Comprehensive Surgical Video

One point five degree locking taper, time tested stable connection, no screws, torque drivers, need for splinting, proven bacterial seal, sloping shoulder, provides bone to support papillae, distributes occlusal stresses, preserves crestal bone. Plateau design, cortical like Haversian bone between the fins. Callus bone formation, thirty percent more surface area. The Bicon design was created in nineteen eighty five, not as a research project to study osseointegration, but rather as a means to restore dentition. Bicon is different, but different by design. The different shape, different geometry, and different surgical protocols lead to different clinical capabilities and different long term results. The design has remained consistent and unchanged since nineteen eighty five and has truly passed the test of time. Scannable temporary abutments allow the clinician to fabricate the prosthesis while the implant is integrating. The one point five degree locking taper with no screws allows for three sixty degree abutment positioning, extraoral cementation, and CAD/CAM restorations with superior aesthetics. No screws results in less maintenance. The one point five degree locking taper allows for subcrestal implant placement and eliminates the bacterial flux present in threaded implants with screw components. Note the lack of inflammation after ten years when the abutment is removed. The one point five degree locking taper connection provides a seal at the implant to abutment interface, avoiding the microbial leakage issues that can result in inflammation. The sloping shoulder and subcrestal implant placement provides more room for bone over the implant, a sensible narrow emergence, and support for papillae. The fins and plateaus offer at least thirty percent more surface area than a threaded implant of the same dimensions and provides for the callous formation of Haversian bone between the fins of the implant, which allows for shorter implants. Slow speed drilling without irrigation is more convenient for clinician and patient alike and allows for autogenous bone harvesting. Sloping shoulder and papillae. Sloping shoulder provides room for bone to support papillae, which aesthetically improve over time. Callus principle versus pressure principle. Osteoblastic activity of Bicon implants provide cortical like Haversian bone with higher mechanical properties. Osteoclastic activity of threaded implants provide appositional bone with lower mechanical properties, plateau design, and Haversian bone. Plateau design provides for callus bone formation and cortical like haversian bone. Treatment planning. Implant dentistry is a prosthetic treatment with a surgical component. Note the relation of the intended prosthesis to the bone that will support it. The implant should ideally be placed in the middle of the intended tooth. For single tooth placements, the pilot bur is positioned in the middle of the edentulous space parallel to the adjacent teeth. For multiple teeth placements, a surgical guide must be used. Bicon implants are ideally positioned two point zero to three point zero millimeters below the bony crest. Depending on the bone’s anatomy, the implant may be positioned more deeply. Deeply positioned implants may require the use of tall shafted guide pins and abutments. To prevent an implant passing into the maxillary sinus or a bone void, a thin crestal temporary abutment may be used. The anatomic limitations, positioning, and trajectory of the intended implant, as well as the functional and aesthetic needs of the intended prosthesis must be clearly understood prior to the subcrestal placement of the implant. Therefore, it is paramount for a clinician to not only have a comfortable practical knowledge of oral anatomy, but also to precisely identify the relative anatomic sites and conditions of each patient via radiographic or CBCT imaging and clinical observation. Patient condition, height of the interocclusal freeway space, edentulous space, anatomic relationship between the mandible and maxilla, class one, class two, class three, bone pathology or resorption, quality and quantity of mucosa, medical history and status. Examine patient with mouth closed to ascertain if there is enough interocclusal space for the intended prosthesis. Radiographically, visualize maxillary sinus, nasal floor, and inferior alveolar nerve relative to the intended site. Cone beam computed tomography, CBCT, can be of value in determining the feasibility of an implant site, especially where there is minimal bone and or concern as to the exact location of anatomic structures. Care must be taken to avoid the inferior alveolar nerve and the mental foramen in the premolar region since the mandibular nerve is often coronally inclined in this area. Care must be taken to avoid the penetration of the submandibular fossa, which is located below the mylohyoid line and especially the sublingual space with the sublingual artery in the anterior mandible. Inadvertent penetration may be avoided by appropriately directing the pilot drill and reamers toward the buccal and monitoring the area with finger pressure while drilling. The location of the maxillary sinus, nasal floor, and incisive foramen must be positively identified to avoid the inadvertent penetration with a reamer or an implant. Implant size recommendations. The following charts contain recommended implant sizes only. Actual clinical conditions and the clinician’s assessment of the patient should be the main criteria for choosing the size of an implant for a particular area. In general, it is better to use a five millimeter short implant than a longer length so that the implant may be positioned two to three millimeters below the alveolar crest. The width of the alveolar bone may be assessed with a CBCT scan, periodontal probe, or caliper. It is advisable to have one millimeter of bone surrounding an implant for a long term favorable prognosis. Note, two point five millimeter well implants have been designed exclusively for maxillary anterior single unit restorations. For any other restoration, including maxillary anterior splinted prostheses, overdentures, or fixed removable applications, it is strongly recommended to avoid two point five millimeter well implants. In posterior sites, the two point five millimeter post abutments may be too retentive and not easily removed. For maxillary anterior implants, anticipate the need for bone grafting or ridge splitting techniques. Note, the three point zero and three point five millimeter diameter implants are generally for mandibular anterior teeth. If practical, their use should be avoided for maxillary anterior and all posterior teeth. It is advisable to have at least one millimeter of bone around the implant. Therefore, an advisable bone width of five point five millimeters is necessary to comfortably accommodate a three point five millimeter implant unless ridge splitting or grafting techniques are employed to widen the site. Surgical templates. Implant dentistry is a prosthetic treatment with a surgical component. Therefore, accurate placement of an implant requires the awareness of its intended prosthetic restoration. Surgical guides should efficiently facilitate the placement of the implant within bone so that its abutment is positioned in the middle of the intended prosthetic tooth. Mounted study models and a diagnostic wax up of the teeth to be replaced are usually necessary for the fabrication of a template for multiple implant placements. Although the location and availability of bone shall dictate the ultimate trajectory of the pilot drill, clinicians should strive to stay within the center of the intended tooth and within ten degrees of the trajectory of the intended prosthesis. Using the adjacent teeth as a guide is a simple way of appropriately positioning the pilot drill for single implant placements. Position the pilot drill in the middle of the edentulous space and parallel to the adjacent teeth. To avoid a parallax issue, it may be helpful to view the positioning of the pilot drill from both sides of the patient prior to drilling. Keys to success. The trajectory of the pilot drill will be the trajectory of the implant and the trajectory of a straight abutment. The final implant osteotomy, to the extent possible, should be centered in the middle of the intended prosthetic tooth. An appropriate mesiodistal positioning of a pilot osteotomy is more critical than a slightly off axis trajectory. Stabilize the template on adjacent teeth, alveolar, and palate, or alternatively with screws. After making an impression and subsequent cast of the diagnostic wax up of the intended restoration, a vacuum form template is prepared on the cast from thin template stock, which is commonly used for the chairside fabrication of transitional restorations. Drill a hole in the middle of the incisal or occlusal surface of the template in the location of the intended tooth. If possible, trim the template to include at least one tooth distal and three or four teeth mesial to the area of the intended replacement. Placing the pilot drill through a perforation in the center of a tooth of a vacuum formed plastic template facilitates its appropriate positioning for multiple implants. Using a duplicated stone model of the diagnostic wax up, draw a line through the incisal edge and occlusal surfaces of the teeth and another line in the center of each tooth to be replaced, intersecting the incisal or occlusal line. Remove the lingual half of the teeth to be replaced. Fabricate a guide by molding acrylic onto the lingual aspect of the model up to the level of the central fossa or incisal of the teeth to be restored. Cut a two point five millimeter wide groove in the acrylic corresponding to the middle of each intended tooth to be replaced. Option. Alternatively, digitally scan the dentition or stone model and create the template via a CAD/CAM workflow with either milling or three d printing techniques. For larger edentulous areas, fabricate a template by using an existing removable prosthesis. When fabricating the template, the buccal aspect is inclined from the incisal edge or central fossa of the teeth back to the crest of the alveolar ridge, which is represented on a duplicated prosthesis as the greatest concavity on the alveolar ridge side of the prosthesis. Insert the denture into the impression material in the denture duplicator and apply separating medium. Fill the other side with impression material, close, and allow the impression material to set. Open and remove the denture. Fill the impression material mold with acrylic, close, and allow the acrylic to set. Open and remove the duplicated denture. Draw a line in the middle of each tooth and a line representing the greatest concavity on the tissue side. Cut a two point five millimeter wide groove in the center of each tooth joining the lines representing the middle of each tooth and the greatest concavity of the tissue side. Remove the buccal acrylic along the slope joining the two lines representing the middle of each tooth and the greatest concavity of the tissue side. Trim excess incisal length to prevent any interference with the head of the handpiece. The template determines the mesial distal positioning. The availability of bone determines the final buccal lingual angulation. Note, alternatively, digitally scan the prosthesis and create the template via a CAD/CAM workflow with either milling or three d printing techniques. Instrumentation. Comprehensive surgical kit. Shoulder depth gauge designed to be used with the double ended instrument holder to facilitate selecting the proper abutment height. Removal wrench designed to unfasten hand reamers, osteotomes, chisels and bone expanders from a threaded straight handle, threaded offset handle or a threaded knob. Double ended osteotomy depth gauge designed to facilitate the measuring of an osteotomy’s depth. Threaded straight handle designed to be used with all threaded instrumentation, hand reamers, sulcus formers, inserters retrievers, tissue punches, osteotomes, chisels, bone expanders and seating tips. Implant inserters retrievers designed to be used with either a threaded knob or a threaded straight handle to assist in the placement and retrieval of implants depending upon the clinical situation. It is essential for a clinician to understand how an implant is disengaged from the insert a retriever instrument prior to using it intra orally. Threaded offset handle designed to be used with implant and abutment seating tips when direct access is not practical. Latch reamers designed to prepare an osteotomy without irrigation at a maximum speed of fifty revolutions per minute and to harvest autogenous bone for grafting. Markings are positioned at six point zero, eight point zero, eleven point zero and fourteen point zero millimeters. Extended latch reamers are also available to accommodate clinical situations. Latch reamer extension: designed to extend a latch reamer to facilitate access when adjacent teeth interfere with the handpiece. If the latch reamer is not fully engaged in the latch extension prior to being used, the latch reamer may become jammed or damaged. Pilot drills. Designed to prepare the initial pilot osteotomy at eleven hundred revolutions per minute and to establish the osteotomy’s trajectory, available in two lengths. Markings are positioned at six point zero, eight point zero, eleven point zero, and fourteen point zero millimeters. Healing plug removal instrument, designed to facilitate the removal of the previously cut black healing plug from the implants well during the second stage surgical procedure. Paralleling pin, designed as an aid to correctly align pilot osteotomies and implants. For multiple implant placements, they may be stepped from the initial osteotomy to the subsequent osteotomies so that the pilot drill can be aligned parallel to the paralleling pin. Osteotomes, designed to be fastened to either a threaded straight handle or an offset handle and are used to prepare an osteotomy especially for internal sinus lift procedures and ridge expansions available in diameters corresponding to implant diameters. Implant abutment seating tips designed for use with a threaded straight or offset handle to facilitate the correct seating of an implant or abutment. When using the implant seating tips, it is imperative that seating tips be fully seated to the bottom of the implants well. Threaded instrument adapter designed to be fastened to hand reamers and sulcus formers allowing them to be attached to a latch contra angle handpiece. Hand reamers designed to be fastened to a threaded straight handle to manually prepare an osteotomy, they can also be attached to a threaded instrument adapter for use with a latch contra angle handpiece. Standard guide pins Designed to be used as a guide for the sulcus formers, they are available in three sizes corresponding to the diameters of the internal connections of Bicon’s implants. They may also be used to assess the trajectory of an implant in addition to examining how well an implant has osseointegrated. Tall shaft guide pins are available for deeply positioned implants which require tall shaft abutments designed to remove any soft tissue or bone above the implant that could prevent the correct engagement of the abutments locking taper connection to the implant. They are used in conjunction with guide pins. They are available in diameters consistent with the hemispherical base of the intended abutment. Threaded knob designed to be used with threaded instrumentation, sulcus formers, inserters retrievers, tissue punches and hand reamers where there is limited access. Surgical mallet used along with other instruments to facilitate applying the appropriate force for seating an abutment into the well of an implant or an implant into an osteotomy. The mallet is also used with other instruments such as bone expanders or chisels. Silicone dappen dish, designed to hold harvested autogenous bone and synthetic bone grafting material. Healing plug cutter, designed to score a healing plug intra orally at the level of bone and to cut the plug either intra or extra orally. Advanced surgical kit. Bicons advanced surgical kit contains all of the instruments in the comprehensive surgical kit plus the following shoulder depth gauge with double ended instrument holder designed to facilitate selecting the proper abutment height, Silicone Dappen dish, designed to hold harvested autogenous bone and synthetic bone grafting material. Bone expanders, designed to be fastened to threaded handles to facilitate the preparation of an osteotomy, especially for internal sinus lift procedures and ridge expanding chisels, designed to be fastened to threaded handles to facilitate the preparation of an osteotomy with a ridge expansion extended latch reamers, designed to facilitate access when adjacent teeth interfere with the handpiece while offering the convenience of not having to use a latch reamer extension. Markings are positioned at six, eight, eleven, and fourteen millimeters. Bicon’s introductory surgical kit contains all of the instruments in the comprehensive surgical kit except for the following shoulder depth gauge, removal wrench, implant insert as retrievers, extended pilot drill, osteotomes, six point five millimeter seating tip, threaded instrument adapter, hand reamers, seven series sulcus former, healing plug cutter. Guided surgery kits, pilot drill stop kit. When the anatomy permits, Bicon’s two millimeter diameter pilot drill stop kit allows experienced and novice clinicians alike to confidently drill a two millimeter pilot osteotomy to a precise depth. The drills are stainless steel with a titanium nitride coated tip and are offered with seven incremental stops ranging from five to eleven millimeters. Guided pilot drill kit, guided surgery kits and guide rings. Designed for guided placement of an implant of a specific diameter using a CAD/CAM fabricated surgical guide with a titanium guide ring. Note that guided surgery is often not practical due to the lack of available bone. Using only a pilot drill with either a CAD/CAM fabricated or traditional Bicon custom guide can be more beneficial since their use provides for ridge widening and internal sinus lift procedures. Two handed drilling technique. The two handed drilling technique provides greater precision and control for the placement of Bicon implants. When initiating the osteotomy with the pilot drill at high speed with or without irrigation, the two handed technique affords greater control and accuracy, which minimizes the risk of an inappropriately positioned implant. When widening the osteotomy with the latch reamers at low speed without irrigation at fifty RPM, the two handed technique affords greater stability and helps to control torque, further increasing the precision in forming the final osteotomy. This technique also reduces strain on a clinician’s hand. For the upper right quadrant, hold the handpiece with your left hand and use your index finger or thumb of your right hand to push the pilot drill or latch reamers into the bone. For the upper left quadrant, hold the handpiece with your right hand and use your index finger or thumb of your left hand to push the pilot drill or latch reamers into the bone. For the lower right quadrant, hold the handpiece with your left hand and use your index finger or thumb of your right hand to push the pilot drill or latch reamers into the bone. For the lower left quadrant, hold the handpiece with your right hand and use your index finger or thumb of your left hand to push the pilot drill or latch reamers into the bone. Drilling and reaming depths. Once the appropriate trajectory of the two millimeter pilot drill is confirmed, continue drilling to the appropriate depth. Once the pilot osteotomy is completed, continue reaming to the appropriate depth. Bicon implants may be placed at varying depths depending upon the anatomy. The ideal positioning of a Bicon implant is two to three millimeters below the crestal bone. If practical, an implant should be placed slightly more palatally or lingually and more deeply than shallowly. For optimal aesthetics in the anterior region, place the implant five millimeters below the buccal gingiva. For certain anatomically challenging areas, implants may be placed at the crestal bone. For immediately placed implants in extraction sites, place the implant four to five millimeters below the crestal bone to allow for some bone resorption. Note, prior to using a pilot drill, it is imperative that its depth markings are identified and understood. No assumption should be made about the height of the first marking. Drilling depths for five millimeter implants range between five millimeters to eight millimeters. In this example, a seven millimeter depth has been chosen. Drilling depths for six millimeter implants range between six millimeters to nine millimeters. In this example, an eight millimeter depth has been chosen. Drilling depths for eight millimeter implants range between eight millimeters to eleven millimeters. In this example, an eleven millimeter depth has been chosen. Pilot drill types and indications. Standard pilot drill. The most commonly used pilot drill. Extended pilot drill facilitates access when adjacent teeth interfere with the handpiece without having to use a latch extension. Pilot drill with stops. When the anatomy permits, such as in cases with a flat and even ridge, Pilot drills with stops can provide experienced and novice clinicians alike an extra measure of precision and confidence. Latch reamer markings. After the pilot osteotomy has been prepared, the latch reamers are used sequentially beginning with a two point five millimeter diameter and ending with the diameter of the intended implant. Latremers are color coded according to their diameter and have horizontal markings at six, eight, eleven, and fourteen millimeters. It is imperative that the depth indicators on the latch reamers are known and understood prior to their use. No assumptions should be made about the height of the first marking on any latch reamer. If there is any doubt about the markings on any drill or reamer, take a measurement prior to using it. Note, latch reamers have a tapered and non-cutting tip. They are intended to only widen an osteotomy and not to deepen it. Reaming depths for five millimeter implants range between five millimeters to eight millimeters. In this example, a seven millimeter depth has been chosen. Reaming depths for six millimeter implants range between six millimeters to nine millimeters. In this example, an eight millimeter depth has been chosen. Reaming depths for eight millimeter implants range between eight millimeters to eleven millimeters. In this example, an eleven millimeter depth has been chosen. Hand reamer markings. After the pilot osteotomy has been prepared, the hand reamers are used sequentially beginning with a two point five millimeter diameter and ending with the diameter of the intended implant. Hand reamers are color coded according to their diameter and have horizontal markings at six, eight, eleven, and fourteen millimeters. It is imperative that the depth indicators on the hand reamers are known and understood prior to their use. No assumptions should be made about the height of the first marking on any hand reamer. If there is any doubt about the markings on any drill or reamer, take a measurement prior to using it. Hand reamers versus latch reamers. Note, hand reamers have a sharp cutting tip and can both widen and deepen an osteotomy. Latch reamers have a tapered, non-cutting tip and are intended only to widen an osteotomy and not to deepen it. A hand reamer can afford a high level of control when encountering challenging conditions such as thin facial bone or minimal bone between the osteotomy and adjacent teeth or implants. It can also be invaluable when working within the confines of a fresh maxillary anterior socket in which the hand reamer can be used to enlarge the osteotomy by engaging only the palatal aspect of the socket while avoiding the fragile buccal wall. Reaming depths for five millimeter implants range between five millimeters to eight millimeters. In this example, a seven millimeter depth has been chosen. Reaming depths for six millimeter implants range between six millimeters to nine millimeters. In this example, an eight millimeter depth has been chosen. Reaming depths for eight millimeter implants range between eight millimeters to eleven millimeters. In this example, an eleven millimeter depth has been chosen. Threaded instrumentation, interchangeability. Bicon’s threaded instrumentation offers interchangeability with threaded components. The threaded straight handle can be used with all threaded components, while the threaded knob and threaded offset handle can be used with some threaded components. Interchangeability example. If a clinician chooses to use a hand reamer, there are options available depending upon the clinical situation or preference. For the mandible, attach the hand reamer to a threaded instrument adapter and use with a latch contra angle handpiece. Note, for this method, do not exceed twenty five revolutions per minute. For the maxilla, attach the hand reamer to a threaded straight handle. Transporting the implant. Removing the implant from the packaging. While wearing sterile gloves, the assistant removes the sterile Tyvek blister pack from the cardboard folder, carefully peels back the Tyvek backing of the blister pack, and allows the inner sterile polybag to fall freely onto a sterile tray. Do not contaminate the polybag, place the label in the patient’s record. Cut the implants in a sterile polybag with a pair of sterile scissors, transporting the implant to the osteotomy with a healing plug. It is safe to hold the implant through the polybag while wearing sterile gloves. Remove the implant from the polybag by grasping the black healing plug and place the implant into the osteotomy until it is stable. Transporting the implant to the osteotomy with an implant insert a retriever. An implant insert a retriever can be used to transport the implant to the osteotomy. Prior to using the implant insert a retriever, a clinician should be familiar with how an implant is both attached to and dislodged from the instrument. Grasp the upper knob on the implant insert a retriever and rotate the lower knob counterclockwise. The outer barrel of the implant insertor retriever will descend gently pushing the implant off the shaft. Two stage implant surgery placement. For the two stage surgical technique, a full thickness envelope or scalloped flap may be used depending on the clinician’s preference. Prior to using a pilot drill, it is imperative that its markings are identified and understood. Place the implant two to three millimeters below the crest of bone. For this demonstration, we are placing a five point zero by six point zero millimeter implant at an eight millimeter depth. Drill two millimeter pilot hole at one thousand one hundred revolutions per minute with or without irrigation. Regardless of implant length, initially drill to only a depth of six millimeters. Confirm positioning with a radiograph. Use a paralleling pin to confirm trajectory of initial pilot hole, making sure the pin aligns with the opposing tooth. Then drill the pilot hole to a depth two to three millimeters deeper than the chosen implant when practical. In this demonstration, a final depth of eight millimeters was chosen. Widen the osteotomy with sequentially wider reamers without irrigation at a maximum of fifty revolutions per minute. For this demonstration, a five point zero by six point zero millimeter implant was selected, so the final reamer has a diameter of five millimeters. Harvest autogenous bone intermittently from the flutes of the reamer burs and from the osteotomy as it is progressively widened. Collect harvested bone into a silicone dappen dish and cover it with moist gauze for later use when placing the implant. While wearing sterile gloves, the assistant removes the sterile Tyvek blister pack from the cardboard folder, carefully peels back the Tyvek backing of the blister pack, and allows the inner sterile polybag to fall freely onto a sterile tray. Do not contaminate the polybag. Place the label in the patient’s record. Cut the implants in a sterile polybag with a pair of sterile scissors. It is safe to hold the implant through the polybag. Remove the implant from the polybag by grasping the black healing plug and place the implant into the osteotomy until it is stable. Other methods of transporting an implant to the osteotomy are demonstrated previously in this video. In denser bone, it is often required to tap the implant into place. Remove the healing plug and tap with an appropriate implant seating tip attached to a threaded handle to be sure the implant is fully seated into the osteotomy. Replace the healing plug and gently mark the shaft intraorally at the crest of bone using the healing plug cutter. Cut the healing plug either extra orally or intra orally at the previously marked bone level. Cutting the plug extra orally affords the clinician the ability to remove any sharp edges from the cut healing plug that could irritate soft tissue. Then use a periodontal probe to transport the cut healing plug back into the implant well. Using a Woodson or comparable instrument, carefully place harvested bone over the implant shoulder. Close and wait a minimum of three to four months for osseointegration according to bone quality. Two stage implant surgery, uncovering. Expose the implant in aesthetic areas with a semilunar crestal incision. Other flap designs may be used for different areas or clinical situations. Remove the healing plug with a healing plug removal instrument. Alternatively, use a scalar or endodontic file. Gently place an appropriate standard or tall shaft guide pin to check integration and angulation. Using a tall shaft guide pin may negate the need to use a sulcus former. Select a sulcus former corresponding to the hemispherical base of the chosen abutment. Standard shaft versus tall shaft guide pins. Tall shaft guide pins are two millimeters taller than standard guide pins and provide for removal of bone three millimeters above the implant, avoiding unnecessary removal of crestal bone for deeply positioned implants. Standard shaft guide pins provide for removal of bone one millimeter above the implant. Slide the sulcus form a onto the guide pin applying apical pressure. Remove excess bone with a sulcus form a attached to either a threaded knob, straight handle, or threaded instrument adapter used with a handpiece. Flush and clean the implant well of any debris with water. Dry the implant well with a cotton tipped swab. Insert the appropriate scannable temporary abutment according to the diameter of the implant well and intended abutment and scan it. Option, insert the selected abutment with light finger pressure only. Use a template to confirm appropriateness of the abutment prior to engagement of the locking taper connection. Tap gently on the abutment at least three times in the long axis of the abutment post to fully engage the locking taper. Snap the healing cap onto the abutment and if necessary, replace flap and suture in place. If you are creating a transitional prosthesis, place temporization sleeve onto the abutment and modify if necessary, then proceed to next steps. Inject acrylic around the temporization sleeve and into the template. Place template with acrylic to form transitional prosthesis. After polymerization, remove and polish acrylic and snap the transitional prosthesis back in place to help form the gingival sulcus. Replace flap and suture in place if necessary. Wait for soft tissue healing prior to taking final impression. Implant level impressions. Conventional implant level impression. Insert the corresponding diameter metal impression post into the well of the implant with only finger pressure. Snap the corresponding plastic impression sleeve onto the metal post. Inject impression material around the plastic sleeve. After the impression has set, remove the impression with the sleeve within it. If the metal impression post is dislodged with the sleeve, repeat the impression since the axial position of the implant may not have been accurately recorded. Remove the metal post from the implant and insert it into a corresponding implant analog prior to inserting them as a unit into the plastic sleeve within the impression for the pouring of a stone model. The laboratory pours a soft tissue model and selects the widest diameter permanent abutment that supports the interdental papillae without encroaching upon them. Digital implant level impression with a digital scan post. Insert a digital scan post corresponding to the diameter of the implant well and scan it. The dimples designate the post well diameter. Design and fabricate the final restoration with the CAD/CAM software of your choice. Digital implant level impression with a scannable temporary abutment. Insert the appropriate scannable temporary abutment according to the diameter of the implant well and final abutment and scan it. The dimples and color designate the post well diameter, and the laser marking designates the abutment diameter and height. A circle around the numeral and letter denotes a tall shaft which is used for deeply positioned implants. Design and fabricate the final restoration with the CAD/CAM software of your choice. One stage implant surgery. For the one stage surgical technique, a scalloped or punch flap may be used for non extraction sites. Prior to using a pilot drill, it is imperative that its markings are identified and understood. For the one stage technique, place the implant three millimeters below the crest of bone. For this demonstration, we are placing a five point zero by six point zero millimeter implant at a nine millimeter depth. Drill two millimeter pilot hole at one thousand one hundred revolutions per minute with or without irrigation. Regardless of the intended implant length, initially drill to only a depth of six millimeters. It may be helpful to place an abutment with a two millimeter post into the pilot hole and confirm appropriateness with a vacuum press template. Once confirmed, drill the pilot hole to a depth three millimeters deeper than the chosen implant when practical. In this demonstration, a final depth of nine millimeters. Widen the osteotomy with sequentially wider reamers without irrigation at a maximum of fifty revolutions per minute. For this demonstration, a five point zero by six point zero millimeter implant was selected, so the final reamer has a diameter of five millimeters. When the scannable temporary or permanent abutment is wider than the osteotomy, the osteotomy should be countersunk by using a wider latch reamer or sulcus former at the orifice of the osteotomy. Harvest autogenous bone intermittently from the flutes of the reamer burs and from the osteotomy as it is progressively widened. Collect harvested bone into a silicone dappen dish and cover it with moist gauze for later use when placing the implant. While wearing sterile gloves, the assistant removes the sterile Tyvek blister pack from the cardboard folder, carefully peels back the Tyvek backing of the blister pack, and allows the inner sterile polybag to fall freely onto a sterile tray. Do not contaminate the polybag. Place the label in the patient’s record. Cut the implants in a sterile polybag with a pair of sterile scissors. It is safe to hold the implant through the polybag. Remove the implant from the polybag by grasping the black healing plug and place the implant into the osteotomy until it is stable. If necessary, tap the implant to seat it fully. Methods of transporting an implant to the osteotomy are demonstrated previously in this video. In denser bone, it is often required to tap the implant into place. Remove the healing plug and tap with an appropriate implant seating tip attached to a threaded handle to be sure the implant is fully seated into the osteotomy. Place an appropriate standard or tall shaft scannable temporary abutment into the implant. Gently tap on the abutment to engage the locking taper. Proceed to final steps. Option, alternatively to previous steps, remove the black healing plug from the implant and replace it with an appropriate standard or tool shaft scannable temporary abutment. Insert implant with the scannable temporary abutment into the osteotomy as a unit. Gently tap on the abutment to engage the locking taper. During this step, some clinicians prefer to place harvested bone or PRF graft between the abutment and implant prior to inserting them into the osteotomy as a unit. Using a Woodson or comparable instrument, carefully place harvested bone over the implant shoulder. Trim excess tissue if necessary. Wait for a minimum of three to four months for osseointegration before removing the scannable temporary abutment. At this point or at any time during osseointegration, you can scan the scannable temporary abutment for the fabrication of the final restoration so long as the abutments entire circumference can be scanned, reducing chair time and patient visits. Two stage guided implant surgery. Guided surgery can be an effective and efficient surgical technique if there is ample bone, especially for novice implant clinicians. It is important to definitively stabilize the CBCT designed surgical guide on the remaining teeth or with screws fastened to the bone. Many experienced clinicians prefer to use CBCT designed surgical guides for use with the guided pilot drill only, especially where there is minimal bone available. This affords the opportunity to use various techniques such as ridge widening and internal sinus lift procedures, which are the hallmark of Bicon’s hand reamers and surgical protocols. Guided surgery sequence planning for a five by six millimeter implant. With a CBCT scan, choose an appropriate Bicon implant from the software and position it so that it lies parallel with the adjacent teeth to allow for the use of a straight abutment. After finalizing the design, send the scan to a guide fabricating laboratory. Place the guide over the adjacent teeth and verify its fit and stability before proceeding. Note the intended implant placement and the five millimeter color coded guide ring embedded within the guide. Use the guided tissue punch to remove a circular piece of mucosa and keep it moist so that it may be replaced. Alternatively, use the guided tissue punch to mark the osteotomy site and then create a flap with a scalpel. Use the guided spade drill rotating at four hundred revolutions per minute with irrigation to create the initial osteotomy. The drill is advanced into the osteotomy until it contacts the color coded ring. When the cortical bone is dense, one should initially use a standard pilot drill to penetrate the cortical bone and then proceed with the guided spade drill. To deepen the osteotomy, use the guided reamers sequentially until the final intended implant length is achieved. For the depicted five by six millimeter implant placement, start with the five by five millimeter guided reamer and finish with the five by six millimeter guided reamer. Rotate the reamers at fifty revolutions per minute without irrigation and harvest autogenous bone as it accumulates within the reamer flute. Open the sterile implant packaging, remove the healing plug, and place the guided inserter into the implant and rotate the lower knob counterclockwise until it is flush with the top of the implant. Note that the guided inserter should sit flush with the top of the implant prior to insertion. Place the guided inserter through the guide and rotate the lower knob counterclockwise to disengage the implant. Remove the guide and place a cut healing plug into the well of the implant. Using a Woodson or comparable instrument, carefully place harvested bone over the implant shoulder. Replace the circular piece of mucosa or flap and suture in place. Wait for a minimum of three to four months for osseointegration. Immediate implant placement. The immediate placement of Bicon implants into extraction sites using the one or two stage technique is a very practical and successful technique. However, it may not be prudent for inexperienced clinicians to do so until they have mastered some of the nuances of placing bicon implants, especially in sites with a furcation. For many extraction sites, especially molar sites, it is prudent to delay the implant placement until there is some bone fill and mucosal healing. Experienced clinicians vary significantly in their preferred techniques. The following considerations may be helpful for sites with a furcation. The anatomy of available bone dictates whether to preferably place the implant in the septal bone of the furcation site or less desirably into a root socket. Place the implant four to five millimeters below the crest of bone to allow for bone resorption. For a maxillary first premolar, place in the palatal socket using the one or two stage technique. For a maxillary molar, preferably place in the septal bone of the trifurcation site or alternatively in the palatal route using the one or two stage technique. Use hand reamers or osteotomes to facilitate centering the implants trajectory. For a mandibular molar, preferably place in the septal bone of the bifurcation site or distal route using the one or two stage technique. Use hand reamers or osteotomes to facilitate centering the implants trajectory. Transport and insert the implant as demonstrated previously in this video. Cut the healing plug at an appropriate level demonstrated in the two stage implant placement technique. Place harvested bone or SynthoGraft over the implant. There is no need to graft the root sockets. Cover the site with a collagen plug or PRF, platelet rich fibrin graft. Some clinicians prefer to use the periosteum of a split thickness flap, envelope flap, a scannable temporary abutment, or a sinus lift abutment. Correct positioning of osteotomies. For a single implant, the osteotomy should ideally be positioned in the middle of the edentulous space and the intended tooth. For multiple implants, they should be placed in the middle of the intended teeth. To facilitate proper positioning and to avoid a parallax issue, view the pilot drill from both sides of the patient. A poorly positioned osteotomy can necessitate using an angled abutment or a cantilevered restoration. Position displacement. While reaming on a slope, reamers may inadvertently move lower on the slope, which is usually distally or buccally. Additionally, reamers may inadvertently move away from more dense bone towards less dense bone, which is usually from the palatal or lingual bone toward the buccal. Reaming on a slope. Because the reamers have a beveled tip, contacting the higher bone on one side inadvertently moves the reamer and the osteotomy away from the higher bone of the slope. This downhill drift can continue with each successive reamer. This drift can continue until the final reamer resulting in an osteotomy that is off center from the initial pilot hole and the intended osteotomy. To avoid this drift, briefly and gently use a four millimeter round bur to form a countersink at the orifice of the pilot hole. This funnel shape allows the reamer to contact bone on both sides simultaneously and guides the reamer into the center of the pilot hole. Alternatively, use a sulcus former at low speed with or without a guide pin to form a countersink at the orifice of the pilot hole. Mesial distal drift. The lingual to buccal drift depicted in the preceding graphics can also occur from mesial to distal. Note the right mandibular crown with a mesial cantilever and the intended implant placement. Alternative technique, three separate positionings of the pilot drill can provide for proper positioning. Drilling in a maxillary anterior extraction site. Initially drill with the pilot drill palatally three to four millimeters coronally to the apex of the extraction socket. This initial angulation can vary between twenty five and forty five degrees depending upon the clinical situation. Immediately upon the pilot drill’s engagement of the bone, change the drill’s trajectory to be more parallel with the adjacent teeth and the proposed restoration.