Surgical Advantages of Bicon Short® Implants

Hi, everyone. This is Shadi Daher. Welcome. I hope that today’s sprint through different types of cases helps shed some light and show you the advantages of the Bicon system that I have been and my patients have been enjoying for almost twenty seven years or so. Today, what we would like to do is to put a big picture out to you all. As you all know, when we do dental implants, we as the practitioners, the clinicians, we have control over the surgical technique, we have control over the restoration, restorative technique, we choose those. But we do not have control over the patient. The best we can do is to select the patients. So we do want to make sure we view the medical history, that we make sure we have appropriate radiological exams, whether it be cone beam scans, whether it be even a simple periapical for simple cases. As you will see in the presentation, sometimes we have scans and sometimes we don’t need them. Even in some cases that may be deemed a little bit too technical. If you can obtain a CT scan, you find this is your standard of care by all means. For us, we are a little bit more selective, although less than we used to be in the past. Review pathology, make sure you know your dimensions, review the surgical anatomy. This is stuff that you know comes back or probably comes to you as naturally now, but also follow a treatment plan. Surgical guides are gaining again, big traction because of the sophisticated methods of making them. You will see that we use mostly checking guides if we use guides at all for those simple cases. Most of them that I will be sharing with you are simple cases. The informed consent is always evolving, but it is a necessary step. And then one of the favorite points I’d like to make is that your inventory, your shelf should not dictate the treatment. So if you decide to make this as a career choice and you only have two implants and you open the flap and all of a sudden you find that it doesn’t really fit, then you are scrambling and you may not deliver the best care you can. So don’t let your shelf dictate your treatment. And finally, the instrumentations, I’m going to spend some time on the Bicon system because the kit, as it has evolved through the years with huge input from you, the clinicians and the surgeons, you will find that this is probably the most complete kit for use with implant surgery. The essentials of the Bicon protocols, again, reviewing what I just talked about, but I want to quickly go over the execution from flap design and so on. Those are choices you make. I am not about to, or do I even have any bit of time to do the details and that it’s part of our basic courses and advanced courses. However, the one portion that I want to review and I will review in detail is the actual placement of the Bicon implant because knowing how the system is set up and the way the surgical kit and all are lined up for you to perform your best work will help you consistently not only deliver good care, but also feel relaxed doing it. So know the system. First, the sizes that are available with the Bicon system. Most of the time you will be living somewhere in the middle right there in the four and a half by six or the four by six and four by eight and the five by six. These are probably my workhorses. For the mandibular anteriors, we will use a lot of three millimeter by six or by eight. If you have these five or six sizes, you will pretty much be able to deliver care for ninety five percent to ninety eight percent of the patients that you will see. But there are all of these options. Some of us may feel that we want a longer implant. I think it’s not necessary, but mind you that the eleven millimeter implants while available, they are used extremely rarely. I think I placed the last eleven millimeter long implant during one course more than three and a half years ago. So I don’t think you’ll need it. Generally, the rule of thumb is when you’re looking at the anterior maxilla, you’re treating the anterior maxilla, this is what the Bicon MAX 2.5. The two point five indicates the size of the well and MAX is because it’s for the maxilla. And these implants have a slightly different locking taper and have a stronger connection and they are four or four point five millimeter in diameter. So they fit in generally the areas from canine to canine in the premaxilla. In the anterior mandible, that’s where the two millimeter well that allows us to have a thinner implant, the Bicon implants, which are three and three and a half millimeters. And those come in three by six or three by eight or three by eleven and three and a half by eight, three and a half by eleven. And the posterior areas, maxilla and mandible, we’d like to go to a three millimeter well so that we can use a three millimeter post. A three millimeter post offers you great strength. Also, it helps with a good emergence profile. And for that, you will use sizes varying from four and a half to five to six in diameter. The Bicon kit. And I find that it’s the kit that is the most complete. This is the advanced kit and I favor the advanced kits for the availability of these longer latch reamers and these site expanders. I find these very useful and I only use this kit. There are kits that do not have the longer ones. For that, you can substitute with using the threaded instrument adapter and using a hand reamer. And the hand reamers are probably the most distinctive feature of the Bicon kits and the Bicon techniques in general, which is where I will spend a little bit more time this afternoon. The bottom tier of the tray of the kit holds these colored instruments. These are called inserter retriever pieces. And just as the name implies, it’s very descriptive. They help you insert an implant or retrieve an implant. Knowing these kits is a must. You’ll find that they are your best ally. They give you control, give you direction and give you a good estimation of where your implant is going to end. And that’s another feature of the Bicon implant that I will highlight during the clinical presentations. The equipment for the Bicon needs to incorporate this. High torque is extremely essential. So whatever system you may have, whatever handpiece you may have, you need to make sure you have high torque. And I’m talking higher than seventy five or seventy Newton centimeters. This is because of the very low speed non irrigated reaming. If you do not have high torque, you’re gonna end up halfway down the osteotomy and get stuck. You can’t come back out, you can’t go back and go forward. So make sure you have high torque. Now there are solutions for that, but high torque is absolutely essential. This is the comprehensive kit. Many of you may have this kit. As you see, it is missing the second row of latch reamers and it’s missing the row of expanders. Now, as we go on with clinical illustrations and presentations, you will see the importance and the real versatility of these parts, including the longer reamers. So I selected a case to illustrate the use of the kit. This is a case where a patient that had sinus disease and she’d had transoral antrostomy and there was a lot of scarring in the area, but she lost also two teeth. She said that she’d had the surgery and they removed two teeth because it was a big cyst. Clinical presentation showed a scar in here. A patient was very squeamish about x rays, etcetera. No history of cancer, but just a very minimally cooperative patient. So in the process of treating her, since we have ample space on the periapical, the CT scan was not necessary since clinically you can tell that there is ample space in the bone. So when we open the flap to avoid any issues, we left the central area. So what I want to illustrate is the use of the kit, but also some of the clinical features that help a surgeon like me deliver implants that are easy to restore to a reasonably trained dentist. So using the kit, you start with a pilot osteotomy. The pilot osteotomy is done with a twist drill that is very sharp and irrigated. The gold coloring is due to titanium nitride. The black bands are between six and eight precisely and eleven and fourteen precisely easy to see, easy to measure. Bicon implants, because of the sloping shoulders, need to be placed within the crest so that the bone can adapt to the shoulder at a ninety degree angle. And therefore, we place them at a depth of a minimum of one millimeter. I prefer to place them two to three millimeters unless there is some violent structure I don’t want to violate, such as the sinus floor or the mandibular canal. So in other words, don’t go causing the patient numbness just to put the implant below the crest. But also, if you have a choice of placing a six or eight millimeter implant at or just above the crest, do not do that. Go with a five millimeter or a six millimeter respectively and place it within the crest. It is very important. It gives you better adaptation. You will have fewer problems and you will have better longevity of the implant with minimal issues afterwards. So using the pilot drill with irrigation, we make our osteotomy. That osteotomy determines the location, angulation, and length of your implant. And then we move on to the latch reamers. The reamers, just as the name implies, just widen a pre existing hole. But now what’s more important is that we reduce the speed and we increase the torque. So the speed at which these reamers are used should be fifty RPM or less, and the torque is as high as your handpiece will allow. Don’t get stuck halfway down an osteotomy in type one bone. It’s very hard to retrieve that reamer. It is very important to remember to reduce the speed and to increase the torque. Reduction of the speed also extends the lifespan of these reamers, and therefore you don’t have to buy a whole new set every other implant. And they have specific geometry. They are designed with extreme forethought with very intelligent people’s input put in the design and execution of these reamers. I spend a lot of time explaining those in our SPP courses because they are the mainstay of the Bicon surgical protocol. Suffice it to say that as you make your osteotomy, then you follow in half millimeter increments. These reamers will pretty much guide you right through to the completion of your osteotomy. The pilot drill is two millimeters. So logically, the first reamer is two and a half millimeter. Most of the work is happening at this part of the reamer. The kind of cylindrical parts help keep those trabeculae that were too soft to be cut, keep them out of the way, kind of compact them into the side of the osteotomy. And so that leads to two things. As we continue, now we go to the three millimeter understanding the way the reamers function helps us realize that as we are proceeding, we’re able to grade the bone. So cases like this one, where there are some shavings, but they’re not filling up the flutes. This is type three bone. If we had just shavings that are packing very tightly in there that are white, that would be type one bone. If those were packed, they were red, that would be type two bone because that means trabeculations are plentiful and they’re well supplied with blood. However, it’s quite often that we withdraw the three point five millimeter latch reamer and we see no bone. That’s type four bone. And based on these types, we will change the selection of implants of the healing times. The one thing that carries through in the Bicon system is those markings and the colorings. All of the six millimeter reamers, whether they be short or long or hand reamers or expanders have this color, which is an electric green and the three and a half, whatever has this dark blue color. So that helps you immediately almost without having to think about it. You just almost intuitively know which part, which diameter you’re working with. Now let’s go to practical matters. When you see the bone, as I described before, that is packing the reamer and or the flute of the reamer and is white, that’s type one bone. For that, we suggest you use uncoated implants. Now you can use uncoated implants in all, and you can use coated, which is CP, which is coated implants in all types of bone. But the TI works best in the type one bone. It works well in the type two bone and it probably works just as well in all the others. But we have very good experience with the CP and we use them in the type four bone where there is no bone shavings coming up in the flutes and in the type three bone where there is a minimal amount of bone shavings coming in the flute. I vary the healing times based on the type of bone, but also the age of the patient. Older individuals will require more time to collect more circulating adult stem cells to make bone and younger patients can heal more quickly. And so the length of time is always a range and it’s always a minimum. Obviously you don’t want to put an implant and leave it for five years, but you may have to leave it for a minimum of say three or four months. Now, in the comprehensive surgical kit, the hand reamers are the same. Obviously, is the same row of reamers, same position of the reamers in both the comprehensive and the advanced. The hand reamers are probably the most distinctive feature of the Bicon system. They are very similar in shape to the latch reamers. However, they have only one cutting side. And if you look closely, there’s a little bit of an offset at the very tip. That offset is zero point three millimeters. That works almost like a wood plane. It’s an end shaving feature of these. If pressure is exerted as we are rotating these reamers and pushing into the osteotomy, they can actually increase the depth. The latch reamers are not designed to increase the depth. They’re not drills, they’re reamers. These with pressure can be drilled. However, it will take you probably half an hour to go in about a millimeter or two. I’m exaggerating a little bit, but my point is, this is why we’re able to approach very, very vital structures without damaging them because we use the hand dreamers instead of the high speed penetrating sharp drill. And therefore, we are able to take full advantage of the ultra short implants being placed in ultra shallow bone. So let’s continue with this case just to finish the illustration. This is the four millimeter reamer. Notice how we switched to the hand reamers, put it on an adapter, a threaded adapter. And because I just didn’t want to wear out my arms reaming this fairly dense bone by hand, this is quicker, but it still allows me to push up, get a little bit deeper without ripping a hole into the sinus. In fact, there are times where I’ve removed all of the bone and with a curette, I could feel the squishiness, the soft lack of resistance, if you will, of the sinus mucosal lining. So that’s one of the major advantages of the Bicon hand reamers as part of the system. Another advantage is if you drop one of those latch reamers, you have a backup. And there are cases where you can do the whole entire case by hand without any power where we lost power one time and I finished the case with a flashlight and my hands and the hand reamers. So that’s another backup plan. So now our osteotomies are complete. You can see how this part, and I was feeling a little bit of a missing bone and I think there was an adhesion between the periosteum and the sinus lining. However, all of this was bone, the floor is bone and so on. Finished it to five millimeters and placed to five by six. The inserter-retriever have special markings. Your goal is to place the implant when it’s seated against base and this is threaded down. The bone should be between those two lines, which indicate two and three millimeter depth respectively. That’s the posterior implant. We finish the anterior implant. Now, why did I place the implant right after finishing the osteotomy? Because in type three bone and type two bone, the trabeculation may bounce right back. If you dilly dally too much, since this is a friction fit implant, you may not be able to seat your implant fully. So if you have multiple implants, even a couple, you finish an osteotomy, put the implant in. Now, my implants were angled slightly. Again, the placement as you see, the implant in, the bone is roughly at the level of between the two lines. Now, with the Bicon implant, because of the hemispherical undersurface of the abutments, because of the versatility of the restoration, slight variation from the vertical, from parallelism is really inconsequential. So by doing this, I avoided an additional surgery. And you can see at the bottom of the screen, this is an image in a mirror. And you see that there was a defect here. Had we had to put these two implants more vertically and use longer ones, we would have had to contend with whatever the disease that had happened with all of the adhesions and all of the scarring, adding unnecessary surgery because of the use of the ultra short implants. These are the two implants. Now, if you’re wondering what these little nubs are, these are not so little, they’re actually quite long, as you may recall. These are called guide pins. Those are designed for the second stage. However, I always use them in the first stage for two reasons. First is I can tell where the implant is going to end up. So once I seal this and it heals and I can’t move the implant any longer, I know I am delivering a reasonable product to my referring dentist. And secondly, if I don’t like the position of the implant and the bone is relatively soft because of the ultra short implants, I can actually pull and modify the final angle of this implant, even after all the osteotomies are done by pushing it and having it dig into the bone, even though it may pull away from the bone on another side of that osteotomy, and it will not affect its success. For any surgeon who’s placed implants and you find that the angle is just a little bit suboptimal, you know exactly how valuable this is. This is what has saved us from easy to fix mistakes because we can easily just change the angle ever so slightly and end up with a very easily restorable case. So make it a habit to check your angle at the end before you seal it. And the way you seal it is by putting the black healing plug, trimming it. You can trim it right inside to right in the mouth, or you can trim it outside the mouth, which is something I like to do often. And then we put some bone. The bone is not a bone graft per se, but it covers the plug, it covers the shoulder. But more importantly to me, if you’re doing this kind of big osteotomy, it supports the flap from collapsing over and gives you a little better contour and better expectation of healing and a result. And these are the two implants at placement. This is four months later at uncovering. I want to spend more time on some more aesthetically challenging cases. This young lady is a nineteen year old, missing laterals. Her orthodontist moved them out of the way significantly for us. Initially she had significant conversions of the roots. So now radiographically, she has good spacing. As you can see, the PDLs are widened. So this is still actively settling. So we took the wire off and then using a perio probe, I step back about a millimeter and a half to two, mark the zenith of my incision, making a semilunar incision on both sides, then extending that incision into a finger flap. If we need to do a little release, we make an incomplete cut so that we don’t have a tear in the middle. So these are very conservative flaps, but with this individual, she has ample bone, is able to sound all the bone, no CT scan was necessary. And the beauty of this is again, in a young individual is that the bone is pretty soft. We start with the pilot drill for the pilot osteotomy, then do the expansion with a two point five to three. And then three point five is done by hand with a hand reamer. And on the left side, the bone was so soft with the three millimeter that I went to the expander. You can tell the difference. The expanders have the marking at the tip. The reamers have them at the neck or the shank. So the upper left expanded, upper right reamed. And the other thing is having a finger against the facial surface, You can almost always feel if the bone is too thin. Keep a finger there you’ll feel before you make a big mistake and cause a fenestration or dehiscence. I expanded the left side, reamed the right side, placed four by eight max two point five. Those are coated implants. And these are the two implants in place. We allowed them to heal roughly five months. Patient was away at college, so she could have come back in three months. She came back at five months in June after she finished the second semester and we are uncovering them. Use again to make that same incision, very conservative flap, papilla sparing. Once we are sure that the implants are integrated, we will then remove or cut the little finger flap, take impressions, inserting IACs after they’ve been fabricated. Those were a little too white, we brought her back and fixed the color, much happier with this. And the beauty of this, remember, this is a patient who never had lateral incisors. And so by using that little trick with papilla sparing and the stepping back, we gave her a nice feminine profile by making the gingiva trimmed in a way to give a slightly shorter lateral incisors at the gingival area rather than making them too short, which is more of a juvenile profile. This will keep the same length incisally. However, in the gingival zenith area at the gingival margins, you see that nice drop down of about a millimeter that’s very feminine and very aesthetically pleasing. And this is in four years in function. And we’ll go to a next one, which is placement in an extracted molar. So, this is a forty five year old patient who had a four unit bridge canine, bicuspid pontic, and then bicuspid and molar abutments. It’s a little bit overengineered for the area, but I think the failure happened in the molar bicuspid area, not in the cuspid. So removing the molar, we section it. Obviously you don’t have anything to hold on to. So we section it, we take them out as four roots, the bicuspid is one and the three roots of the molar as another. Once these are out, we will survey the sockets. So when we critically look at these sockets, and if you may recall on the radiograph, we have a lot of clearance from the sinus. So I’m not worried about the maxillary sinus. What we want to see is how do we treat this case? Now you have many options. You could put the implant all in the palatal root, but I find that this gives you the least favorable way to trap food. It’s not comfortable for the patient. It’s very difficult to restore. But in this case, the furcation, the furcal bone is where we want to place our implant. So this is what we’re going to try to do. We open a flap and we will place those pilot osteotomies and the pilot osteotomies we will have the paralleling pins. But this is key. The design of the treatment here is by using the ultra short implant, we’re going to confine ourselves to the furcal bone only. We’re not going to extend beyond the furcal bone by a lot to obtain primary stability. However, we will use the properties of the cortical like bone of the sockets and these kind of I beams, the walls of bone between the roots to hold the implant. Again, using the reamers allows us to expand and slowly mobilize this bone without breaking it. And then, quickly we switch to hand reamers and at the end with even expanders. This is a six millimeter expander. And we place a six by six millimeter implant in the molar using the inserter-retriever. Once it’s placed, there’s a five by six here and a four by six, I believe, or four by eight in this area. But let’s focus on the molar. It’s getting a lot of stability from this confluence of the walls, as well as the expansion, the elasticity of the buccal wall of the palatal root and the palatal wall of the distal buccal and some of the mesial buccal roots. So this is important because now let’s say the sinus were closed, we don’t have to worry about it. We’re to stay within the socket. Using an ultra short implant allows you this luxury. Now to close it, I use bovine Achilles tendon collagen and this is the placement. Now, this is a five by eight and this is a four by eight and this is a six by six. All of these are short implants. This is an ultra short implant, far from the sinus, no big to do, no waiting, no grafting. But also you look at them and say, wait a second, is he losing it? This is a little too deep. Remember, this is an adult patient. We are extracting the teeth. No matter what you do for an extracted tooth in an adult individual, you will lose about one to two millimeters. Since we want our implants to be within the crest by about two millimeters. And since I am not worried about the vital structures, I am going to place them at about four millimeters. And that means when we come to uncover, what we see is the bone settled down. We have the prescribed necessary bone loss from the extraction and the loss of teeth. And yet our implants are well within the confines of the crest. They are well integrated and they’re ready to restore. Our cases are uncovered by restorative dentists who have been trained with us. And basically we don’t see them sometimes for years on end. Now, what if you didn’t have as much room as this case? What if you had just about five or six millimeters, something like this one and a sixty one year old individual who had history of sinus disease, there’s a little bit of cloudiness here. And he said, can you do an implant? And I said, well, fine, we’ll need to get a CT scan. At the time we did not have a scanner in the office. I was in ‘seven. He said, well, you got to go there, get one done and so on. He said, well, can you do it? I don’t want to go and so on. And of course I said, well, accepted because we have the hand reamers. If I did not have the hand reamers, I would have said, absolutely not. You have to go get a scan so I can have exact depth and I can have exact markings and I don’t poke into your sinus. So on the day of surgery, you open a conservative flap and using hand reamers by hand, this is two and a half and go on three, three and a half, four. And basically what I do is I’ll remount a little bit and I will check the depth. If I still feel bone, I can remount more and measure. And all I want is about six millimeters or seven millimeters of depth, which I think I have easily here. And we went all the way up to five millimeters and placed a five by five millimeter in there. That is then checked again, remember what I told you about the guide pin, check your angle, place the black healing plug. It’s very hard to cut it when you don’t open a very big flap. So I cut it outside, sneak it in with a perio probe and cover the shoulder with some bone, close it. Five months later, we uncover it. Notice that we’re right at the floor of the sinus, no sinus lift. We didn’t violate the sinus. You can still see the shadow of the floor as it remodels. Is there a bump up of bone there? You’ll be the judge. The point is we uncovered that. And this is six years in function. I only saw this patient because he needed another implant. So I have this x-ray, this has been in function. And as you can see, the bone consolidates around it. It adapts itself to the shoulder. It’s very stable. Again, some of you may be wondering, with the kind of friction fit implant as you have here, can you do immediate loading? And we can because we also rely on bonding the teeth. So this is a case of one of our colleagues who at the time was sixty eight years old. His two centrals were failing, needed them replaced. So he’s actually from out of town, sent us a model of his teeth. We modified them, trimmed away the top, had a CAD/CAM shell of a Maryland type ridge for the two. It was then stacked with ceramic type material with a ceramage. So this is what we have. And the day of surgery he shows up, he had everything set yet actually a day or two before it fractured his tooth. We anesthetized and removed these as atraumatically as possible, the two central incisors. Using luxators and approximators and then atraumatic extraction forceps, We delivered the two roots without a problem. And now placing these implants, there are some nuances as to the placement since we don’t want them to approach the facial surface too much because we can blast through it. There are some nuances about placing them against the palatal slope of the bone. My goal is to place max two point five with the sizes of four and a half by eight short implants. So we place the pilot osteotomy, check the angulations, and then go with the reamers. Again, notice there’s always a finger. I do not want to feel that the reamer is touching the buccal plate. It’s very thin. If it touches it, maybe the very last reamer that’s acceptable. But anytime before that, I have to make a correction. And that is by using hand reamers, etcetera. But you do not want your latch reamers to contact the buccal plate of an extraction socket prematurely. In other words, not before the very last size. And we go to four and four and a half. And at four and a half, I could almost feel it, but not quite. Okay. Place four and a half by eight. Obviously, clean your osteotomies before you place your implants. Place the four point five by eight, max two point five on both. And that’s the beauty of the immediate loading for the surgeon. We checked the angle, this one needed to go slightly more to the palatal. I felt that the apical portion is a little too thin. So slight variation, which were done clinically right at the time of surgery. And as they proceeded, slight differences, but nothing that would make clinical significance for the long term makes the job of the restoring dentist to put the temps on a little bit more challenging, suppose. But it worked very quickly using universal abutments and copings that were picked up and then modified and then picked up again with bonding and bonded, giving the patient a temp immediately after the extraction of teeth. And this is the post op radiograph. Patient returned and you can see the healing is complete right up to the shoulder and right to the hemispherical undersurface. The temps are removed, impression is taken and poured. The lab fabricates these beautiful integrated abutment crowns, which are then seated and the patient is sent on his way. That’s what we have. Now let’s talk a little bit about the other advantage of the ultrashort implant, which I’m sure you all know, which is the ability to place implants very close to the mandibular nerve, where any other type of a system would have required that you A, drill with extreme care and fear and B, may not be able to place without cortical grafting or crib grafting, etcetera. Whereas with the Bicon, again, I’m emphasizing that hand dreamer technology, if you will, where that step at the very apex allows you to deepen an osteotomy at very slow speed with high degree of confidence and safety is the mainstay of our procedures with areas or with patients who have had an atrophic mandible. Like our patient, who was fifty three at the time, had a lot of implants, has very odd shape of the maxilla. These implants are not touching. It’s just the way the maxilla is. It looks like they are on the panorex. But in the mandible, we placed all of these, these seven implants in one visit. But he wouldn’t let me go beyond because he was afraid of getting numb. He must have come back five or six times, thinking about it as though talking about it is going to change it. Finally, he gathered up the courage and he said, Okay, whatever it is, I want to have teeth in the back. I don’t care. Do whatever you have to do, doc. And he came back and we said, okay, let’s start. He said, can you do everything? I said, no, because there’s only one thing worse than paresthesia and that is bilateral paresthesia. So we started with the right side. On the right side, open a pretty wide flap, but very carefully dissect where the nerve is. Not because we just want to play with it, but because we want to see where it is so that we can protect it. And I don’t let anyone hold the retractor in this case. It’s my responsibility because a lot of times it’s slipping and crushing the nerve that causes paresthesia, not the drilling. So again, without much of a guide here, we’re able to use the paralleling pins and some of the features of the Bicon placement techniques to place our implants at the proper spacing. And we have two paralleling pins inserted after the start of the osteotomy. And that’s a keyword. We start the osteotomy. I plan on making about a six millimeter osteotomy total depth that is in the area of the second bicuspid, this one, and about a seven to eight millimeter in the area of the mole. So my osteotomy, my pilot osteotomy was about four millimeters. This is barely in the bone. And then I switch from the high speed, sharp, powerful pilot drill to the two point five millimeter hand reamer that is mounted on an adapter and the adapter makes it sort of a drill except that it’s advancing so slowly. And with the markings, I can easily tell exactly how deep I’m going. And I can tell that very, very carefully and with great care. So we advance this until I’m at about six millimeters or seven millimeters in the bicuspid and about seven or eight millimeter in the molar. And we carry on with that. Try to do the full depth with the two point five millimeter because obviously the pointiness increases your PSI, that means the pressure and you end up getting in there a lot more efficiently, more quickly than if you had waited to the wider sizes. We expand, we go to four, four and a half and five. Now before I place the implant, I also check the depth and I find that it’s a little bit lacking here. So I take the reamer again and this time I stop pushing and reaming and then what you see is this white stuff. The white stuff is cortical bone. And where is that cortical bone coming from? This by our, not estimate, but what we know clinically is the bone of the roof of the mental foramen. So when you get to that point, I would suggest you stop. And then we go to 5×6 and 5×5. The 5×5 goes in the bicuspid and the 5×6 goes in the molar. Now the implants are at the edge of the bone on the facial and below the crest slightly on the mesial and distal. But this bone here is all cortical and that will not stay for too long. It’ll be remodeled since it’s lost its blood supply. You will lose about a millimeter or so as you would see clinically. So to reinforce this area, sometimes I put a membrane, in this case that were deep well within the confines of the bone, I just put all of the autogenous bone, packed it and sutured this area. And this is our post op film. We were right on the nerve. Now I did give the patient postoperative steroids. However, there was no paresthesia whatsoever. As you can see, those were restored. And after about four weeks or so, we moved to the left side, repeated the process. And again, we placed these two implants, again, a five by five in the bicuspid. One thing that we had to do here, think, and it has to do with visibility. I’m right handed, so I stand on the right hand side of the patient and I made my first two pilot osteotomies. And once I checked them, they were not in the correct spot. That’s why we will make the very first mark about two or three millimeters only so we can verify the position. And so I had to make a correction, moved it mesially about two and a half millimeters for both, and then completed the two osteotomies. In the same fashion using hand reamers and latch reamers. This side had a little bit more bone so I did the first couple of sizes with the latch reamer and then deepened it a little bit more with the hand reamers. That’s the four, four point five and finished at five. Again, check the depth one more time, and we placed our implants. Let me show you the implants placed. Here is the five millimeter reamer. Here’s a five by six and the five by five. Both are receiving their cover screws, if you will, which is the black healing plugs and bone goes over the shoulders. I pack it tightly. All of that bone was collected because we use no irrigation when the reaming is at such a slow speed. Again, the implant in this case is sitting right near the mental foramen on this side, since he did so well with the first side, I need to give him steroids and he did absolutely fine. And this is a close-up and this is that uncovering. Remember what I told you about that bone that we remodeled that used to be about three millimeters high or maybe more now it’s about a millimeter. Dense, relatively avascular cortical bone. Once you uncover it, you lose a lot of it. Mental foramen on the right, on the left implants are integrated. The trickiest part here was splitting this one or two millimeter band of attached gingiva. But that’s all you need. If you can preserve it, you don’t need to do grafts, etc. Because of the shape of the neck of the bicon abutment that post. If you bring it all together, it will adhere to the undersurface of the abutment and it gives you good protection as long as you have some attached gingiva. It is not essential, but it’s very helpful if you have it. I like to try to keep as much attached gingiva as possible and remove the black healing plug, check integration, take impressions, etc. And you get the idea. After the impression is taken, the area is split. So we have some healing by secondary intention with attached gingiva on the lingual attached gingiva on the buccal, we get new attached gingiva and the patient is then restored with IACs. And so ten years in function, notice how the bone is nicely consolidated around them at the shoulders. So the five by five work, they are really a very good implant. Five by sixes are our workhorse. We’ve used them everywhere. As well as this patient had failed, these implants, allowed them to heal when he returned and it took him a while to return to us. This area was extremely dense. And because it’s extremely dense, it’s type one bone, took a CT scan. And as you can see on the scan, you can see the nerve. Now we have type one bone that we’re dealing with. When you have type one bone, I like to use Integra TI, which is uncoated implants. And so this is a close-up of it. This is a five by six at the time. I did not have five by five that were uncoated. And this is a four and a half by six also uncoated. So we open our flap, see the, well, I could see it. I couldn’t take a picture of it. It’s kind of deep in there. Collect some blood and then pilot osteotomies. And in the same fashion, as I described to you before, partial osteotomy just about four millimeters, then the two point five millimeter really completes the depth. And then we continue to do the expansion to four point five in the bicuspid and five in the molar area. But when we place those because of the thickness of the buccal plate, we have part of the implant shoulder and one of the plateaus is visible and in the molar, the shoulder is visible. It’s outside the buccal area. So what to do with that? Remember, we have the mental foramen very close here. You’ll see the x-ray after. What you cannot afford is to have graft material that is nonresorbable sneaking around and causing a scar around the mental nerve, which can cause not immediately, but after scarring and consolidation of the scar, you could have paresthesia with late onset. So what I want to do is use a membrane. This is the bovine collagen resorbable membrane. I put it in and burnish it. So it’s kind of a sticky surface in there. And I want to lap it over the crest. That way it will be less likely to slide down. In this case, we were lucky that we got a lot of autogenous bone and we only needed about a millimeter or two of thickness at the crest because of the sloping shoulder. So I took all of that bone and I packed it to a thickness of roughly four millimeters or so, maybe five. But I packed it very hard and by packing it toward the medial, toward the lingual and slightly apically, I was able to create a nice volume right over the shoulder of the implant, and then we’re able to suture it. And the nice thing about these flaps is the buccinator muscle and the mucosa are so stretchy, you can pack five, six millimeters of bone and still be able to close it primarily. I use continuous sutures. You don’t have to, but I like using continuous sutures. And I do like using gut sutures except when there is other call for some reason. And there are different reasons why I wouldn’t use that. In this case, we use gut sutures, avoiding the mental foramen using slight bit of angulation to not have to nick it in this process, place the four point five by six short implant and a five by six short implant. Both have three millimeter wells. We place those and allow it to heal. Again, as you can see from the dates, this is almost ten months later. Patient takes his sweet time coming back. We uncover those, his dentist restored them, asked them to come back. We took an x-ray a year later and this is three years in function. And we had occasion to bring him back for a CT scan for something else. And on the scan, can see that these two implants, this is the molar, remember that had graft on top and there’s the bicuspid, remember that had the buccal shoulder and a plateau were completely denuded of bone. And yet here they are with autogenous bone, collagen membrane and just the plateau design. Now, and I would like to put some of these ideas together from a little bit of teaser about the sinus lifting and the bone grafting and so on. And I will share with you this case because probably in your practices, you encounter some of these cases where it’s never a simple one thing. And this is a patient who had her dentist removed two teeth that were supporting a bridge. The teeth were from the lateral to the first bicuspid. She continued to have pain and she was getting swollen and redness and so on. We put her on about a month of antibiotics. By the time she saw me, was starting to get better, but the area was still red and tender. This is the x-ray I had. We waited another, I think two months. So after three months she returned and the x-ray was no different. So we said, okay, let’s see what we have in there. Open the flap and this is what we saw. The socket of the lateral was healing relatively well. You know there’s a callus in there but the socket of the bicuspid was a whole other story. You touch this, it’s squishy. So I put a curette to it and it popped out like a pearl. So now what we have is a defect and cleaned the socket of the lateral. So let’s survey the surgical site. We have a socket, reasonable. We have an area of the canine. It looks pretty big because it’s filling the screen, it’s actually pretty thin and fairly dense. This has been missing for a long time with broken down infected tooth next to it. So when we are dealing with this, we’re going to have almost like three different surgical areas in the same one and a half or two centimeter by half a centimeter area. And so in the lateral, it’s very easy. We go straight in the socket, use the socket and the central next to it as our guide In the canine, there’s a transition, there’s a sharp turn from the premaxilla to the posterior maxilla, and that’s in the canine. And that made it a little bit difficult to get that angle just spot on. But it doesn’t really make much of a clinical difference as you’ll see in the end. But now we come to the bicuspid. I had no prior x rays of the bicuspid. I’m guessing it was infected. It was probably fractured and floating in there for some time because there was no buccal plate and this is the sinus. If you push hard, you would poke into the sinus. But yet the socket was kind of irregular and needed to put the implant in there. So we tried to do is place each implant individually. The lateral was placed using hand reamers on the adapter. We started the osteotomy for the canine and immediately you see a little bit of a crease right there. So that’s gonna offer another challenge, In the lateral, we placed a four by eight. So we stop at about four, eight millimeter. This is about eleven millimeter on the distal, maybe slightly deeper on the mesial. So in the aesthetic zone, I placed my implants roughly three to four millimeters below the crest. I feel that the emergence profile of the abutments is very supportive of the aesthetic profile of the gingiva, especially in patients with thick biotype. Again, we place our implant using the inserter-retriever. On the distal, the bone is ideal, on the mesial slightly elevated, but I don’t think it makes a big difference for the bicon system. You cannot apply these principles with platform type implants or with other implants with platform switching that are designed to be at the crest that can cause you big problems. We seat the implant properly. Now I turn my attention to the canine starting the reaming and all of a sudden there’s a crease here, but let me accentuate it by putting the implant and seating it fully. And when you look from a cresta view, you see that this actually was expanded bone. This is not mobile, but just elastic a little bit. And it’s a deformation that would be elastic if I were to extract this implant. Okay, but the implant is keeping it propped up. I turn my attention to the bicuspid, I want to place a 5×6. The socket itself is deep on this side, but the opening of the socket is a little offset so to speak. So I just wanted it to be wide enough so that I can put my implant and then push it in the right space. So I did a little bit of reaming and then use the sinus lift osteotome and fractured the floor of the sinus slightly, then mixed SynthoGraft®, which is pure phase beta tricalcium phosphate with blood from the surgical site and some of the bone and packed it into the floor of this osteotomy like so, and use the inserter-retriever with a five by six millimeter implant to push it, forcing the sinus lift, using the friction to hold it in place. Using the inserter-retriever, I could retrieve it, move it back or mobilize it. Then again, this is key. I take the paralleling pin, push this implant. So the osteotomy was here, but by using the shorter of the implant pushing it out within the sinus lift, proper positioning of the implant. Now we have a significant amount of the surface exposed. We need two millimeters of bone here. We’re going to create that by using a collagen membrane. We’re going to place a retention suture and then we will use a horizontal relieving incision. Pack some autogenous bone right on top of the shoulder and the SynthoGraft® mixture on top of the autogenous bone, you can reverse the order, it doesn’t really make too much of a difference. Then we put the membrane and we strap the membrane down so that the graft doesn’t move easily distally and the membrane doesn’t move either. And because of the releasing incision in the maxilla, that’s important in the mandible, as I pointed out before, it’s not. We are able to close without tension. And this is our internal sinus lift. There’s a bone graft here as you can see. Simple implant, slightly less than simple implant or more than simple implant depending on your perspective. Second stage, as you can see a few months later, five months or so, the sinus lift is remodeled. We have a new sinus floor. Patient had lost a lot of the volume of that. She has a low lip line. So it’s just a question of camouflaging, not of creating new bone. And so we open the flap and here is our graft. There’s a better view of it. This is the new graft. This is all new bone with SynthoGraft®. It’s not osteoid, maybe a little soft here, but it’s solid bone. Clean and remove the black healing plugs. There’s a little bit of a scar, but I remove that, allow fresh clot to form. Check our integration. Patient, elected to have her dentist place crowns on. So we put, healing abutments and then she returned and we put these final abutments on. And this is my personal email and I welcome your questions. I hope you found this rapid sprint through some of the Bicon features, helpful. Thank you again.