Learning from My Mistakes: How to Drill Perfect Bicon Osteotomies Every Time

So that’s very important. Without further ado, I’d like to introduce my friend Bill Schaeffer, who’s an oral maxillofacial surgeon, works in private practice in London. He has experience with all major implant systems and has used Bicon for the last seven years. Bill. Hi. Good afternoon. I’ve been placing Bicon implants for seven years, and I have made loads of mistakes placing them. But most of the mistakes I’ve only made once and I’ve learned from them and I’ve avoided them again. But there have been some problems that I’ve had that repeated themselves. Despite my most careful effort, the same errors happen time and time again. And it’s taken me a long while to work out why those problems occur and how to avoid them. And that’s why I’m here speaking to you today so that you can learn from my mistakes and drill perfect Bicon osteotomies every time. Particularly in the two following situations where I had lots of problems, drilling on a sloping bony surface and drilling into extraction sockets in the aesthetic zone. Got a lot to get through, so I’m gonna move straight on to drilling on a sloping bony surface. Now here is a sloping surface. Doesn’t just have to be a mesiodistal one like this. You can have any sloping surface. It’s all relevant. And if we focus in on this, we’d like to place our crown in this position. Which means that we’d like our implant to be centered on that crown. And so we’ll start our osteotomy by drilling with our sharp pointed pilot drill, running fairly fast, eleven hundred revs. And we’re gonna end up with a pilot hole centered exactly on that crown position. Now we line up our two point five millimeter reamer bur and this where the problems begin. Because this is not a spiral twist drill. It is not running fast. It’s running at fifty revolutions a minute or less and it’s only got two cutting surfaces. And when you line it up with your pilot hole, it will only contact the bone on the uphill surface. And when it starts rotating, it’ll move from this position to that position. I’ll go back and forwards again. It’s a very subtle movement. You won’t even feel it happen. But we’ve moved downhill with a reamer bur and now when we drill down, it’s got bone on both sides of this reamer, so it won’t move any more downhill and you will be able to drill your osteotomy straight down. But if you look at this picture, the shaded portion has already been drilled. You’re only removing bone from the downhill side of your osteotomy. In other words, the whole osteotomy is beginning to move in the direction of the red arrow. And you’ll come and you’ll line up your three millimeter reamer bur and you’ll line it up with the middle of the hole. You probably won’t even realize that that’s not the center of your planned crown position because your osteotomy has already started to slide downhill. But you won’t notice that and you’ll start drilling. And again, when it rotates, it’ll move downhill because it’s only contacting bone on the uphill side of this hole, And it’s gonna move from there to there. A movement you won’t even notice. And you’ll start reaming. And when you ream, the shaded portion has already been removed and the only bit of bone that you are removing is from the downhill side of the osteotomy. Every time you go up with a reamer, you’ll just take bone from downhill. What will that mean? It’ll mean that instead of your osteotomy being in the dark dotted line, you’ve got the osteotomy well downhill. That was where you wanted the center of your implant to be, but that’s the center of your actual osteotomy. Okay. And hopefully you can see from this something that we’re going to come on to time and time again in this presentation is that when drilling on a slope, the pilot hole stays where it is and everything else gets removed from the downhill side. So the pilot hole becomes the uphill margin of your final osteotomy. And if your osteotomy is going to look like this and your crown and your implant are going to look like this, you’re going to have a mesially cantilevered crown of an implant. Okay? That’s the center of the crown, that’s the center of the implant. And if you don’t think this happens, I’ve just taken the following cases off the Biocon website. A crown cantilevered measly off an implant that’s been drilled on a slope. A crown that’s cantilevered measly off an implant drilled on a slope and a crown that’s cantilevered measly off an implant drilled on a slope. Of course, it’s gonna be more noticeable in the bigger, the wider, the six millimeter diameter implants because you slid more downhill. Okay? Now, it’s much easier for me to show you these things on models. Not only because there’s no blood and saliva, but because I can screw up as much as I want without having to worry about the patient. Okay? I’ve taken a plastic model and I’ve ground down one side so we have a sloping surface to drill on. And I’m gonna drill a pilot hole. It’s my pilot bur. And if we look down, that’s the pilot hole. And I’m gonna mark with a pencil right on the middle of that. And that’s where the pilot drill in. And I’m now gonna do some reaming. Two and a half, three, three and a half, all the way up to five millimeters. And you can see that we slid downhill from the pilot hole that has remained uphill. Everything else is removed downhill and that’s the center of your final osteotomy. We slid in the direction of the red arrow. Now, if we know that that happens, how can we avoid it? There are only three ways to avoid it. The first is brute force. Okay? It’s not a good technique. Alright? If we know that that’s where we’re gonna center our osteotomy and we center our pilot hole here, If we know we’re gonna move downhill with the reamer burrs, we can lean on them. We already hold the the handpieces usually like a bat, like a club, you can really put some force on them, and you will end up drilling a straight osteotomy. Is it a good technique? No. It’s an awful technique. Why? Because it’s bad for the reamer birds. You’re gonna blunt them quickly. It’s bad for the handpieces. You’re gonna burn out those bearings. And it’s really bad for the bone. You’re gonna heat it up. So if that’s a bad technique, what are the two good techniques? The first one was taught to me by Shadi Dahar and that’s if you know you’re gonna slide downhill from the pilot hole, start the pilot hole uphill. If you know that’s where you want the center of your final osteotomy to be, start the pilot hole uphill. How far uphill? Well, we’ve already seen that when drilling on a slope, the pilot hole becomes the uphill margin of the final osteotomy. So that’s exactly where you want to start it. Just a little way uphill. When you come with your reamer bur, you will slide downhill and your implant will be centered exactly where you want it on the crown. It’s a great technique because there’s no wear on anything and there’s no extra bits of equipment. But the downside is it’s impossible or hard, if not impossible, to use with a drill guide, with a stent. The stents have a groove marking the middle of your intended crown position and yet you’re having to drill the pilot hole uphill from that. So it’s very hard to use. So perhaps it’s one for experienced users who aren’t so reliant on stents. What’s the third way? It’s to countersink the pilot hole. I have to thank Rainier Urdaneta for telling me this technique, and I love it. And I use it for almost every implant that I place. What do I mean by it? Well, we’ve seen these pictures before. We drill our pilot hole centered on the crown position, and we then take a big round burr and we countersink the hole. What bur do I use? I use a bur and a latch reamer handpiece. Sorry, a latch handpiece. You see it’s a fairly aggressive bur. It’s a crosscut bur. You can get these bur from any dental supplier. I use it in a one to one handpiece. I have it running as fast as my motor will let it spin with some cooling irrigation. And I can hear some of you thinking, well hang on a sec, thirty thousand revs? But our pilot bur only runs at eleven hundred revs and we have it running only that fast so that it doesn’t heat up the bone. If you have it running thirty forty or fifty thousand revs, you’re gonna burn the bone, the implant won’t integrate, it’s gonna be a disaster. That will never happen. We’re not talking about a long narrow pilot bur that you bury way down deep in the bone, well away from any cooling irrigation. We’re talking about a bur that is always at the surface, always accessible to the cooling irrigation. It’s a big hunk of metal. It transmits temperature quickly. You’ve got to have it running fast because it’s a wide burr. If you have it running slow, it’ll just bounce you out of position. Okay? You want it running as fast as your unit will allow so that where you touch the bone, the bone’s gone, disintegrates. Then you can be really subtle, really delicate and place your countersink exactly where you need it to be. What size bur is it? I use a four millimeter diameter bur. And again, I can hear some of you thinking, well hang a sec. What if you wanna use a four and a half millimeter diameter implant or a five millimeter implant or a six millimeter implant? Do you need separate burs for each one? I have separate burs for each one and I never ever use them. I only ever use a four millimeter bur. And if I wanna go wider, all I do is I jiggle it about a bit. And I know that doesn’t sound scientific or precise. It’s incredibly precise. Why? Because if you’ve got a reasonably narrow ridge and you’ve got this burr spinning fast, four millimeters, you make a four millimeter diameter countersink and you look at the ridge. And you can look and you can see easily. Do I have bone either side of this four millimeter hole? If you do, you just wiggle it around a little bit wider. It’s very very easy to make subtle changes. You can see from this picture that you have taken more bone away from the uphill side of the hole than the downhill side of the hole and that’s the whole key. Now when you put the reamer burr on, it’s got even bony contact either side. It’ll drill straight. When you go up a size, even bony contact either side. And not just uphill and downhill, Three hundred and sixty degrees around this rim of vert. So it’s gonna have smooth bony contact and we’ll come on to that in a moment. You’re gonna end up drilling straight, your implant straight, you’re gonna have a great crown position. Here’s the other side of the model and again, I’ve drilled it down so there’s a sloping bony surface and I’ve drilled my pilot hole with my pilot bur. That’s looking end on on the pilot bur and that’s looking in the hole. I now take my four millimeter countersink bur and I drill a five millimeter countersink. And it’s a little bit hard to see, maybe from this angle is the best one. You can probably see that I’ve drilled away more from the uphill side than I have from the downhill side. And that automatically happens when you drill over your pilot hole. I’ve now put the pilot bur in simply so that I can mark neatly the center of this pilot hole so that you can see where it’s centered. And if we look laterally, it’s roughly centered over that pilot hole. I’m not gonna go through all the intervening remembers. I’m just gonna go straight up to the five millimeter. And you can see that it’s pretty central on that view. It’s much easier to see. You can’t fool with camera angles this view. You can see that I am dead center. Now, this next bit is important. You have to take my word for this. I can’t prove it to you. But I was not holding the handpiece like a club, like a bat, you know, tucked into your side and leaning in. I was holding it I like I hold an air rotor, like I hold a high speed drill, like I hold a pen. Gently, subtly. You don’t need to grunt out these osteotomies when you do this. And you can see that we’re dead center. Even though we’re drilling on a slope and I’m holding it like a pen, the osteotomy gets centered on the countersink. The downsides of this technique are that you need extra equipment. One bur, one handpiece. Your reaming will be so much faster afterwards that you’ll save so much time. There is less bone to collect in the flutes of the reamers because you’ve drilled away some of the bone, but your implant’s gonna be perfectly positioned. When you do this, you won’t need loads of bone. There isn’t any wear on anything, which is always nice. And this next one, really important. Anyone that’s drilled a Bicon osteotomy using the Bicon reamers, they know that you have to fight the handpiece. It bucks and kicks and jerks around. Patients hate it. Dentists, I hate it. And that’s why we’re taught to hold the handpiece like a club. It’s not very subtle, but we’re taught to show that reamer bur who’s boss. Because you have even bony contact with the countersink all the way around the bur, you will be funneled down into the middle of the countersink. Okay? Every time. Effort is smooth. No jerking. Now there are so many other advantages to this technique, but the one of them that I’m gonna go into briefly is that you can correct the position of the pilot hole without any effort at all. We’ve all drilled the pilot hole, looked at the alveolar ridge and gone, I wish that was just a millimeter or two, mesial distal buccal lingual, whatever. Okay? You can’t drill another pilot hole right next to a pilot hole you’ve already drilled. Just slide into it. Okay? This technique, easy. Here’s another plastic model that I haven’t ground down into a sloping surface. This is a flat surface and I’ve just marked with a pen in the middle of the ridge. And I’ve made a red circle that’s six millimeters wide. Because for this demonstration, I would want to put a six millimeter implant in. I wouldn’t normally clinically, but just to show you how powerful this technique is. And I’m now gonna screw up as much as I can with my pilot hole. I am as far on the edge of that six millimeter circle as I can possibly be. Alright? If we look at it without the drill, it’s a bit easier if I put a little pink dot over the top of it. But you can see that is right on the edge of my eventual planned implant position. Does it bother me? Not in the slightest. I take my countersink burr. It’s four millimeters in diameter, the countersink burr. I drill a six millimeter diameter countersink. Okay? If we look close-up, you can again see the pilot hole is way off to the side. As far over as it can be. Doesn’t bother me at all. I pick up my four hundred to one handpiece. I hold it like a pen. That is a two and a half millimeter reamer hole, three reamer, three and a half, four reamer. That’s a four reamer burr. That’s a four reamer hole. Oh, sorry. Four and a half. Well, this is a five reamer. Five reamer. Hole. Five and a half. Six millimeter reamer. Look at the position. Effortless. Wasn’t holding it like a bat. Take a look. Close-up. There’s red pen on both sides of this. Buccal and lingual. Alright? No wear on any bits. No having to force a patient. Alright? This will happen every single time. It’s a very, very powerful technique. These are the before and afters. I love it. I use it for almost every osteotomy that I drilled now. But there are some osteotomies that you can’t use it in. You can’t use it when you’re drilling into sockets in the aesthetic zone, which was another one of these repeatable mistakes that I kept ending up with my implants way too labial. Obviously, this is also called immediate implants in the aesthetic zone. And I wanna make it very clear that what I’m talking about is only situations where you take out a tooth and you’ve got a bony socket all the way around. So use periotomes, use luxators, however you wanna do it, but I’m only talking about situations that aren’t dehiscences, aren’t fenestrations. And whenever I’ve taken a tooth out and I have that intact bony socket, I’ve always looked on that and thought this is the perfect starting point. I’ve done the hard bit. I’ve taken the tooth out beautifully. This is a blank canvas for me to paint on. I should be painting a masterpiece every time and I wasn’t. When you have a tooth and you take it out in the aesthetic zone, you have a very, very thick palatal wall of bone and you have a really thin sliver of bone labially. If you don’t think it’s as thin as that, that’s the apex of the socket. That’s the thin labial plate. Look how thick it is palatally. Again, another one. That’s the apex. That’s the thin labial plate and you’ve got the thick hunk of bone palatally. And again with a canine, apex of the socket, thin labial plate, and you’ve got a thick hunk of bone palatally. We all know that when we take out a tooth, we don’t drill straight down the middle of the apex of the socket because we’ve seen the Bicon cartoons that show us that we will blow out the labial wall. And so we know that we have to drill into the palatal wall somewhere. We come up a little bit from the apex. But no one’s ever stated how far up. And so what I used to do is I used to come up about a quarter of way. I used to think that was right. And I used to do what Bicon taught me, is come in with my pilot bur at an angle, gain a bit of purchase, upright it. Upright it to where? Well, upright it to between the contact points and drill my pilot hole. The moment my bur touched the bone, I was destined to have a bad implant. Alright? It was always gonna be in the wrong position. Why? Because from here on, we’re gonna be drilling on a slope and it’s a really steep slope. Okay? We know that when we do this, our reamers are never gonna end up going uphill. They’re only gonna end up going downhill and that means that our final osteotomy is gonna be there. Look how thin the labial plate is. If we put an implant in, that’s the biggest implant we’re gonna hope to get. You don’t go any wider with the osteotomy because you can already feel the reamer bending, bowing that labial plate. It’s already thin enough. If that’s the biggest implant we can possibly get in, then it’s always gonna have a two millimeter post. It’s almost always gonna be an angled abutment. Do we like two millimeter posts and angled abutments in the aesthetic zone? No. Because they come out more often. Alright. And look how thin the labial plate of bone is. Often you have to sink these way down deep in order that the angle change can actually get you somewhere that’s restorable. And yeah, you can do clever things with IACs and you can end up with them looking kind of acceptable with the pink IAC material. But that’s not what I wanna end up if I’m given that perfect starting point of an intact bony socket. I don’t wanna end up like this. The masterpiece that I want to paint if I’m given a blank canvas looks like this. You put a crown on it, that’s what I want to achieve. Why is that the perfect implant? Well, first of all, it’s a big implant. It’s a five by eleven for laterals or four and a half by eleven for centrals. Every time. And I know Vin will say, you don’t need to go so long. You can put a five by eight and it’ll carry any tooth in the mouth. And he’s quite right, but we’re drilling into a socket. So most of the top part of this implant is gonna be surrounded by socket, blood clot, air. Alright. And I want to go down, put an eleven millimeter implant in because then at least I know that the apex of that implant is surrounded by good healthy bone and it will allow me to harvest more bone which you’ll see what we do with later. Why else is it a perfect implant? Well, if we’re using implants that size, it’s always gonna be a three millimeter post. Every time. And if it’s in that position, you’re gonna have a zero degree abutment every time. Do we like zero degree abutments and three millimeter posts in the aesthetic zone? Yeah. That’s all we ever want. Alright? I’ve put here that I use a stealth abutment and that’s because I will always want to try and immediately stabilize these. Alright? Put a restoration on straight away. I’ve also written that I wanna use a five by four stealth abutment every time. And again, can hear some of you thinking, well, it’s gonna be hard enough knowing what implant you’re gonna use, let alone what exact abutment you’re gonna use before you even drill the hole. I’ve been doing this technique that you’re about to see for a year. I haven’t used any other implant. I haven’t used any other abutment. I know every single time. I only take out the box one abutment. It’s gonna be a five by four zero degree abutment every single time. And you’ll see how you can achieve that in a moment. What else is good about this implant? Why is that the position that I want? It’s all to do with the labial plate of bone. Alright? Especially over the shoulder. Why? Because of the blood supply to the labial plate. When you have a tooth and that really thin labial plate, that thin bit of bone has two blood supplies only. A blood supply from the periodontal ligament and a blood supply from the gum from the periosteum. It has no significant blood supply from within the bone endosteally. Why? Because that thin little bit of bone is two cortical plates fused together. There’s no cancellous bone in there. So there’s no endosteal blood supply. Obviously, if you take out a tooth, you lose one of those two blood supplies to that bit of bone. And the only blood supply left is from the gum, from the periosteum. Clearly, if you put an implant in there, if that bit of bone only has one blood supply from the gum, it’s not gonna take a lot of an insult to the gum, but a gingivitis and tooth brushing trauma, to interrupt that blood supply, the only blood supply for the bone, and you’re gonna begin to get recession. And let’s face it, it’s not a very thick bit of bone to recede. It’s a thin sliver, and it’s gonna get lost. I want my implant here with a thick bit of bone, not only because it’s a bigger volume of bone that would have to be lost in order to get recession, but more importantly, because if I’ve made that bone thicker, then I will have cancellous bone within it and an endosteal blood supply. That means it’s got dual blood supply. You can have as much gingivitis as you want. You can have as much tooth brushing trauma as you want, And the bone is still gonna be perfused with blood endosteally. And so if we come in twenty years time for the fortieth anniversary of Biocon, I hope to be able to show you pictures that have fairly stable gum margins. If that’s the implant we want to achieve, how do we get it there? Well, we’re gonna be drilling on a slope. We know that when drilling on a slope, the pilot hole becomes the uphill margin of the final osteotomy. What does that mean? Well, if that, the implant and the crown that we want, that’s the position of the implant in the socket, the only place that you can have your pilot hole is here. The only place. If you have it any more down the socket, you’re gonna end up with narrower implants or crowded up against the labial plate. Where is where does that pilot bur enter the socket? It enters the socket here. Three quarters of the way up. Now that’s way more than than I used to do. I used to come up a quarter of the way. Three quarters away. That is the only position that you can start your pilot hole if you want this perfect implant. You must start the pilot hole three quarters away up the palatal wall or the bony socket. Now, one important thing to remember is it’s the bony wall of the palatal socket. I’ve made the mistake of going from the apex of socket to the edge of the gum, but sometimes you’ve got really thick gum. And so three quarters of way up that is in the gum. It’s three quarters of way up the bony wall. If you do that, you’ll end up with a beautiful implant. Now, how do we drill this? I don’t want to drill it in the classical Bicon technique of coming in with my pilot bur at an angle and uprighting it because I’d be too worried about going all the way through. It’s too easy to do. I wanna have a little bit more control than that when I drill my pilot hole in this situation. So how do I do it? I start off with a little dent. Three quarters away up the wall. What do I use? I’m a surgeon. So I’ve used a surgical bur, surgical handpiece. This is just a surgical round bur. And I simply put it into the socket and I simply move it palatally, make a dent. And when I drill that dent, I come in with a bur at that angle, but when I come out with my bur, I come out from the dent in that angle. And why? Because I wanna get rid of this bit of bone. Why? Because I wanna end up with a ledge like that. And the reason is that I can now lay my pilot drill straight on that bit of bone. I don’t have to upright it at all, and I can drill straight down and create my pilot hole. Now you can probably see from this that the whole while that that pilot hole was being drilled, the bur is touching the soft tissue at the margin of the socket. Alright? You must have that pilot bur so upright that it touches the soft tissue. Alright? And it’s gonna look weird. It’s gonna look like this. That’s the end of the pilot bur. Alright? Looks like this can’t possibly end up with a good result. It’s the only way you’re gonna end up with a good result. If we look in, that is the pilot hole. That’s the apex of the socket and we’re three quarters of the way up. Okay. Bear with me. How deep do we go? Well, we know that we wanna put in an implant that’s eleven millimeters long. I’ve explained why. And we know that with Bicon, you bury them at least three millimeters below the bone, which is at least five millimeters below the gum. And this is an aesthetic region, so I’m gonna go six millimeters below the gum to the top of the implant. So that means I wanna go seventeen millimeters deep with my pilot hole. Is there a marking on the pilot bur at seventeen millimeters? Well, it just happens as a handy marking, which you can line up with your gum, which you’re lying right next to. Okay? Once you have got this, you are destined to have the perfect sized implant in the perfect position. Every time. You could, if you’re of the mind, go and have a coffee and let your nurse finish off the osteotomy because you’re drilling on a slope. You are only ever gonna slide downhill with a reamer bur. So you’re gonna end up with an osteotomy that looks like this and an implant that looks like this every time. If you wanna see some clinical examples, that’s obviously the pilot bur end on touching the gum. That’s the five millimeter reamer. Look at where it is in relation to the contact points. Here’s central incisor. That’s obviously the pilot bur. That’s a five millimeter. Look where it is in relation to the contacts. Here’s two of them. Looking end on, touching the gum. Now you’ve a four and a half for a lateral and a five for a central. Look at the position with in relation to the contact points. Perfectly placed. You’ve now got perfect sized implants in the perfect position, but they’re not perfect implants yet. We’re almost there. What else do I need? I wanna graft some bone labially and over the shoulders of the implant. Then we’re gonna get a perfect result. Now, know, it’s obvious, that if I don’t put something in the well of the implant to fill it up before I graft over the top, then my graft material is just gonna go straight into the well. Okay? So we have to fill it with something. I can’t put my stealth abutment with its acrylic sleeve on because if I do, there’s no room around it to put my graft material around. You can see from here there’s just no space. I’ve tried using guide pins. Don’t do it. Alright. Why? Because it’s got a shoulder on it. And if you pack your graft material on that shoulder and you take the guide pin out, what comes out with it? Alright. You only make that mistake once. Here’s a clinical situation. You can see guide pins in the implants. If you pack bone over that and you pull out the guide pins, it’s gonna be a mess. So what do you use? You use your healing plug. It’s got no shelf, no shoulder on it. It’s a nice smooth taper. It fits the implant well very nicely. And you can see here, loads of space around the post to be able to put some graft material. What graft material? Well, because you’ve gone down and you’re gonna use an eleven millimeter implant, you’ve got a load of autogenous bone. There’s usually enough space to graft that I tend to mix it with whatever your favorite graft material is. Bio-Oss, Puros, it doesn’t matter. Mix it with something and pack it in. And there you can see it packed in. When you take out the healing plug, you’ve got access straight away, for your stealth abutment to go right in. And when you push the post into the well of the implant, the hemispherical base is gonna compress that bone graft right over the shoulder, right where we’re constantly being told you need your good bone. Alright? You’re gonna end up with a result like this. Here are two. You can see how much room there is around these posts to be able to pack the bone graft. That’s your autogenous bone. Mix it with whatever you want. Lay it on the gingival margin and just poke it down. And eventually, you’ll see your healing plug sticking through. Not bad position for those. Take them out and stick in your five by four zero degree abutments. Alright. That’s that’s the only ones I ever use in this region. Tall narrow sleeve for lateral. Short fat sleeve for central. Coming right to the end now. This is a lateral incisor. Look how far away we are from the labial plate. We haven’t encroached on it. And when we’ve we’ve grafted under before we put that on, look at the bone over the shoulders. Every time. Very final case. Central incisor. You’ve seen these pictures before. That’s the pilot bur. That’s the five millimeter reamer bur. Look at the space labially that we still have. We haven’t encroached on that labial plate. We’re gonna put in some bone graft. We’re then gonna put in our stealth. Look at the position. Every time. Alright. And look at the x-ray and look at the bone over the shoulders. This technique is so predictable that if you are able to take out teeth with an intact bony socket and you have a blank canvas like this to paint on, you will be able to paint a masterpiece every time. I’d like to thank Bicon for inviting me to speak. I’d like to thank David Hallowes who’s done an amazing job on these illustrations. They’re just fantastic. I’d like to thank Vanessa, my wife, for putting up with me. And finally, I’d like to thank all of you for your attention. Thank you very much.