The Internal Sinus Lift with SynthoGraft®

Good afternoon, everyone. Thank you for joining us today. My name is Shadi Daher. Today, we will be talking about the sinus lift, the internal sinus lift, specifically using SynthoGraft. The normal sinus, when I talk about the sinus incidentally, I’ll be talking only about the maxillary sinus. And so the maxillary sinuses are the two paired cavities below the eye of the orbit, lateral to the nose, and cephalateral superior to the teeth. They start out as small little vestigial pouches in an infant and over a lifetime they expand. Certainly when there is some tooth loss, this expansion accelerates. Even without tooth loss, you will see some patients have extremely pneumatized sinuses that can reach all the way to the midline. Most of the time, however, it’s of no consequence to a normal patient. It’s when we need to replace the missing teeth with the placement of root form implants that can come into play. One sort of seminal paper that gives you a lot of information on that was published in the Clinical Oral Implantology Research as a supplement in twenty eleven by Janner, and I invite all of you to look it up. I get it. It does have incredibly detailed information about the dimensions of the sinus and so on. As the title of this talk implies, we are not talking about lateral sinus lifting, but rather only about internal sinus lifting. However, we still need to know the anatomy of our surgical site. Now, we’ve all seen images like this one. This is from Grey’s Anatomy book. It’s a very old plate and it shows the osteology of the maxilla, the maxillary bone with the teeth in place. What is important to us is this area, the area from, say, the first bicuspid or second bicuspid all the way to the second molar. The alveolar process is where we are working and it says that right there in this nice script, alveolar process, the alveolar process is obviously where the roots are and this is where the implants will need to be. Now, when the sinus is pneumatized or hyper pneumatized, it will occupy that bony space. And all of a sudden, instead of having room for implants to be placed unhindered with plentiful bone all around them and good circulation, now you have the space or the void of the maxillary sinus and air cavity. Now, the talk obviously is about managing that and pushing it out of the way. What do we push out of it? What is the it that we push out of the way? It is the maxillary sinus mucosa, and the mucosal lining of the sinus is composed of a very relatively thick adventitial layer right in this area and the innermost lining, which is the respiratory epithelium, which is the pseudostratified columnarcelliated epithelium. It is important for us to remember that because number one, we don’t work with this single cell layer. We work with the entire mucosal layer, thankfully so, because we could never dissect these single cells with our macro instruments. Even the thinnest and finest of our instruments can cause tears and perforations in such a thin mucosa. The mucosal dentition layer at the base with the periosteum at its base as well give us something to work with. The real key is that the cilia are our friend. If we protect this and preserve this, will help fix our mistakes. If, on the other hand, we cause significant perforations and tears, introduce foreign objects and not protect the patients, we can get an infection or the weight of fluids from mucus, retained mucus to pus or other fluids that can cause a mechanical pressure on the implants as well as other organic pressure shots such as infective. The dimensions of the sinus are not as important to us when we’re talking about internal sinus lifts, but they are important in case you’re considering lateral lifts. Every case is different and obviously there are ranges of approximately a centimeter, a variation in width and height, etc, etc. But it is important to know our patient and know where they fit in that kind of spectrum. What I do want to mention is the sinus septa. In the anterior and middle area, this is again from that paper, we find about two thirds of the sinus septa and they are present in a way that can influence our surgical technique and they can be pretty significant. Here’s an example. This is just the panorex, and as the previous slide says, most of them are easy to detect on panorexes, if not all. And on this one, you see this, you know, a hint of one. So when we went in, we thought this would be easy to manage. But as we went in, this is for a lateral lift, but for the sake of illustration, this turned out to be a whole chamber practically. Surgically, we could not bridge over the gap and ended up doing two side by side lateral sinus lift windows as such. So recognize the presence of the septa as if we are trying to fracture the floor as we do for internal lifting and you come right at this septum vertically, it becomes a very significant thickness of difficult bone to fracture. So you do not want to try to break that. It’s unpleasant for the patient and it’s fraught. If you break it, it’s not really a success because that piece can then pierce the sinus mucosa and you end up with bigger problems. You’re better off kind of glancing and avoiding it. The hypertrophic sinus comes in many different presentations. We can detect some of them on periapicals. We can detect them on panoraxes. We can see them in our cone beam scans. So there’s another panorex. What we want to look for is not just the bare kind of essential information that a panorex gives you, such as the line of the floor of the sinus. You want to look for other hints. And so play a little bit of detective because that will color our treatment planning and our treatment sequencing as well as show us where things can become a challenge. In this case, for instance, we know that this patient has been having significant caries, been having pain as a diabetic, so you wouldn’t know that, but obviously we knew that. And his problem was mostly on the left side. And as we see this molar tooth, which was endodontically treated with the sinus proximity, and yet we see this area right above the root of the molar that shows some separation or widening and sort of an acystic development. When we extracted this tooth, this area deflated, for lack of a better word. And so when we went to do the sinus lift, this is a prime area for adhesions, in other words, the scars between the sinus mucosa and the bone that will be very hard to separate in a surgical approach. And this is where, if we’re going to have tears in perforation and lateral lift, this is where they most often will happen in an area of multirooted teeth that have had, infection and or endodontic treatment. So when we are doing a sinus lift, the sinus lift is a graft. The graft just happens to be sort of in the sinus or underneath the sinus cavity per se. So obviously, a graft requires a grafting material. So what is the ideal grafting material for a sinus lift? First of all, we want to do this procedure once. We’re not going to re enter and do touch ups if we don’t have to. So we want to have volume stability. When you lift the sinus, you want it to be lifted and stay lifted. You want it to be able to produce bone. But that’s for every graft material. You don’t want it to have infection. Again, that goes without saying. But in the sinus, since it’s a closed, not very easy to access location, you want it to have low incidence of infection. In other words, you want to be able to produce it, to have it or to procure it sterile, keep it as clean as possible, as sterile as possible. You want it to be easy to handle. Patients obviously or more often are awake. We have and they go about their business. Some of them have the procedure done on their lunch hour. And so you would want to have them able or want yourself to be able to place the graft and have it stable and steady and not moving and easy to handle so you don’t spend five hours doing a simple procedure. You want it to be available and you want it to help you stabilize the implant because that obviously is the ultimate goal. So the autogenous bone was was long thought to be the gold standard for internal lifts. They work very well. You hear every now and again of someone’s experience anecdotally or some papers being published. There was a consensus conference in nineteen ninety six about lateral lifts. And in that conference, they came out with sort of the politically negotiated term, saying that autogenous bone is really the best, it’s really great, but it’s okay to have a xenograft mixed with it or xenograft and so on. Well, I’m here to tell you that we’ve done hundreds of those cases, and we are now probably approaching thousands of the cases with the beta tricalcium phosphate in its purest form, the SynthoGraft. And we have not had any major issues success with it. That rivals the ninety five percent or so success that has been reported in that ninety six conference and in subsequent publications. So just to situate ourselves, our gold colored quasi rectangle there where the calcium phosphate is represented is a subgroup of the alloplastic materials, which is a subgroup of any bone augmentation material. The autogenous group is by its lonesome on the far left. Allografts, these are the material obtained from bone banks. And those are in great use, but they have their obvious limitations from allergic reactions, disease transmission risk, etc. And xenograft, again, their lack of resorbability can become a problem and their sort of inertness can present a challenge. Our alloplastic materials, the synthetically derived material, I find they offer us the best of both worlds, especially the beta tricalcium phosphate. And that is because the tricalcium phosphate is made of calcium and phosphate ions, just like our own bone or any non demineralized or mineralized allograft. And so those, as they break down, the breakdown products, the calcium and the phosphate, are taken up locally by the cells and used up in the laying of the non organic matrix or non organic components of the bone. And we want that, that’s desirable. And in the case of the beta tricalcium phosphate of the SynthoGraft, which is the most or the purest stoichiometrically. So if you took this and analyzed it, it has the highest percentage of tricalcium or beta tricalcium phosphate available. And yet it is manufactured in a way that gives it multiple micro and nano porosities rivaling the naturally occurring bone, giving it the ability of turning over very, very quickly. And recently I’ve had the pleasure to work with colleagues Drs. Larry Levrini, Paulo Coelho, and Estevam Bonfante. And we published this paper from one of our patients who wanted to have non metallic implants placed and insisted on having his Bicon implants, which were functioning beautifully, removed. And the paper shows a series of analyses of this slide after we retrieved this implant that was placed with a sinus lift using a SynthoGraft. This was the original or the line of the native bone. Above it is the line where the SynthoGraft was introduced and below it was the native bone. On the left side of your screen, you see a prepared slide, a section right through it, and then we go through magnifications. In the paper, we only selected three spots: one here, one here, and one here. And that is one in this sort of distal or posterior sinus graft, one in the anterior sinus grafted area, and one in the native bone. And here I’m going to go clockwise showing the native bone with different growth rings. Incidentally, these implants were in function for roughly three and a half years in the patient for about four years. So those integrated, they were in function. As you see, those growth rings with vascular channels and some cancellous spaces and so on. This is going a little bit farther up. We’re still in native bone. A little farther up, we see a little bit less magnification. Now we’re encountering some of the graft particles that have been encased and very few of them are left. And yet what’s telling is that in the plateau spaces, which are bone growth chambers in our consideration, the bone has formed very well. The graft particles have resorbed incorporated, and this implant is integrated. Now remember that the implant and the graft were placed together at the same time. And so continuing on to the other side, this again is an area in the graft just above the level of the autogenous bone or native bone, and there’s a close-up of it with a different staining. Incidentally, the stain here shows the bone with this pink fuchsia color. These are forming new bone, turning over bone, and you see the growth rings. The point of this whole exercise, and this is the native bone, is that the difference between the native bone and the synthograft filled or grafted sinus floor is minimal. The synthograft with the plateaus interact so well together that you get that new bone formation at the same time as the implant integration, which is why we are emboldened. And we have been for well over a decade now placing implants in majority of the SynthoGraft, some of them barely touching native bone at all. And after a period of anywhere from five to six months, we’re uncovering or loading them. And you see that in our publications, in our lectures, and I’ll show you some of them today. Now, before you start drilling and fracturing floors of sinuses, you need to select your case as well because our goal is simply to reclaim the depth of the alveolar process. We don’t want to stack the deck against us before we even start. So we need to create bone in the posterior maxilla. We need to get the implants to osseo integrate. And obviously, after what I have just told you, it’s not that hard if you get the modicum of stability of the implant and you encase it in SynthoGraft that is slurry or mud, if you will, that has been well mixed with the patient’s own blood. Now, our ultimate goal obviously is to get the support for a functional loading of the prosthesis with as little morbidity and complication rate as possible. So, when do you do a sinus lift separately first, I. E. A lateral lift, and when do you do both? Now, if you use Bicon Ultrashort implants and you’ve been to any of our courses, you know that we try to do the immediate or simultaneous implant placement for virtually every case. It’s been my mission to eliminate the need for lateral or sinus lift first. So our goal today is to expand on this, the crestal approach. Now, for those of you who practice in the United States, the CDT code for the internal sinus lift or the crestal approach is the vertical sinus lift, and that’s a D7952. Okay, for the lateral window approach, it’s a D7951. I have used the D7951 a handful of times over the past year or two, whereas this is virtually a daily, probably sometimes multiple times in the same day that we deploy this technique. So as you’re selecting your cases, you are making that decision. What are you going to do? What are your limitations? Basically, the cut off is dependent on your experience and expertise and level of comfort in the type of implant or length of implant you want to place. And I strongly urge you to use the ultrashort implant. They work and they minimize your risk. And secondly, it depends on the native bone and the combination of the two. As I said before, or not in this talk, in prior talks, we control what we know, but we can’t control what the patient has. We can just select them. And so if you have somewhere in the neighborhood of about four to five millimeters of residual native bone, it should be a good place to start for an internal sinus lift. Less than that, now the interplay between your expertise, the type of implants and the type of techniques that you’re familiar and comfortable with comes into play. And so, also, we must select, we must look out for sinus pathology because you may have a lot of bone, may need to do just about three or four millimeters of a sinus lift, and yet you have significant pathology. Things like sinusitis, even rhinitis, allergic or infective or viral rhinitis. You may not want to approach the sinus because the mucosa, when inflamed, becomes very friable And a procedure that would have been minimally invasive can cause complications. So a lot of our patients, when we’re confirming, we do ask them. And some of them will tell us, you know, I’ve had a cold or I’ve had a head cold or I’ve had sinus infection. Typically, reschedule them until the sinus is clear, and this can be treated with antibiotics or decongestants or just simply time. Other surgical management for infected processes. We’ve approached the sinuses transorally or trans nasally, but what I find, especially in the town where we are, we have a lot of specialists, it’s easiest to just refer them to a friendly specialist of your choice or theirs. And so when we look at CT scans, this is a hospital CT scan, we see this is a significant sinus disease. It’s filling up the sinus. And even though we have roughly about six or seven millimeters, just drilling in this area causes a risk. A small puncture, even inadvertent, even microscopic, can cause major failure. But worse, this mucus that could be infected can cause infection in the bone like osteomyelitis or the sort. And when you see calcification, this has to be sorted out. Is it because of a benign process or more malignant or otherwise? But sometimes we get fooled. We see on a panorex something elevated like this and it’s just a little bit of mucosal thickening. But since we have a prevalence of cone beam scans available, when we look and depending on the size of your cone, if you have a small cone that shows you just the very bottom of the sinus, then you have to make a judgment call here. Do you expect that it’s only the five millimeters that you see or is it thicker than that? I prefer a little bit larger cone like this one where I’ve set my cutoff at nine millimeters. Anything higher than nine millimeters, I find that it’s not totally arbitrary, but the weight of the mucus or mucosal lining will weigh on the implant and push it down, especially if I need to do a sizable like three or four millimeter or five millimeter sinus lift. Okay, and so when you see on top of that some air bubbles, this is an actively bubbling, infective process. And so these patients should see an ear, nose and throat doctor. They should have this area cleared. And if they get to a point where this is calm and it’s not infective, it’s just a reactive and reactive thickened mucosa, but otherwise it’s not actively infected, we can then contemplate the sinus lifting bilateral window or otherwise. You also can see things like a large cyst. I would not approach this. This is about two, two and a half centimeters of weighty, homogeneous fluid filled lesion, as is this one. And in this case, we have an air fluid level. So those are the cases that you would want to avoid starting an internal sinus lift on, or any sinus work for that matter, because you just simply have no control over that situation and this is in terms of case selection, this is what you select out. This is what you exclude from your practice until it’s cleared up and cleared out. Now, we prepare our patients with antibiotics and consent, etc, you know that. The main principle of the internal sinus lift or the vertical sinus lift is that the implant be placed at the same time as the sinus is lifted. And so we are grafting, so we will use bone particles. Now, there have been studies and I know some of you may have tried it, I know we have done it, where we just tent the mucosal lining of the sinus and allow a blood clot to form with the plateau spaces of the implant and the minimally invasive procedure. We get bone forming with no problem. However, the bone grafts are not just as a graft. They function as a surgical instrument. And that I will elaborate on that in a little bit. But suffice it to say, I am a fan of using them, especially the fine particle size and especially making that fine particles into a slurry like very wet, near viscous liquid. And that will help us complete the treatment. It is very important, however, that the implant be stable at the end of the procedure so that it doesn’t move and cause perforation. The dehiscence, herniation and most likely failure of the graft because of the constant movement. The consideration for the Bicon implant, particularly because it’s intracrestal placement and the sloping shoulder implant, have to have a significant thickness so parts of the base of the shoulder and maybe another plateau or two be touching the native bone, so it gives you stability. You want about five millimeters. If you do the math, that gives you about two millimeters of full contact between two or three of the plateaus and bottom shoulder. Now, if you cannot achieve that, you have less than the five millimeters or so. You will need to extend your implant. This is where the sinus lift and a temporary abutment comes into play. And that basically makes the implant longer so that it grabs and fits and makes use of the full crest right onto the top of the crest. But there is a certain way you have to use it so it embeds itself into the bone, creating an additional means or an additional way that it stabilizes the implant. I’ll show you some cases on that. And so when you have a very, very thin bone, two millimeters or less in the past or for many of you even now, you have automatically shifted to a lateral lift technique. That’s perfectly acceptable. I think it’s expected even. But with ultra short implants and some of the techniques that we can deploy, it may be unnecessary. Now, one of the other limitations of the internal lift or the vertical lift is how much can you really push that membrane blindly through a hole in the center of it and expect it to kind of follow you and not tear. As a rule of thumb, I’ve noticed that when the osteotomy is small, intuitively, the amount of pressure I exert on it and not cause it to perforate is a lot smaller, and therefore I can make it travel only about a distance roughly equal to the diameter of that osteotomy. And therefore, whenever I wanted to do an aggressive sinus lift without a lateral lift, I would go to as wide an implant possible, but that taps out at about six millimeters. So I can lift it six millimeters. Well, what if I needed to lift it more? Say I want to place a six millimeters long implant, but I only have one or two millimeters of native bone. And so to put that plus the six and another couple on top, I’d have to lift it about eight millimeters. And so for that, I would want to make a wider surface area without losing the contact for the implant. That’s where the floor transport technique comes into play. And the technique I would explain at the end of the talk today. Okay, so let’s quickly go over some quick points because I hope that by the end of this talk, you will find at least some pointers that will help you treat the patients with the internal lip using ultrashort implants and the SynthoGraft. Now, we beat that point, I think, to death with respect to the different depths that you can work with. But what you do is as you are preparing the osteotomy, it is not a complete osteotomy, obviously. You are going to prepare to within a millimeter to, if you have fairly soft bone, of the floor of the sinus. Now, how do you know where the floor of the sinus is? There are many different techniques. The best one is you measure, you measure, and you measure, and you again, you drill very slowly and keep measuring, coming out, measuring and drilling, or reaming very, very slow. For the Bicon system in particular, you have an invaluable tool, and that is the hand reamers, which are able to remove bone in very, very slow, meticulous increments. So if you know the depth, you know the location where you’re working, you can approach that floor extremely cautiously and avoid perforation. And even better, if you are a little bit more aggressive with the hand reamers and remove all of the bone, if you’re doing it slowly without a lot of apical pressure, you could actually remove all of that bone and still not damage the soft tissue of the floor of the sinus mucosa. Learn how to use the hand reamers. The edges of the osteotomy come together, that’s the shape of the apex of the reamers, and so that comes to a funnel. And so you would still need to fracture them, otherwise they will not allow the implant to move relatively freely. You need to use a lot of hammering, which is very unpleasant to the patient to seat your implant. So I advise that you use an osteotome, the round sinus floor osteotomes, then introduce your graft. This is why I want to mention to you the non Newtonian fluid characteristics of the fine SynthoGraft particles when mixed with blood. Non Newtonian fluid behaves like a solid impacted with high inertia, with tapping, with a mallet. So what happens is as we introduce those particles, obviously, very carefully, meticulously, we just inject them into the osteotomy and then we take an instrument. Typically, I use expanders and we give it light taps with a surgical mallet. That tapping compacts them and makes them behave as though they are part of the instrument, lifting the mucosa off of the floor. However, because of the shape that they are in, because they are spreading in all three dimensions, you will not force the mucosa only vertically, but rather you will push it on all sides and causing the mucosa to separate from the floor of the sinus. And then when you are not tapping, that simple weight of the mucosa, just the elasticity of it, will make the graft kind of relax and go back to the sort of liquid phase and they stay where they are. And we repeat the process. And then at the end, when we introduce the implant, it will keep them where they have injected themselves. That’s why the internal sinus lift using the SynthoGraft particles that are wet works so well with the Bicon ultrashort implants. So again, my point about lifting the mucosal lining is revalidated because it is the limiting factor. Now, can sometimes, if you have plentiful autogenous bone, you can use that in cases like this one where we place the short implant and placing autogenous bone. You just have to get the x-ray just right. So you see the shadow of the lift. And yet as it consolidates over months, that bone becomes more and more defined. And then when you put it to function, the definition increases. And then after about two and a half years in function, you see that this has been maintained. Okay, and so this is what we see with our sinus lift with the SynthoGraft. So let’s look at now the first case today, a forty three year old woman who had failed molar. This is an upper left first molar on the six year molar that had been repaired and restored. Eventually, the tooth gave up on her. So our plan was to remove the tooth and place an implant at the same time. This is looking at the periapical, and we can see that a five by six millimeter overlay fits just barely and it will require maybe a two or three millimeter sinus lift. However, when we removed the tooth, the socket was a pretty traumatic extraction. We decided to let it heal first so that we can do a sinus lift. And then a short three months later, when she returned, you see the bone consolidated. And that, which used to be about five or six millimeters deep, is now just about three millimeters deep or maybe four millimeters. Now the sinus lift has to get a bit more aggressive. Now notice the orientation of the overlay. Like with every implant, what you should be focused on is the space of the crown. So we draw an imaginary line connecting the contact points and we try to have the implant axis, long axis intersected at its middle like so. And that’s the goal. Now, this is all fine and nice with drawing, but let’s see if we can achieve that clinically without a guide. And even with a guide, because of the reaming of the Bicon system, it still relies on your ability to maneuver in the area. After about three months, this is the clinical presentation. We look at the way the socket healed. We still have nice attached gingiva, but we will not be sacrificing that. So we will open a flap keeping the papilla. It’s a papilla-sparing flap. And as soon as we make the incision for the SynthoGraft this is a very important point, the inventor and manufacturer’s recommendation is that it be mixed only with blood, the blood of the patient. So I usually, as soon as I make the incision and we draw some of this mixed arteriovenous blood coming from the incision, we pull it and set it aside. For a single tooth graft or for a minor internal lift, we roughly need a fifth or a quarter of a cc. That will get a quarter gram very nicely moistened for the procedure. Set that aside, even if it coagulates, we break down the coagulant and mix it with the graft, you know, kind of mix it thoroughly. Elevate a flap. You don’t need to over dissect the flap, so keep a finger as you’re lifting the flap so you don’t rip it and protect it. I use a retraction suture. It may be to you, may be a waste of time, but it just makes the procedure so much smoother. And certainly if you’re taking pictures, it’s invaluable. And then I made a couple of little back cuts so that I can be sure I see the edge of the palatal slope. And then this is from the Bicon kit, a six millimeter sinus floor osteotome. I’m not lifting the sinus yet, but what I am doing is seeing where a six millimeter abutment, because that’s for a molar, that’s the recommended abutment, where it would emerge. Does it emerge with good room for the papillae? And it shows plenty of space. Okay, and then I can make a mark with this edge as to where the distal, where the mesial edge of it. And then using my pilot drill, I will then just mark the center of where the implant has to go. And that’s roughly a millimeter or two deep, which I can then check. Okay, see the little notch from the osteotome and the marking. Again, I’m focusing on that imaginary line drawn between the contact points. Yes, I may not have a guide, but I have a lot of teeth in there and I will use them as my guide. Okay, we need to be in the center of the crest. And if we have sort of fairly thin crest, I favor going a little bit closer to the palate. I want thicker buccal bone if I can help it. And certainly if I want to be about a millimeter or two, maybe even more, away from the buccal cortex. We complete our osteotomy and here, as you see, this is the first black band. So this is six millimeters to eight millimeters. We’re getting within two millimeters of the bottom of this one, so we’re at four millimeters depth. By our measurements, have about five millimeters depth, so we are keeping one millimeter of safe bone away from sides. We put the paralleling pin. You notice the paralleling pin doesn’t go in very deep. That’s because obviously it goes in until that pointed part of the pilot drill starts and then it obviously is stopped. Then we start with the reamers. These are at very slow speed, fifty rpm or less. No need for irrigation. Again, we’re going only to a depth of about four millimeter. Okay, that’s the three, the three and a half, the four. And then when I get to this point, I noticed that the buccal plate was starting to show a little bit of a shadow. So I have about two millimeters or a millimeter and a half. So what I did is went to hand reamers and ream to only the palatal part. So we start with this cutting edge on the distal buccal, rotate roughly a half or two thirds of a turn, stop and pull out. Okay, like so collect all of that bone. All of this is excellent bone that we could use in the graft. You can use it over the implant. And quite sometimes, a few times, we get enough bone that we do not need any bone graft or just use the autogenous bone from the osteotomy. Here’s a five millimeter reamer. Again, notice how much bone is coming out. All right. And now we take an occlusal view of this. The palatal bone at the crest is right here. It’s about the same thickness. I don’t want to have the dehiscence. So I had to sort of split the difference. Now, when you look at this, it looks like it’s a little bit more mesial. And with all of our measurements and everything, what happens is the bone is a little denser on the distal. So it moved us ever so slightly. And yet we will use one of the advantages of the Bicon system and make sure it fits. So measuring the depth at the edge of the osteotomy, it’s still about four millimeters. We take the implant osteotome. These are called the trumpet or the bicon osteotomes. Those have an outward flare and that outward flare allows us to fracture a wide disc, maximizing the surface area and thereby minimizing the risk of perforation. Introduce it. It will sit also more shallow because, again, the osteotomes come to a funnel edge. So this sits at the top of the funnel, not at the bottom of it. And then we tap brace the patient’s kind of bridge of the nose so that they are not rattled and then tap until you hear or you see the floor of the osteotomy give out. Prepare your implant on the insert or retriever. This is going be a five by six. Take your SynthoGraft. This is the fifty to five hundred micron. This is defined. A quarter gram is adequate for one tooth. Mix it thoroughly until you get to this sort of mud or slurry phase. You want it to be more liquid. Now, for a bone grafting over an implant, you can have it relatively dry. But for a sinus lift, an internal sinus lift particular, you want it to be kind of a slurry face. If you shake it a little bit, it has a little glisten on top and it settles with a smooth surface. That’s the consistency you’re looking for. We introduce it into the osteotomy with a syringe, metal syringe carrier. Okay. Again, you don’t blast it like a shotgun blast in there. You want to inject it very slowly. That’s starting to work on lifting the mucosa off of the floor. We use the next size down site expander. This is the four and a half or a five millimeter osteotomy. Its round, smooth shape helps deflect and push the particles in all directions. Again, when we tap, they behave like a non Newtonian fluid, lifting the mucosa, separating it and also compacting against the bone. Then we take our implant with the insert or retriever. Learn how to use this because in case you make a mistake, you can retrieve the implant. And with gentle tapping, we seat it to final seating or very close to final seating. We know it’s stable, it’s secure, it may need another millimeter of seating. More often than not, we’re finished with that. Then we disengage the inserter retriever, trim our black healing plug, place it. Then we take the autogenous bone, which I set aside. More often than not, I will leave it if I’m doing a two stage implant and just place this right near the incision. A) It heals more quickly. B) If some particles of it are out. So I noticed, by the way, cleaned all of these little loose particles, the stray particles of the SynthoGraft are gone. And when we put autogenous bone in there, if a little bit of it comes into the incision or into the soft tissues, it is not a problem. It doesn’t cause this irritation to the patient that can be inflamed and tender and so on. Okay, So it heals better, it looks better, it feels better, and it heals more quickly. And then a quick figure of eight suture. That’s, by the way, the removal of the retention suture. And we use resorbable chromic sutures, and this is a figure of eight and two interrupted sutures. So if you remember what I told you, we went slightly more mesial. However, if we look at, again, the space in between the two contact points and we draw a line straight down through the center of the implant vertically through there, get sort of right in the middle or near the middle where we want it to be. This is five months later at uncovering. Notice how this settled. You can see how well this bone remodeled, integrated, and all of that had settled nicely. Just for one implant, it’s totally worth it to do the internal lift using the ultrashort implant. Another example, and I chose this case because it illustrates very well how do we deal with the presence of septa. This patient has a septum right in the middle of the space. It’s evident on the periapical as well. This was a recent extraction. So we open a very conservative flap. It has a high lip line, even camouflaged with the beard. You can still see the necks of the teeth. So we did not disturb the papillae or the gingival margins of the adjacent teeth, just all within the socket. Using the pilot drill and immediately went to hand reamers or latch reamers. I wanted to feel for that bone and the hand reamer was a little bit too easy going back to the latch reamers. And these are in sequence going all the way up. Now, the depth to which I reamed was roughly about six millimeters and finished it with the hand reamer at five millimeters. But now instead of using the sinus lift osteotome, what we used is one of these, the blunt osteotomes or the site expanders. Now, there are osteotomes in only if you fracture the floor of the sinus with them. And so notice the angle in which this is introduced into the socket. There’s a significant mesial tilt coming from distal occlusal to mesial apical. Okay, the idea is the tip of this osteotome, which is a little thinner, is going to come at or near the base of the septum. And as I tap it to introduce it, it’s going to bulge through the floor, glancing off of the septum itself. And then I pull it toward the mesial sort of body movement of this instrument, push it this way, and give ourselves as straight a position as possible. We’re within about ten degrees, which is as good as straight in my book. And then now, instead of having a bony floor to our osteotomy, we have a hole in the bone and yet no hole in the soft tissue. You can verify that with a curette. We take the SynthoGraft. In this case, I mix the SynthoGraft with the bone. If you want to do that, expect it to be a little bit drier and don’t over mix it because the mixing can kill all of these viable cells in the bone. Now, in this case, we did not need to do a lot of lifting just a little So I wasn’t relying on the graft particles to finish the job. Just wanted them to be there to cover the apex of the implant. And indeed, we introduced the particles lightly, placed the five by eight short short implant, seated it using the seating tip, sealed it and a little bit more of the graft particles. So this is where we learn our lessons, right? This is a relatively old case. Those little pieces of the, graft that is stuck here and there, those can become annoying to the patient. That’s where we switch to saving the graft, the autogenous bone for the crestal component. So this is what we end up with. The implant has a sinus lift and the sinus lift is contained. The septum is pushed to the side, and the implant is in place. This is the implant restored, and this is the implant eleven years later. Look at the bone level, how stable it is with the synthograft. If anything, the patient with the loss of teeth lost some of the crestal bone. You waited too long to have these teeth that should have been treated. Now there is a nice variation and a nice adjunct to our placing implants with internal sinus lifts, and that is the use of the guided surgery. Now, one shift with guided surgery is when we plan our case, we plan it as to where the top of the implant is going to be. But for an internal lift, or for a sinus lift for that matter, if we’re going to use the technique I’m going to describe, which is a guided osteotomy but not implant placement, Just the osteotomy is guided so that we don’t over drill and cause a perforation. We will focus on the apex of the implant clearly and obviously. So we place our implant as though it’s a 4×5, a 5×5 or a 4.5×5. And we use the appropriate kit. In this case, we’re going to place an implant in the maxillary first right maxillary first molar area. Now, this is a patient who’s extremely phobic, very nervous. And she also happens to be at the time to be the teacher of one of my daughters. So I did not want to cause any distress to my daughters through their teacher. So I wanted her to be nice and relaxed and happy. And I said, we will do a lot of the surgery without you being in the chair. We’ll do that on the on your computer model. So we took a cone beam scan and on the cone beam scan, we planned the surgery. And if you look closely, we see that we plan to do a five by five millimeter implant coming right up to the floor of the sinus. And so if we were to place this implant like we wanted it to be, we would have had a little bit would have been way too deep. So what we did instead, we just placed it so it’s coming right to the floor, not through, but to the floor. And that’s too shallow. This is where the bone is going to end up. And what’s even more important in this case is that when we sent this to sci cat, they worked with us and they said, well, this is the angle you want it at. This is where your ring is going to be, and this is where the implant is going to end up. And that’s clearly above the crest by at least a millimeter. And remember, in the interim, this bone is consolidating and healing and so on. The sinus hopefully will stay in the same spot. It didn’t take too long for us to get the guide back, probably a couple of weeks. And we brought the patient back and the procedure was very, very we have all of the design features, how it sat in there in the presentation. But what I just want to go through is the actual procedure itself. This is the clinical appearance, the guide in place, the punch right through the ring. So that’s one step. Take the guide out, collect that little gingival plug, set it aside. That’s step number two. Now with irrigation, we take one pilot spade drill. We do it once and that takes roughly about five seconds. With irrigation, the bone, remember, is very soft and it’s very shallow. Then we use the 5×5, the first reamer in the kit. Now you may have to go a couple of reamers if you’re doing a longer implant, but if you’re doing an internal lift, I will tell you ninety nine percent of the time, you are going to only need the very first reamer because otherwise you could just put a short implant with no sinus period. K? So you’re gonna do the five by five. You get some bone. So that’s step number three. K? Set it aside. Take the guide out. Keep it aside. K? Then make sure you still have a floor and place your osteotome. This is not guided now. Tap it lightly. You’ll effective you will then affect the fracture. And remember, this is a punch right here. Right? Mix your synthograft with the blood. Okay. Introduce it. Tap it lightly. Now for the sake of illustration, we use the surgical guide to place the implant, but only at the fullest depth. I wanted to show you how it looks. Guided surgery kit, place it right through the guide, until it’s fully seated. But as you can see, it’s still pretty proud, very high in there. It needs to sit two or three millimeters. So I use these markings on the regular inserter retriever to tap it until I see that I’m happy with the seat. Then I seal it with the black healing plug. Then the autogenous bone goes over and the gingival plug is then retrieved. We keep it on saline and placed over and then a strapping suture holds it in place. Obviously, could either open the flap if you don’t want to use a punch. You could also, if you lose this for any reason or you don’t like it, you can just use a collagen plug. If you’re not going to use the gingiva, I suggest you do a flap and retract it fully to one side so it doesn’t interfere with your guide. But this is quick. The procedure took minutes, you know, result in the end. That’s before, this is after. And this I found in a case where the bone was not clear. Even on a cone beam scan, as you saw, it wasn’t very well defined. We would have had to wait probably months, maybe a year or so to have it nicely defined. And so in this case, it helped us. Once we restored it and we put it into function, you see how the bone, just like Wolf’s Law implies, that as you use it, it consolidates. It responds to those stresses. And over a period of four years or so, you see the bone is stable and consolidating and consolidating. And so I want to talk about the enhancement of the stability using the sinus lift abutment, which is an important adjunct to your sinus lifting work with the ultra short implants. It gives you that full flexibility to placing implants in very low residual bone. It was designed to have an oblong shape, and it was designed to also separate the implant to a depth of two millimeters from the flat top to the shoulder. So we use all of those to our advantage. Sometimes we turn it so that it is mesial distal or somewhat in that kind of angulation or sometimes buccal lingual. Just be cognizant of the fact that this sharp or relatively sharp edge that can cause the hissances. So orient this sinus lift extension or abutment to the most favorable way so that it is nicely covered and padded by the graft and by the tissue overlying. Okay, let’s look at the seventy one year old patient who had a failed first molar. Okay, so we removed it. Very large span, close sinus. We let it heal. About two months later, she presents back and you see this is the soft tissue and this is the residual bone. The bone was so soft I didn’t need a pilot drill. Just did everything by hand. Two and a half to three to three and a half, all the way up to six millimeters. We’re collecting all of that bone, but all of it is really mostly sort of osteoid and the clot. We set those aside. This is the six millimeter and take the six millimeter sinus floor osteotome with this little flare, introduce it into the osteotomy and we tap it and it fractures fairly quickly. We mix the scintograft with the bone is plentiful and it was fairly wet. So we got to sort of a slurry stage. Now we mixed a quarter gram. You can’t see it here, but it’s a quarter gram with all of the bone and the blood and so on. We ended up with a total volume of about a third of a milliliter. And so that reinforces our kind of notion that with SynthoGraft fine, the numeric value of the weight is kind of indicative of the volume you’re going to get if you wet those particles together. And a quarter milliliter is a significant sinus lift for one implant. We introduced the particles and obviously gently they moved fairly easily and introduced the implant fairly quickly there. Now, we had quite a bit of those left. Now, the implant is sitting fairly high in the socket. I would not close over that. This will be a cause for failure. Left quite a bit of bone on the facial, not so much on the palatal, slightly low. So I want it to be lower. So I take the sinus lift abutment. This is just the suction tip. You can hold it with anything. Now it has two millimeter locking taper well in the center. You can take it with that. K. We introduce it. Pat a little bit of bone over the shoulder. You don’t have to do that, but I had so much graft. So we put that in and, push the implant. The nice thing about the sinus lift abutment is it gives you a bit of a nail head in this case. There is an even wider one for the six millimeter implants, but that has a little bit more technical challenges because it can be pretty wide. But for those of you afraid of falling into the sinus, do use it. It helps you relax. It helps you be secure. Okay, so we tap the implant until the top of the sinus lift abutment is flush with the crest and so that we can close, we can suture and it’s flat. And that’s the sign that we did our job and the implant is flush with the crest. As we can see here, only about one plateau is contacting the native bone. And in this case, you can make a case where maybe it got more, so it probably got more stability. But look at the orientation. And I was able to seat it more deeply so that I can bypass that slightly lower or thinner palatal plate without fear. And the amount of the sinus that we grafted and lifted is significant, is almost equal to a small, conservative lateral lift. And after about five months, the patient comes back and we have new native bone. You cannot even tell. And that’s one of the advantages of of the scintograft is incorporated so quickly and so completely in resorb that you it becomes trabecular, almost like the native bone and quickly at that. Okay, and so I just wanted to for you to see that example, that difference. So I think the last case, this patient, sixty two year old, she has a sort of a double whammy. She has a missing all the molars in the maxillary left and soon there on the maxillary right. But we also have a bit of a vertical defect, so we have a bit of a subtle deformity as well as pneumatization of the sinus. The combination makes for a difficult defect to treat. If you were to place a platform type implant, how will you place it? Will you shave the bone down, thereby compromising the health of this tooth? Or would you try to graft the bone vertically, which is very unpredictable? And in my hands, it yields almost always less than a quarter of what you hope for. Whereas when using the Bicon implants with the sloping shoulder, the internal sinus lift and a sinus lift abutment, we’re able to achieve that with minimal fanfare, with a lot more relaxed and much easier. So the day of surgery, open a conservative flap again, papilla sparing. But I make it fairly wide just in case I have to do more than the internal lift. So always think in terms of contingencies. We open the flap, put a retraction suture, mark our location and go about a depth of about two millimeters or so. Just check the angle and location of the implant. Now, thing is, know that the implant or the osteotomy is going to be very deep on the very mesial end of it, but very shallow on the very distal end of it. So we place implant after a series of reamers going all the way up to five millimeters. And then check the integrity of the walls and the floor. And we fracture the floor using this osteotome. And so it’s then fractured. The graft is lifted, is mixed again with bone. It’s not a slurry stage because most of the lifting was done in this case and the there wasn’t much to be dissected with that. We didn’t need a very large graft. So I introduced very slowly packing and so on. Placed the sinus lift abutment with the five by six ultra short implant and carried them as a unit into the osteotomy and seated. Okay, tap hard. This is key. A sinus lift abutment is meant to wedge itself into the crest, and by wedging itself with your tapping into the crest, it gives you added stability. And as a sort of a pedestal, it will hold the implant even though some parts of it may not be touching a lot of bone, maybe a fraction of a millimeter. That will still give you stability, especially if you have the buccal and palatal walls contacting the implant at the base of the shoulder. And in this case, we see on the radiograph that this implant was barely touching at the very base of the shoulder on the distal, and yet it’s got this almost full surface on the mesial contacting. And, on the mesial, it’s two millimeters, maybe two and a half millimeters below the crest, and it’s about a millimeter and a half below the crest on the distal. Right? So all of these are the features of the implant that we take full advantage of with the use of the scintograft and the internal lift and the sinus lift abutment. So in second stage, we see that bone is healed nicely. The crest is nice and smooth and straight. And when we uncover our implant, we see that you can actually tap on it. You can hear that it’s bone hard, very metallic sounding sharp note. And then we grab it with a rongeur, give it a bit of a twist, comes off. We check integration, ream it to the proper size, and then place after the impression, the IAC once it’s fabricated. This is the IEC in two thousand seven. We have several year follow-up on this, a six year follow-up at least, and actually we do have seven years. Finally, eleven year follow-up on it. Notice how stable the bone, how nice the shoulder sits, and the sinus lift has been, incorporated. It’s become part of the bone, and I think we will close with this. I appreciate your patience. This is my personal email. I will try to answer all your questions since we don’t have time for questions in this presentation. This has been a fairly rapid fire introduction of the internal sinus lift, the vertical sinus lift of the Bicon implant. Thank you.