and it will cut the the bone that excuse me, the membrane that I have no control. A square technique, it’s a lot easier. You can hear. You can feel the bone better. Does that make sense? Thank you. Yes. Yes. A suggestion. Okay. So we’re placing our implant. Again, use a slight twisting motion to sort of escape the edges of the rectangle. Be careful. Now we’ll tap it the rest of the way. Are you okay, Arthur? Yeah. Yeah. More tapping. So we’re used to that by now. Any pain? Yeah. Feel it in your nose? Okay. Okay. Now we will put the sinus lift abutment, which is this baby. Okay? The easiest way to hold it is with the suction. You have best control and you see best. Now I wanna put it with the widest part against the buccal and palatal like so. I can correct it if it twists a little bit. What happens now, this is gonna create the best stability for this implant because it’s gonna engage the rim of the osteotomy. This one. And there is a slight depression in the center that will allow me to use a a three millimeter point or nip to see that. I’ll give it some bone graft right underneath that because I will not have access to it again. I just put a little bit of bone graft there, and I’m going to pack it in. Just make sure it’s where I want it to go. Okay? Now this is too high, and it is stable still. Let’s hope to keep it stable as that. And the one thing is because of the osteotomy being so wide mesiodistally bear with me. That’s it. I’m done with that. Okay? A little bit of resistance here. That’s it. Okay. Good. So I’m gonna take that. Some more. Tricky mesh. Nope. I don’t need it. Okay. We’re gonna put some board in to off this anterior and the distal part of the doesn’t need Are there any questions? I didn’t recognize you. Is there any questions? Yes. This is a surgical question. Yes. I just like to ask the technique involved in securing a short six millimeter implant Which is found in a square site or a rectangular site. Yeah. When you actually pushed their whole floor up, you know, that all that burley was tapping is now part of the apex of that implant. Yeah. And he fills basically basically sludge around it, it doesn’t give primary stability either. So I’d like to know how certain… are made to give adequate primary stability that you get osseointegration and are any membranes placed in a case like this? You can of course place membrane at any stage. I’m not particularly fond of membrane not being a periodontist but that What happens with the six by five point seven in that area, okay, the graft itself, okay, with all of that membrane, and that’s basically the best guarantee that the membrane is still intact, that it’s bouncing back. Now we have two ways of stabilizing it. If the soft tissue were kind of thin and if we don’t have a good contact with the I actually finished. Can you have him bite on gauze? We don’t have contact over the sinus lift abutment, which is correctly identified as not round by Pete, is actually is oblong, and it’s six and a half millimeter or more on on its longest dimension. So this will sit on top of the osteotomy even if it were a round osteotomy. Okay? And then what will happen over the next minutes or so, the clot will hold everything together. This isn’t the first time. The the one thing that you don’t wanna do, obviously, is have this implant under permucosal loading or something like that. But this is very thick soft tissue on top, and Pete was absolutely correct that the actual soft tissue coverage is going to give us the final immobility. Now the putty, the the sort of the jelly like substance of the graft and the bone, excuse me, the blood is going to to act as the precursor for the integration of this implant. I also heard someone asking about the crown to implant ratio, and I I then missed the the answer. If you’d like me to address that, I’d be happy to. And any other questions? Okay. Well, I’m gonna switch rooms so we can do the x-ray. Okay. Shadi, question number one. Morning, everybody. Shadi? Just a minute. What is the maximum height or distance of maxillary residual ridge that you would advise using this technique in? So that residual ridge you’ve just done is two to three millimeters high. How much of a ridge do you max do you suggest you don’t need to do this technique and do a normal closed osteotome technique? I would say five millimeter or four to five millimeter or more depending on your skill and comfort level and the implant you use. Obviously, if you you should be using Bicon because it’s the best implant for this. If you have four to five, you can use a the closed osteotome technique, the so called closed the the internal sinus lift. Anything less than four, three millimeters or so, you can use the floor transport. Remember that as I was, trying to push the wind the window into the, alveolus, it’s actually compacting a little bit. So although it may start at three, it’s actually more like two or one and a half millimeters. Okay? Now the limiting factor, and and I really don’t wanna spend too much time on this, but but the limiting factor is not so much the thickness of the bone. It’s how much are you going to move the membrane without risking tearing it. Because there’s only so much you have control over from just the access through the crest. Okay? So if you have already four or five millimeters of thickness, and then you’re going to push them up eight millimeters, now you’re trying to go almost like with a tent pole, pulling or pushing the whole membrane up something like twelve millimeters or even more or at the very least twelve millimeters if you’re gonna use a six millimeter implant. So you see, that is going to be untenable and the risks are going to be too high. Now with your skill level, you may be able to do it. But initially, what you want to do is find the area where the ridge, the crest, the buccal, and palatal slopes are close together so that you can have buccal and palatal friction and immobilize your implant as I did before. And then your limit on the elevation, you choose the the shortest implant without pushing it too high. And that’s why it’s successful. This technique was is really made possible by the ultra short implants, the six millimeters and and the five millimeter implants from Bicon. Question. Thanks for that. Thank you. Who’s next? Guys? Please don’t be shy. Put your hands up quickly. Would it be of any use to use cone beam tomography in your planning stages for a case like this? Say that again? Will it be of any value to use Cone Beam Tomography in the planning stages of this type of approach? Yes. There would be there certainly would be a use, a significant use to it. But after you’ve done a few, you sort of can read your panorexes and your, you know, the the resistance that the bone is offering you. But yes, it would be of great value to us to do that. Just a question regarding peri implantitis. Can you please elaborate on how you treat with a Bicon implant given peri implantitis is not easy to treat anywhere with any implant. The the main reason for peri implantitis is the the close proximity of the implant to the soft tissue covering. And as you know, with Bicon, with its being subcrestal or intracrestal, you have a layer of bone that helps you avoid that. Now, can you hear me? I don’t know. Yeah. Okay. And so Yeah. We can hear you. Okay. And so treating it with Bicon system, thankfully, is not that common, but when we get to it, it’s an aggressive treatment and it involves decontamination mechanically with a diode laser and with irrigation, hypotonic irrigation. And finally we are now just using some grit blasting with tricalcium phosphate, beta tricalcium phosphate, which seems seems to provide a very good interaction for those, you know, two, three millimeters of the implant that may come in contact with the contaminated tissue. And we’re finding preliminary results very encouraging. However, our sample size is very small as I said. Yes. Daher, quickly, anybody? Yeah. Where’s the I’m just searching for the next one. Does anybody else want to? Don’t be shy, guys. Think that we just asked the question again. You want to know what? Is there a higher incidence of peri implantitis with a short implant? Shadi, is there a higher incidence of sorry, a higher incidence of peri implantitis with a shorter implant? No. Thank you. Mean, you want to go and have a very, very long answer to a short question, I can. But the short answer is no. Thank you. I’m just trying to see if there’s anybody else. Is Christine here? Second. Could you go on about the crown root ratio, a little bit more about that? The crown root ratio? And why Bicon succeeds? Well, initially, you know, it’s counterintuitive, right? Like every one of your colleagues are thinking the same thing and we would all admit, we all thought the same way, this couldn’t possibly work. However, decades of eight millimeters long implants succeeding in the presence of over one point five to one ratio, which goes against everything we know from dentistry, led us to think, well wait a second, if that doesn’t apply at this level, let’s see what happens. And so clinical realities dictated that we end up with crown to root ratios that are two to three to one, but also we followed that up. Initially, we the study of the success of the implants, over time showed that there was no difference between the ultra short implants and the non ultra short implants. So we know that although these are loaded and placed in all kinds of patients that are not selected, they succeeded. So then we took it one step further to see well, if an implant failed, was it more likely to have a high crown to implant ratio or no? And again, the results showed that there was no difference. So although the failure sample obviously is smaller than the success sample, still it was statistically significant. And this paper has been published showing that it doesn’t affect the success or failure rate whether the crown to implant ratio is prosthetically or dentally unfavorable. But for implants, it actually works fine. The final thing is, well, what about longevity? What about long term maintenance of this crestal bone? Which basically intuitively would tell you that, you know, if there is a significant significance or a significant effect of the unfavorable or seemingly unfavorable crown to implant ratio, you would start seeing bone loss at the crest. And that again has not been proven. Actually, it shows that there is no correlation between the crown to implant ratio and the maintenance of of the crestal bone. In fact, we see just about the same amount of bone elevation and growth on the implants rather than bone loss irrespective of the of the crown to implant ratio. And and when we’re refining the sample, we’re we are now postulating that an actually higher crown to implant ratio is fit more favorable to the crestal bone. Now this lies in the in the actual entirety of the design, where all of these plateaus work together to stimulate the bone better, to resist all of these pressures, what whether they be loaded centrically or eccentrically and still have solid bone maintained around the implant. Thank you. You can see a lot of this is Is anybody? We do have the X-ray to show you incidentally. The X-ray is up. Alright. Don’t tell me they’re too close together. Thanks. Is anybody else like to at this stage, would like to ask Shadi a question? Yes. Just to close When can you start loading there? When can we start We will consider this a sinus lift and in about four and a half, five months, we will we will open them to take the impression. The the I know you guys are thinking those look a little bit too close together. Okay? And the fact is they the bodies appear close, but the shoulder where the papilla lives, where the restoration is going to end up being affected are far apart. They’re more than four millimeters or three millimeters apart. And so that doesn’t affect the restoration of the case. Invariably, because of the thinness of the the bone. And because if you look can I show them here? If you were to extrapolate. No. Right here. If I were to extrapolate where the flap was and then the window is, my osteotomy ended up here because of the overhang to the mesial of the molar. Okay? So we have to stay away from it. This very routinely happens when replacing implants in this kind of proximity. However, this doesn’t affect neither longevity nor aesthetics nor function because of the sloping shoulders. Okay? So I’m not at all concerned with it. Okay, well, are you going to wrap up now, Shadi? I am finished. Dr. Morgan is here to say hello and goodbye. If you have any other questions please email us or call us. We’d be happy to talk with you. Thank you for your attention.