Bicon Restorative Techniques

My name is Vincent Morgan and since nineteen ninety two I have been providing my patients with the many benefits of the Bicon implant. During this video, I shall explain a variety of the restorative procedures for the Bicon dental implant system. Hopefully they will provide you with an understanding of how to successfully use and restore Bicon implants for not only your benefit, but also that of your patients. However, prior to speaking directly about clinical techniques, I shall review a video of a fifteen year old clinical case in which, for aesthetic reasons, three individual porcelain fused to metal crowns were replaced with three new integrated abutment crowns. Our demonstration begins with a radiographic and clinical evaluation of the three fifteen year old maxillary anterior implants. The removal of the three fifteen year old individual porcelain fused metal crowns is easily achieved by simply applying a rotating and pulling force on them with an extraction forceps. Since the well diameter of the implants is two millimeters, three red two millimeters titanium impression post in their corresponding red plastic sleeves are inserted with only finger pressure into the well of the implants for the making of an implant level transfer impression. After removal of the full arch closed tray impression, the three titanium impression posts are removed and assembled with red implant analogs prior to their being inserted into the plastic sleeves within the impression for the pouring of a soft tissue model. The fifteen year old porcelain fused to metal crowns are then used as transitional restorations. After fabrication of the permanent integrated abutment crowns, the fifteen year old porcelain fused to metal crowns are removed from the implants and the new IACs are inserted. This clinical case clearly demonstrates the prosthetic simplicity and long term radiographic soft tissue and aesthetic results of the Bicon implant. The Bicon implant can be restored in a variety of ways with different techniques and abutments to satisfy almost all clinical situations. For removable overdentures, the brevis o ring abutments or locator abutments can be used. For removable crowns, bridges and bar restorations, fixed detachable abutments can be used. For telescopic restorations, the non shouldered abutments can be used. For single metal, porcelain fused to metal, all ceramic, composite, or mill crowns, and for multiple unsplinted or splinted crowns, or fixed bridges, the stealth shouldered or non shouldered abutments or fixed detachable abutments can be used. For the revolutionary cementless and screwless integrated abutment crown, the IAC, any Bicon abutment may be used that can provide for maximum titanium sub gingival contours. Since the vast majority of Bicon implants are restored as single units with either integrated abutment crowns, the IAC, or porcelain fused to metal crowns, PFM. We shall initially describe the techniques for these two restorations. However, we should first speak about impression techniques and how to select an appropriate abutment. Although a direct impression of an abutment and an indirect impression of an abutment with a transfer impression sleeve and abutment analog are straightforward procedures, most clinicians and technicians prefer to use the implant level transfer impression technique. Is not only very reliable, it is also the most convenient and cost effective technique. For it requires minimal chair time and minimizes the number of components the clinicians must have in their inventory. The implant level transfer impression entails the use of a red, blue, or green color coded titanium impression post, plastic sleeve, and implant analog, which are specific respectively for a two millimeter, a two point five millimeter, and a three point zero millimeter implant well diameter. In our demonstration of the implant level transfer impression technique, four blue colored two point five millimeter titanium impression posts are inserted with only finger pressure into the corresponding two point five millimeter well of the implants, and blue plastic sleeves are inserted onto the titanium impression post prior to the making of an impression. Upon removal of the full arch impression, the titanium impression post must remain in the implant and only the plastic sleeve should be retained in the removed impression. If a titanium impression post were to be removed with its plastic sleeve, it would not necessarily have accurately recorded the position of the implant and therefore the impression must be remade after first confirming the definitive seating of the titanium impression post in the well of the implant. The indirect abutment transfer impression for non shouldered abutments entails the use of a blue, red, yellow, green, or purple color coded impression sleeve, which is specific respectively for a three point five millimeter, a four millimeter, five millimeter, six point five millimeter, and a seven point five millimeter abutment diameter, and an aluminum non shouldered abutment transfer die. In our demonstration of the indirect abutment transfer impression technique for non shouldered abutments, red plastic sleeves are placed onto the seated four by six point five millimeter non shouldered abutments for the making of the impression. Upon removal of the impression, four point o millimeter aluminum non shouldered abutment transfer dies are inserted into the red plastic sleeves prior to the pouring of a soft tissue stone model. The indirect abutment transfer for the Stealth Shouldered Abutment entails the use of a cream colored impression sleeve and brass abutment analog with the diameter corresponding to the diameter of the stealth shouldered abutment. In our demonstration of the indirect abutment transfer impression technique for stealth shouldered abutments, four tooth colored plastic sleeves are placed onto the seated four by three and a half millimeter stealth shouldered abutments for the making of the impression. Upon removal of the impression, four millimeter Stealth Shouldered Brass Abutment Transfer Dies are inserted into the four millimeter tooth colored plastic sleeves prior to the pouring of a soft tissue stone model. The direct impression of the abutment entails the use of no impression components. It is simply a matter of making an impression of the abutments as if they were natural teeth. It provides the opportunity for a clinician to intra orally modify an abutment with carbide burs to provide occlusal clearance or a sub gingival shoulder for aesthetics. The non shouldered and stealth shouldered abutments come in numerous diameters, heights, angulations in varying post heights on certain abutments. Prior to selecting an abutment, it is essential to have an understanding of how abutments are measured and described. For non shouldered abutments, the diameter is measured at the widest point of the abutment, which occurs at the top of the hemispherical base. For non shouldered abutments, the distance from the top of the hemispherical base to the top of the coronal aspect of the abutment is the height. The distance between the hemispherical base of the non shouldered abutments and the top of the implant is variable, depending upon the diameter and length of the abutment post. For the two millimeter diameter post, the distance is three millimeters. For the two point five millimeter post, the distance is two millimeters. For most three millimeter posts, the distance is two millimeters, except for the two extended lengths of the five millimeter by six point five millimeter abutments, which have either a distance of four millimeters or five point five millimeters from the top of the implant to the maximum diameter of their hemispherical base. All non shouldered abutments are available in angulations of zero degree and fifteen degree, while select sizes also have an angulation of twenty five degrees. The stealth shouldered abutment has a machined shoulder and is measured and described differently than the non shouldered abutment. The stealth shouldered abutment’s height is measured from the top of the hemispherical base to the top of the implant. The distance from the machined shoulder to the top of the prosthetic post is a constant for all stealth abutments. Stealth shouldered abutments are available in angulations of zero and ten degrees. The use of an abutment shoulder depth gauge seated in the well of the implant facilitates the selection of a stealth shouldered abutment with an appropriate shoulder height relative to the soft tissues for aesthetics. The horizontal markings indicate a distance of two millimeters, four millimeters, six millimeters, eight millimeters from the implant to the shoulder of the abutment. An abutment should be positioned in line with the adjacent teeth and be large enough to support the soft tissues or interdental papillae without encroaching upon them. For aesthetics, the shoulder or height of contour of the abutment should be positioned two millimeters below the crest of the soft tissue, particularly on the facial. The length and width of the prosthetic post should be small enough to provide sufficient space for the necessary metal and porcelain materials of the PFM crown. If an implant is deeply positioned, a long shafted stealth shouldered abutment should be considered. Alternatively, a color coded guide pin of the same diameter as the implant well with a color coded sulcus reamer corresponding to the diameter of the intended abutment can be used to remove any impinging tissue between the implant and the abutment. The seating of an abutment is similar to the seating of an integrated abutment crown, IAC. Once the appropriate abutment has been selected, it is inserted into the well of the implant and rotated until it is satisfactorily positioned in line with the adjacent teeth. It is then definitively seated by applying tapping force with a straight or offset driver handle. Some angled abutments have a dimple that facilitates directing the seating tap with a two millimeter red implant abutment seating tip in the long axis of the implant well. An abutment can be efficiently removed from the well of an implant by applying a rotating and pulling force, or preferably by applying a tapping force on the handle of a forceps while it is grasping the abutment. An abutment can be removed and reinserted multiple times over a period of days or years without damaging its bacterially sealed locking taper connection. The use of an abutment preparation holder instrument facilitates the extra oral modifications of abutments by providing a means to securely hold the abutments. On one end of the instrument is a three millimeter well and on the other end is a threaded bore for either a two millimeter well tip or a two point five millimeter well tip. The handle of the preparation holder is interchangeable with the handle of the osteotomy and shoulder depth gauges. A soft tissue sulcus depth greater than seven millimeters may result in a localized soft tissue only bacterial infection, which is usually resolved by irrigation of the sulcus. White plastic healing abutments and transitional healing abutments, as well as titanium temporary abutments, are used to facilitate the formation and or maintenance of a soft tissue sulcus over an implant. Their stated diameter corresponds with the diameter and shape of the hemispherical base of the intended permanent abutment. Prior to the insertion of a healing or temporary abutment, the appropriate diameter sulcus reamer is rotated on a guide pin seated in the well of an implant to remove any tissue that would prevent the seating of the intended permanent abutment. A clinician should choose an abutment with a sufficient diameter to support the interdental papillae without encroaching upon them. Often it is necessary to modify the facial aspect of an abutment to prevent the recession of the facial tissue due to excessive pressure from the abutment. The transitional healing abutments, in conjunction with an acrylic sleeve, provide the opportunity to fabricate an aesthetic and functional transitional restoration. The titanium temporary abutments may also be used at the time of implant placement to act as a transmucosal abutment for the one stage surgical technique. Additionally, they all may be used to prevent a sulcus from closing whenever a permanent abutment is removed from the well of an implant. To prevent the need for the removal of a two millimeter broken post, all clinicians should restrict the use of two millimeter diameter posts to the anterior mandible, if possible. It is highly unlikely that either a two point five millimeter or a three point zero millimeter post will fracture, regardless of where they are placed. In order to remove a broken two millimeter abutment post, it is essential that it can be clearly seen. The technique to remove a broken post is similar to that of doing a pulpotomy on a mandibular incisor. Coincidentally, the length of the broken post within the implant is the same length as the cutting edge of a fifteen fifty seven carbide bur. After the initial center cutting of the broken post, a radiograph should be taken to confirm the fact that the bur is cutting in the same trajectory as the implant well and abutment post. Once the clinician drops into the well of the implant, as though penetrating into a pulp chamber, the penetrated post is removed by using a number four round bur and a slow handiece in the same manner as it would be used to remove the roof of a pulp chamber. The penetrated post will usually be removed on the shank of the number four round bur. If the removal of the broken post has been successful, the implant is capable of being restored with the same cemented restoration on a new abutment. The integrated abutment crown is a cementless and screwless restoration, which after the making of an implant level impression and soft tissue transfer model, the IAC is fabricated in the laboratory by chemically and mechanically bonding a poly ceramic indirect composite material to the titanium surface of a Bicon abutment. The prosthetic post of this abutment can be significantly smaller than the metal support necessary for fired porcelain restorations. A four millimeter by four millimeter prosthetic abutment post is all that is necessary to properly support the indirect composite material for an integrated abutment crown. The fact that minimal metal support is necessary for the poly ceramic material means that far fewer abutments with different angulations and heights are necessary to have in the laboratory’s inventory because the smaller abutments are more universal in their use. The poly ceramic materials are stronger in bulk, therefore, it is best to have at least three millimeters of material around the titanium abutment post. After the preparation and cleaning of the abutment, various layers of light cured poly ceramic material are added to the abutment, contoured and mechanically polished to simulate the morphology and aesthetics of the intended tooth. As previously mentioned, the selection of an appropriate abutment depends upon the type of the intended final restoration. For an integrated abutment crown, the IAC, the appropriate abutment is one that will provide for the maximum bulk of poly ceramic material, mesially, occlusally, and distally, while providing for a maximal titanium sub gingival contours, consistent with aesthetic requirements. It is essential that the poly ceramic material does not come in close contact with bone. For, if the poly ceramic composite material were placed on the abutment post in close proximity to the crestal bone, there would be a very high likelihood that the crestal bone around the implant would be lost. Therefore, it is of paramount importance to choose and modify an abutment so that it will provide maximum titanium contact with the soft tissue’s subgingival. The use of a digital image to record a few shades adjacent to the natural teeth against a black background is an efficient way to communicate the intended shade to the technician by simply sending the digital image via email or via flash drive. Prior to the definitive insertion of an IAC, the appropriateness of the IAC’s cervical, soft tissue and bony contours and its mesial and distal interproximal, as well as its occlusal contacts must be confirmed. If there is blanching or resiliency of the soft tissues that prevents the IAC’s complete seating, a simple relieving incision often facilitates its seating unless there is also a bony impingement with the titanium abutment. Bony impingements can be removed by either modifying the IAC crown extra orally or by intra orally inserting a color coded diameter guide pin into the well of the implant onto which a sulcus reamer with the same diameter as the abutment’s hemispherical base is placed and rotated to remove any impinging tissue. Prior to any adjustment of the interproximal contacts, IAC should be rotated slightly with an extraction forceps to see if a new position could achieve appropriate interproximal contacts. To achieve a passive interproximal contact to passage of dental floss, a carbide finishing bur or a rubber wheel can be used extra orally or an abrasive metal strip may be used intra orally to remove excess material. Alternatively, to close an open interproximal contact, the interproximal surface is roughened and cleaned with alcohol prior to applying a modeling liquid and composite material to the IAC, which is then light cured and polished either extra or intraorally. Although any composite may be added, it is best to use the same material as that of the IAC. If the exact shade of the material is not available, the use of a translucent shade often facilitates achieving excellent aesthetics by picking up the underlying shade of the IAC as well as the shade of the adjacent tooth. The definitive seating of most IACs can be achieved by simply having a patient closed onto a cotton applicator. However, for many maxillary anterior IACs and others with marked angulations, a thermoplastic seating jig must be used to properly direct the seating forces in the long axis of the implant well. The thermoplastic seating jig is fabricated in a caliber like device by closing its movable member with the IAC attached into the stationary member with the warm pliable thermoplastic material to form the custom seating jig, which will be used with a crown seating tip attached to a threaded straight handle. If there is a concern for the potential loosening of a maxillary anterior abutment or IAC with either a two millimeter or three millimeter diameter post, then meticulous attention should be paid to the cleaning of both the abutment post and the implant well with alcohol prior to the IAC being inserted. Contaminants such as blood or glove powder can reduce the efficacy of the locking taper by fifty percent. Confirmation of passive interproximal contacts should be done several times while the IAC is receiving six definitive intermittent seating taps. The use of Bicon’s Max two point five implants provides clinicians with a significantly tighter abutment connection and virtually eliminates the concern for inadvertent abutment loosening. Additionally, fastidious elimination of all excessive incisal contacts must be achieved to prevent the loosening of unsplinted maxillary anterior abutments with either a two millimeter or three millimeter diameter post, especially where the implant has an adverse trajectory or where there is an inadequate posterior occlusion. Since the two point five millimeter diameter post abutment is significantly more resistant to loosening than either the two or three millimeter diameter abutment post, the two point five millimeter post abutments do not require the same meticulous attention to details of insertion and seating as are required for the two millimeter and three millimeter post when they are used to restore maxillary anterior implants that are unsplinted. Therefore, only minimal seating force should be used on the IACs or abutments with two point five millimeter diameter post until all concerned parties are satisfied with the restoration, for their removal may be difficult. To identify the excessive incisal contacts, a patient must simulate the contacts that occurred during bruxism while sleeping. Therefore, the patient must be instructed to move their mandible in all extreme excursions while clenching. Frequently, the most problematic contacts are on the facial aspect of the maxillary anterior teeth, which are caused by either the extrusion of a lower tooth or by a maxillary restoration that is too thick facially. These problematic contacts can be generated when the mandible is retruded from a protrusive position while clenching. The modification, finishing and mechanical polishing of poly ceramic or hybrid composites are readily achieved if the appropriate techniques and instrumentation are employed. The use of a spatula to smooth and remove excess material with multiple gentle strokes facilitates the final polishing. A carbide finishing burr such as a seven thousand nine hundred four or a white pre polisher facilitates initial modifications. Polishing is achieved by the successive use of a pink ceramic polisher, a silicone carbide brush, a soft goat hair brush with a diamond polishing paste, and lastly with a cotton buffing wheel. Because of Bicon’s three sixty degrees of universal abutment positioning in the well of its implant and the inherent nature of the poly ceramic indirect composite materials, the Integrated Abutment Crown, IAC, provides clinicians and patients alike with remarkable clinical benefits that are simply not possible with other implant systems. Some of these clinical benefits are the intraoral bonding of bridges, the facility with which modifications can be made to conceal metallic margins and clinically crown length discrepancies, the intraoral closure of open interproximal contacts or occlusal contacts, and the ability to achieve intraorally an ideally polished surface of any modification. Perfect marginal integrity of the titanium poly ceramic interface is another meaningful benefit. Even with an electron scanning microscope, no space can be discerned at the poly ceramic titanium interface. However, the most meaningful benefit for all concerned is the minimal amount of clinical time required to consistently restore an implant with excellent aesthetics and functionality that have been clinically proven by the test of time, even when an implant is poorly positioned. The following clinical examples demonstrate the facility with which many mundane and frustrating clinical situations can easily be resolved satisfactorily for all concerned. An unesthetic metallic cervical margin can be rectified by simply removing the IAC with an extraction forceps and preparing the abutment to receive additional hybrid composite material. After polishing, the IAC is simply reinserted into the well of the implant. Additionally, clinical crown length discrepancies can be resolved in a similar manner. Because of the nature of the hybrid composites in the variety of their gingival shades, a clinician can readily manage gingival aesthetics. In our example, the patient’s soft tissues will be used to intraorally shape the gingival contours of the additional hybrid composite material prior to their being light cured in the removal of the IAC for finishing and polishing. If a closure of an open interproximal contact cannot be achieved by simply rotating the IAC, then the IAC can be removed from the well of the implant by grasping the IAC with an extraction forceps and tapping on the forceps handle. The interproximal surface is roughened and cleaned with alcohol prior to the application and light curing of modeling liquid. Poly ceramic or hybrid composite is then added to the interproximal surface prior to the IAC being reinserted into the well of the implant for contouring and light curing. The IAC is then removed for finishing and polishing prior to its being definitively seated in the well of the implant with a few gentle taps. Restorations can be functional for years at a given vertical dimension before new material is added to them for the purpose of increasing their height when it is appropriate to open the patient’s vertical dimension of occlusion. Because of the bacterially sealed and cementless IAC restoration, poorly positioned implants can be restored easily as well as well positioned implants. And poorly restored implant restorations can easily be replaced with aesthetic IACs. The intraoral bonding of fixed bridges is a revolutionary concept that provides clinicians and patients with the opportunity for remarkable savings of clinical chair time, as well as eliminating many of the frustrations associated with achieving passive metal frameworks. After confirmation of the appropriate aesthetics and functional adaptations of the individual cantilevered IACs, their common interproximal surfaces are prepared for the bonding of additional hybrid composite material prior to their being reinserted. After being definitively seated the excess hybrid composite material is removed prior to the light curing and polishing of their bonded connection. In the unlikely event that this connection were to break, the clinician would simply redo the intraoral bonding with minimal chair time and effort. The porcelain fused to metal restoration is probably the most commonly used restoration. Because of Bicon’s three sixty degrees of universal positioning of the abutment post, the PFM crown can be either intra or extra orally cemented with either the non shouldered or stealth shouldered abutment. Alternatively, by using the fixed detachable abutment, a crown can even be screw retained. Most clinicians and technicians prefer to use the implant level transfer impression for the fabrication of their PFM restorations because of its simplicity and the minimal required chair time. However, the direct impression of abutment intraorally offers the clinician the ability to modify the abutment intraorally with carbide burs and to make an impression directly on the abutment without any implant components, just as if it were a natural tooth. Alternatively, an indirect impression using a color coded plastic sleeve and transfer abutment analog for either a non shouldered or stealth shouldered abutment is also a practical impression for those clinicians who want to personally choose the abutment. But, as with the direct impression technique, the indirect impression requires the clinician to invest in maintaining an inventory of a variety of abutments. The cementation of a porcelain fused to metal crown on a Bicon abutment is similar to the technique with natural teeth. However, because of Bicon’s three sixty degrees of universal abutment positioning, the clinician has the possibility of extra orally cementing the PFM, which eliminates the issues of having extraneous cement subgingually, which could cause significant bone loss if it were left over time. In our first demonstration of a porcelain fused to metal restoration, a six point five millimeter non shouldered abutment is aligned and inserted into the well of the implant prior to being definitively seated with a few gentle taps in the long axis of the implant well in the abutment post. The six point five millimeter non shouldered abutment was chosen since it had a sufficient diameter to support the interdental papillae without encroaching upon them. After the seating of the abutment, an indirect abutment transfer impression is made by the insertion of a modified six point five millimeter green acrylic sleeve onto the abutment and its removal within a full arch closed tray impression. A six point five millimeter green transfer abutment is then inserted into the six point five millimeter green acrylic sleeve within the impression prior to the pouring of a master stone model on which a cream colored acrylic sleeve is used for the waxing in the fabrication of the porcelain fused to metal crown. With minimal cement, the porcelain fused to metal crown is intraorally cemented in the conventional manner. Particular attention is given to assure that all extraneous cement is removed, since any extraneous cement could result in the loss of bone around the implant. In our second demonstration, after clinically determining the appropriateness of the fabricated porcelain fused to metal crown, it is extra orally cemented onto the abutment. After the removal of all extraneous cement, the crown and abutment, as a single unit is seated into the well of the implant with a few gentle taps. Alternatively, the patient could have seated the restoration by simply applying occlusal pressure onto the restoration. After the making of an implant level transfer impression and the fabrication of an all gold crown on a prepared non shouldered abutment, the gold crown and prepared abutment are inserted into the well of the implant to confirm their appropriateness of their fit prior to their being extra orally cemented. After the removal of any extraneous cement, the gold crown and abutment are inserted as a single unit into the well of the implant with a couple of gentle taps. The restorative techniques for fixed bridges and splinted restorations are essentially the same as they are for natural teeth. However, because of Bicon’s three sixty degrees of universal abutment positioning in the well of the implant, it affords clinicians significant clinical advantages that are not possible with natural teeth or other implant systems. One advantage is to use the finished prosthesis to orient the abutment’s position in the well of the implant, which usually resolves many of the issues about passive castings and ill fitting restorations. In our first demonstration, we shall show the insertion of a long span mandibular porcelain fused to metal fixed bridge, which begins with the making of an implant level transfer impression using three millimeter green titanium impression posts and acrylic sleeves. Due to Bicon’s three sixty degrees of universal positioning, the final prosthesis can be used as a means to orient and seat the abutments in the well of the implants. Initially, the canine abutment is inserted into the prosthesis and then aligned and seated in the well of the implant by aligning the mesial of the prosthesis with the distal of the lateral incisor. After removing the prosthesis, the abutment is gently tapped into the implant’s well. Prosthesis is then reinserted to confirm its appropriate positioning. The molar abutment is then inserted into the prosthesis for its alignment and initial seating in the molar implant. Prosthesis is then removed, and the molar abutment is definitively seated. The prosthesis is then reinserted to confirm its appropriate positioning clinically and radiographically prior to its cementation. Another advantage of the three hundred sixty degrees of universal abutment positioning is the ability to interorally bond multiple crown or bridge units, thus eliminating many of the issues involved with achieving passive castings. In our demonstration, a three unit bridge is fabricated by interorally bonding the distal of the canine cantilever with the mesial surface of the maxillary first bicuspid, IAC. After each individual IAC has been inserted with all necessary adjustments, one is removed and their contiguous interproximal surfaces are prepared for bonding. Each surface is cleaned with alcohol prior to the application and light curing of a modeling liquid. Polyceramic material is then added to each surface and after the removed IAC is definitively seated and the excess polyceramic material is removed, Vaseline is applied prior to the light curing of the material. In our second case, a laboratory fabricated pontic is simply bonded to the adjacent IACs. The surfaces of the two adjacent IACs are roughened, a modeling liquid is applied and light cured. A modeling liquid is also applied to the roughened surfaces of the pontic in light cured. Poly ceramic material is then added to the surfaces of the IACs and the pontic. After inserting the pontic, the excess poly ceramic material is removed and Vaseline is applied prior to the final light curing. The telescopic or sleeve overdenture restoration is an excellent alternative to extensive cortical bone grafting that is often necessary for the treatment of atrophic alveolar ridges. Although it is a removable prosthesis, the patient perceives that the overdenture has the stability of a fixed prosthesis. This is particularly useful when there is a need for maximal lip support. Three implants placed bilaterally is the ideal support for this prosthesis, however other arrangements are acceptable. Straight and angled non shouldered and stealth shouldered abutments with three sixty degrees of universal positioning not only facilitate the fabrication, but also enhance the possibility for exceptional aesthetics of the telescopic restoration because the abutment itself can act as the primary crown, thereby providing more space for aesthetic considerations. In our demonstration of a telescopic restoration case, prior to the uncovering of the implant with two millimeter wells, an occlusal registration is made which will facilitate the fabrication of the final prosthesis. After the uncovering of the implants, an implant level transfer impression is made by placing with only finger pressure red two millimeter titanium impression posts with their corresponding red acrylic sleeves into the well of the implants. The red acrylic sleeves are subsequently picked up in the full arch closed tray impression. It is paramount to assure accuracy that only the acrylic sleeves are picked up in the impression. The titanium impression post are then removed from the implant well and inserted into the two millimeter well of the two millimeter red implant analogs prior to their being inserted into the acrylic sleeves within the impression. The impression is then poured in dental stone. Appropriate abutments are selected and milled parallel with their two degree three millimeter long retentive tapers prior to the fabrication of six metal copings and a corresponding horseshoe shaped strut. A yellow acrylic insertion jig is fabricated over the milled abutments to facilitate the accurate alignment and seating of the milled abutments intraorally. After the insertion of the milled abutments, another occlusal registration is made prior to the insertion of six individual metal copings in the corresponding metal strut, which is luted to the copings with acrylic, prior to their being removed as a single unit in a full arch transfer impression. The milled abutments are removed from their implants and inserted into the well of the two millimeter implant analogs prior to their being inserted into their corresponding metal copings within the full arch transfer impression for the fabrication of a new master stone model. The final telescopic prosthesis and a newly relined seating jig are fabricated on the new master stone model. The milled abutments are again removed from the model and with the newly relined seating jig are definitively seated intraorally into the well of their implants prior to the insertion and occlusal adjustment of the final telescopic prosthesis. Although the bar over denture is a popular restoration, clinicians should do a cost analysis of the components, laboratory fees, and clinical time relative to the cost of doing multiple fixed bridges with the intraoral bonding of integrated abutment crowns prior to choosing the baroven denture. However, it does have merit for those patients requiring significant lip support. In our first demonstration, after the uncovering of three mandibular implants with two millimeter wells and the insertion of three fifteen degree fixed detachable abutments with their five millimeter long hex coping screws, the abutments are rotated to achieve parallelism of the three coping screws. Once parallelism has been confirmed, the abutments are definitively seated into their implants with a few gentle taps. The hex coping screws are removed and the three titanium transfer copings are attached to the fixed detachable abutments with ten millimeter long coping screws. Cotton is placed into the threaded bore of the coping screws and red acrylic is applied with the transfer copings to provide stability during the making of an open tray transfer impression and stone model. After the impression material has set, the ten millimeter long hex coping screws are unfastened for the removal of the full arch transfer impression. Three titanium abutment analogs are attached by coping screws to the titanium transfer copings within the impression prior to the pouring of the stone model. Occlusal relationships are recorded in a conventional manner. Once a satisfactory wax try in of the denture has been achieved, the model and wax up are laser scanned for the CAD/CAM fabrication of a titanium bar and processed acrylic denture. The mill bar is fastened to the three fixed detachable abutments with three hex retention screws and the prosthesis is delivered to the patient. In our second demonstration, after the uncovering of four maxillary implants with two point five millimeter wells, an implant level transfer impression is made by inserting blue two point five millimeter titanium impression posts with their corresponding blue acrylic sleeves into the well of the implants prior to the withdrawal of only the plastic sleeves and a full arch closed tray impression. After the removal of the blue titanium impression post, white plastic healing abutments are inserted into the implant wells to help shape the tissues until the next restorative visit. After a period of healing, the white healing abutments are removed and two point five millimeter guide pins are inserted into the implant wells to facilitate the selection of appropriately angled fixed detachable abutments. An abutment depth gauge is used to facilitate selecting an abutment with an appropriate height. The selected abutments with coping screws attached are inserted into the well of the implants prior to being definitively seated with a few gentle taps. Titanium transfer copings are placed onto the abutments and retained with a hex retention screw, which will be removed prior to the removal of the impression tray. Red acrylic is placed around the transfer copings to provide for stability during the making of an open tray transfer impression and stone model. The female threads of the fixed detachable abutments are protected by a male cover screw during the conventional recording of the occlusal relationships. The laboratory processing of the mill bar and denture fabrication is the same as our previous case for three mandibular implants. The mill bar is fastened to the four fixed detachable abutments with four hex retention screws, and the prosthesis is delivered to the patient. The implant retained and tissue supported over denture is probably the most common and cost effective implant restoration for the completely edentulous arch. Four maxillary and two mandibular implants is the ideal number of implants for most patients. If the intention is to remove the palatal coverage of the maxillary denture, then four implants are advised. However, there is still merit in placing only one mandibular in two or three maxillary implants. Although the placement of more than four maxillary or three mandibular implants is possible, their efficacy and cost effectiveness should be considered relative to fabricating a fixed prosthesis. The fabrication of an implant retained and tissue supported over denture either chair side or in the laboratory is a straightforward procedure. However, for it to be done well, particular attention must be paid to certain details to prevent the prosthesis from being implant borne or supported, rather than just implant retained and tissue supported. If the prosthesis were to be implant supported, bone loss around the implant is likely to occur with the subsequent fracture of the implant. Because of Bicon’s three sixty degrees of universal abutment positioning, it is relatively easy with a combination of zero and fifteen degree abutments to achieve the parallel positioning of the abutments, even when the implants are not parallel. The selection of appropriately angled abutments to achieve parallel abutment positioning entails the use of a red, blue or green color coded guide pin, which are specific respectively for two millimeter, two point five millimeter or three millimeter implant well diameters. The guide pins are inserted into the corresponding well of the implants to indicate their trajectory, which facilitates the selection and positioning of straight or fifteen degree angled abutments. Our demonstration of an implant retained overdenture utilizing two brevis abutments begins with the registration of the occlusal relationship between the two dentures prior to the uncovering of the two mandibular implants. After the surgical uncovering of the implants, a red two millimeter guide pin is inserted into the well of the implants indicating the trajectory of the implants, thus facilitating the selection of the appropriately angled abutments to achieve parallelism and whose hemispherical base is in contact with the alveolar mucosa. Once parallelism has been achieved by rotation of the abutments, the abutments are definitively seated into the well of the implants with a few gentle taps. A piece of rubber dam is placed over the newly seated brevis abutments to prevent extraneous acrylic from locking the denture on the brevis abutments. For additional assurance, Vaseline is injected under the rubber dam. Slightly viscous acrylic is then injected onto the seated brevis housings and into the liberally relieved denture. The denture is inserted and appropriately positioned over the brevis housings with the previously fabricated occlusal registration. The patient is asked to clench while the retentive acrylic is polymerizing. The denture is removed for the trimming of the extraneous acrylic and removal of the red plastic cap from the housing and polishing of the denture. If upon insertion of the denture, there is not adequate retention of the denture or in time excessive wear of the rubber o rings, the housings may have been displaced on their abutment by a too viscous mix of acrylic. The housing should be removed and appropriately repositioned actually on their abutments for another pickup procedure. Our demonstration of an implant retained overdenture utilizing two locator abutments begins with the insertion of an abutment depth gauge into the well of the implants to facilitate the selection of a locator abutment with the appropriate height. The abutments are then inserted and white block out rings are placed to prevent the inadvertent locking of acrylic under the housings. The housings are inserted and marked with a black marker to indicate their relative position to the undersurface of the denture. The denture is liberally relieved with an acrylic bur to accommodate the housings. After confirmation that the denture has been appropriately relieved, acrylic is injected onto the housings and into the denture. The denture is inserted and the patient is asked to maintain occlusal pressure on the denture until polymerization the acrylic is complete. The core tool is used to replace the black processing cap with the appropriate retention sleeve, and the denture is finished and polished prior to being inserted. As any experienced clinician knows, there are many different ways to achieve excellent clinical results for patients. The depicted techniques you have seen in this video are some of the clinically proven ways to restore Bicon implants. Hopefully, some of these techniques will facilitate your providing quality care for your patients. Thank you for having watched.