The Bicon Short Implant: Introduction, Rationale, and Technique

Good morning. It’s a great honor to be here. It’s a pleasure to see all of you, new friends, old friends, people who have come back again and again. I’m humbled by the fact that some of you still call and email and ask us questions. It keeps us on our toes, keeps us young, and thank you for doing that. Please do not stop. I also want to thank Dr. Morgan, excuse me, for being a friend, a mentor, and a leader in this field and in our practice and profession. Thank you, Dr. Morgan. I also want to thank Tom Driskell, who’s been a great friend. I’m very honored to have met him, and I know you all who have come in contact with him. You share my feelings. A great mind who’s really given us a great device to help our patients and help our families, as well as Fred Weekly. I also wanna thank the my colleagues at the IDC, Dr. Hirayama, Dr. Urdaneta, Dr. Leary, Dr. Donohoe, Dr. Katherine Morgan, all of the staff. And I don’t want to name names. They all know they’re very valuable to all of us, and I do want to thank them. But I really want to especially especially thank Alison and Veronica for helping put this together. We wouldn’t all be having all of this facilitated meeting with this beautiful room without their tireless efforts with all of the staff at Bicon. I have been tasked with giving you a long talk about a short implant. The newest siblings in the Bicon implant family are the six by five point seven and the five by six implants. I will use the word obviously a few times over the next few minutes, quite a few times as a matter of fact. It is obvious to all of us that we need, we want short implants. It’s always been obvious because we know that the the inferior alveolar nerve and the sinus can be so close as to preclude the placement of any implants without further grafting procedures. We know that may not be obvious, but we have seen many cases where the root proximity will leave us no room at the apex of an intended implant of the order of eleven millimeters or even ten millimeters, and certainly not thirteen or fourteen. We also know, and maybe not so obviously, that the ridge variation will present a challenge, such as a significant depression below the crest on the buccal aspect of a ridge. You have a crest of approximately a centimeter width, and yet that whole width is taken up by an exostosis. It’s made up by an exostosis. What can you do with that? Your options become limited if the patient refuses bone grafting, or if you happen to not have the substrate, or if you’ve looked at the ridge and the x-ray and it looks pretty good. But then as soon as you pass the first five millimeters, you’re in a big void in the buccal. What about the submandibular fossa? You look at a panorex, and although you may have palpated, you neglected to see that the internal oblique ridge is extremely prominent. And the floor at the roof of that ridge is constituting a new inferior border of the usable area of your implants, and you end up with a usable depth of less than eight millimeters. What can you do then? You want a short implant. What about the the symphysial posterior slant? How many times you look at a Panorex and you see that the anterior part of the of the of the edentulous mandible has a good fifteen millimeters depth, even corrected. But then when you go into the the surgical site, and you start making your initial perforation, if you have neglected, as I hope you never do, but if you have, like I have done in the past, not palpated or have been unable to palpate because of the the lingual musculature, And all of a sudden, you’re drilling at about five millimeters, six millimeters, and there’s a tremendous amount of resistance. That’s because of the slant. And all of a sudden, that fifteen millimeters doesn’t look usable at all. And sure enough, the only thing that would save you is a very short implant, or you abort the case, or you risk perforating into the substance of the musculature of the infra lingual space. It wasn’t easy for us to come this this way along. We have a lot of opinion leaders who have written papers after papers, after many failures in the in the late eighties, early eighties, even early nineties. This is from nineteen ninety by professor Van Steenberghe from the Catholic University of Louvain. That he says that you must have ten millimeters or thirteen millimeters in the maxilla of depth. Without parsing the statement too much, he’s saying that if you did not use all of that depth, you’re not worth your diploma. You have to put these long implants in. So we are starting from an area or from a location in our history, in implant dentistry, that says, when you see bone, use all of it. You have to make a lot of bone and put everything, every all every little bit of it to use. However and a a review paper by I think it’s it’s pronounced Hagi, could be Haji, in two thousand and four, reviewed twenty one papers that you were able to, in in these papers, to identify particularly the type of implants used, the lengths of the different implants, their locations, and then statistically were significant from the standpoint of the statistical analysis. And the failure rates for longer than seven millimeter implants were fourteen millimeters or less. Now, as you all know, if you’ve ever placed any implants, when you have a failure rate of zero point zero, there’s either one thing. You’re placing no implants or not enough of them. So I would look at this number with a little bit of skepticism. But the larger number is a little bit disconcerting. If if anyone told you, you do a procedure and a third of it will fail, you would think very, very hard about it. And that is what we started from. Seven millimeters or shorter are going to fail up to a third of the time. And that is in centers that is after excluding a lot of implants that may have failed, but were excluded from a standpoint of statistical analysis or from follow-up standpoints. So who knows? This number may well have been closer to twenty, and this number may have been closer to fifty. But we can’t parse these statements either, but it’s still very telling. So what happened? It’s still the need was always there. The impetus for the different manufacturers, for the different clinicians, for the different study center and opinion leaders was always there. And you have now available in use for years, the different short implants. Nobel Biocare has one. It’s a screw type. Straumann ITI has one, six millimeters, the integratable surface. Even they have a tighter screw configuration now. Innova, the old sintered with spheres on the surface has has been in use for for several years. But we all know if you’ve you know, obviously, you’ve been here for the past two days or day and a half, and you know that the plateau design lends itself very much to a great transduction of energy into the bone that will help even a six millimeter or even slightly shorter implant work very well, transduce forces, and produce very predictable results in the maxilla or in the mandible. So how did the Bicon short implant come about? Without any illusions to anything, the implant was initially called the fat boy. I don’t know if Tom came up with that or Vin, but it was called the fat boy initially in ninety seven, I think. The design and the manufacturing was completed. Very brilliant design, as we all will agree on all of the designs that Tom Driskell has produced for us. They’ve all been brilliant, they’ve proven their value to us over the years and decades now. The first implants were placed in nineteen ninety eight. Think we have a picture of it coming up. And it has been working ever since. Hundreds of cases were were were treated successfully. And those cases were submitted to the FDA for backing up the claim that this is just like all of the other implants that we have been placing. And sure enough, the FDA gave it its final approval at the very end of two thousand and two. And I know that many of you, if not all of you, seen it, have probably used it. Let’s let’s just maybe dwell a little bit on the topic and show it to you in a little bit more detail. What is the anatomical basis? What is the one piece of information that Tom Driscoll says helped him design and envision this short, wide implant? The fat boy, so called. The design was intended for use in between the two oblique ridges. The two struts of the mandibular skeleton, the two buttresses, if you will, at the angle of the mandible, that make the angle of the mandible so strong, are the external oblique and the internal oblique ridges. In between them, in cases where you have no height because of the loss of the alveolar process, you have width. It’s good bone. It’s cortical bone. So that is where the the design that is why we went short, but we could go wide. Now due to its width and the plateau design, this implant acts almost like a sphere with which you you’ve imparted some fins, some wings, and stopping surfaces that prevent it from rolling. So any and all energy transduced through the crown on this restoration is dissipated very efficiently into the bone on all sides. And that topic will be addressed later on in the upcoming talks. It was proven to quickly have excellent stability and restorability and integration. And it was soon used for other locations, when the width allowed. So now the Bicon family of implants consists of this beautiful lineup. And very prominent, right in the middle of it, right in the thick of it, are the two very short ones, the six by five point seven and the five by six. The five by six is the newest sibling. So let’s talk a little bit about the dimensions. The six by five point seven, it is six millimeters wide, five point seven millimeters long, obviously. But if you look closely at this shape, at this design, count the fins with me. Seven. Correct? The top five of the fins are in a parallel, in a cylindrical fashion. They occupy just under four millimeters of the total length, or excuse me, just over three millimeters. There is a significant step from the second apical fin to the third one. In that, when you are introducing the implant into the osteotomy, you quickly go from a very short, very narrow top fin, crestal apical fin, about four millimeters, to six millimeters. What does that mean in practical terms? I’ll show you. What will mean to us is the introduction is going to take a little bit of more finagling of doing. Before I go into that step, I just want to call to your attention a common feature between all of the Bicon implants. And it’s very prominent in the six by five point seven implant. And that is the vertical cut, that vertical slot. The vertical slot is an added element. It’s an anti rotational element in the bone. But at the same time, it transforms every fin surface to a cutting surface. So if you’re able to introduce the fin with a twisting motion, this will cut, will allow you to shave bone. And the fin spaces then become flutes of a drill, and they will allow the bone to escape it. I know I’m repeating this for a lot of you who’ve been to our courses, but it’s a very important point. It’s a key factor of the design. What is not intuitive to us, what was not obvious to me anyway, is this number right here. The surface area, total surface area of the six by five point seven millimeter implant, is actually higher than the workhorse of the five point eight, and the other workhorse of four by eleven. Five by eight, I meant. When I first saw this slide, and I know Fred Weekly worked very long on getting the surface area at the behest and the request of Pepe Mariconti from Italy, who’s not with us today. We sent him our best. This was not very obvious. But when you look back at it, you say, that’s probably why. It works well. It’s it’s all a game of a surface area. You add the fin design, you add the plateau, you add the quality of bone, the stimulation of bone, and it and you know you know even beforehand that it should work. It will work, and it does work. So this is one of the very first implants, if not the very first one ever placed. If you recall, it was very common before then to place the four by eleven everywhere. And sure enough, behind it, back in nineteen ninety eight, I think it was in January or February, where this implant was placed, eight years post operatively. Why is it that this bone is so much better? This goes back to the transduction of energy, of forces, into that bone, from every little even the lateral, even eccentric loading is transduced into the bone very effectively, very efficiently, with the six by five point seven implant. You’ve seen this x-ray. It’s right on all of the brochures and all the slides. Everybody has it. Because it is a very telling x-ray. This one as well. Shortly thereafter, we started using it in the maxilla. It is wide and it is shallow. Use it. Even at an angle, it still will allow bone to be maintained, and sometimes even generate itself. Some obvious nuances when you’re placing a six millimeter wide implant. Very obvious. You’ll have to drill a little bit wider. You’ll have to drill a little bit less, a little bit more shallow. But at six millimeter width, at fifty RPM, your peripheral linear speed, in other words, if you had a wheel and you let it run at that speed for one minute, you will move about a yard. Now it’ll take you a long time to get to New York. But if you’re dragging that wheel, then maybe the surface you’re dragging it against will not get heated, but the wheel will probably get heated. So think of that image and take it in your mind and wrap it into that little tight space where you’re introducing an implant. The first obvious thing, and that will be a little bit disconcerting, and you will see that every time you use not every time, but the majority of the times you use a a six millimeter wide implant, is there is a higher likelihood of your encountering the cortex, either on the buccal or on the lingual. Because you get wide, you gotta get some you gotta run out of the cancellous bone. You have a higher likelihood of running out of cancellous bone. Maybe not in the mesial and distal, obviously not, unless there’s some other issues. But quite likely in the buccal and lingual, or buccal and palatal. Okay? There’s higher torque. Just think about it. Just the lever arm principle. It’s a wider thing. The cutting surfaces are a little bit farther away from the center of the circle. The torque necessary to accomplish that is higher. Especially if you think, I don’t want to go at fifty rpm. I wanna go slower. Then you need even higher torque. And now every little bit of an irregularity in the surface, and these irregularities when you’re hitting cortex are a lot harder, is going to interfere with your trajectory. It’s going to be bouncing you all around. And then you take into consideration that you’re not going very far down. You’re engaging the parallel wall of your reamers very short distance. Do you recall how much? Just under four. Just under four millimeters. Okay? That, if you are not careful, if you allow it to bite, and you don’t remember your trajectory. And I repeat that a lot in the course, that your most important surgical tool when you’re doing implants is your memory. A lot of times, one of two things will happen. Your reamer will bind, it will either break or break the bone. Okay? And if you’ve ever tried to take a broken reamer that fell out of the handpiece, out of a dense bone that caused it to break in the first place, you will know the joys of oral surgery. Okay? Higher resistance. You’re trying to go there and you think, wow, I’ve gotten down to the bottom. But if you pay attention to the lines, all of a sudden you’d see that you didn’t go all the way down. And now you don’t have any leeway because you started off with a shallow area. You started off with a little bit of distance. And now you’re going many, many steps. If you all recall, if you’re going into all of these steps and you don’t pay attention to the complete depth, and you don’t go to the full depth every time, now you have two extra steps that will get you even shallower. So that’s another risk of it. Now don’t be scared of it because it is so shallow, your osteotomy, that you’ll be able to complete it without a problem. But then, go back and think of the picture of that implant. When you put it in the osteotomy, only about three millimeters, slightly over three millimeters of it, is touching bone. Even the simple act of putting the black healing plug in, or taking it out to cut it, or cutting it, can move the implant. Pay attention to that. Let’s look at some examples. This illustrates how wide a six millimeter reamer. For all of you, for any of you who have not seen it or used it, just compare it to the size of a bicuspid. It is wider than the widest bicuspid root at the CEJ. It’s very wide. Odds are, if you’re doing it immediate post extraction, you are going to fill the whole neck. And if you’re not careful and doing it very carefully, you can demolish it. Placing the implant, taking advantage of the vertical slots cut into the fins. How can you take advantage of that? Only by the use of the inserter retriever. The twisting action that you can accomplish by using the inserter retriever, either on the long handle if it’s on the maxilla, or on the short handle if it’s in the posterior mandible, allows you to get the implant past whatever flash of soft tissue. Get it into the osteotomy, control the osteotomy very well, lock it in place by giving it an extra twist when it’s bottomed out, and then disengaging it. If you must, and if it gives you great joy like it does to me, you can hammer it into place. Everybody needs something in their lives. I like the hammer. So you can tap it into place. Just remember, when you’re taking your inserter out of the implant, just drag it right out. Okay? And you see that in this case, it’s just at the crest of the mandible. If we had any more depth, we probably would have used the longer one. But this is an implant that worked beautifully in this area with a crestal defect, And it succeeded in achieving what we needed it to achieve. Let’s look at some x rays. In this particular case, patient had had two bone grafting procedures, and two different implanting procedures. All four failed. What happens when you have four failures in the same site? A lot of scar. Who wants to graft under a scar? Good, we have a lot of wise people in this room. Because I certainly don’t want to graft under a scar. So what we had to do is get this patient some occlusion, and we were able to achieve that by using the six by five point seven. In the area between the two obliques, there was no problem. Just past the external oblique, the four point five by eight actually blew out the buccal. A few fins were visible, so a graft was made with an overlying membrane, a little tack used to hold the membrane over the implant. Both of these osteotomies went right through the roof of the inferior alveolar canal. With a gentle curetting motion, we were able to tickle the nerve. But the patient luckily did not have any paresthesia. And he has had this restoration for about five years now. More examples. It’s been placed to avoid a sinus lift, again to avoid a sinus lift, into a sinus lift. And I know you have doctor Schulte talking to you later about the lack of effect of the crown to root ratio with the Bicon implant. It’s been placed in a saddle deformity in the mandible, very close to the inferior alveolar canal. It has been placed, again, in that same location where the inferior alveolar canal formed the floor of the osteotomy. So this is a great use of the implant. Look at this one here. Remember what I said about it tipping? Some of you may have seen us place this implant, because this is one of the course patients. And as you’re answering questions and giving commentary, I did not pay attention. It’s purely my mistake. This implant can be perfectly, perfectly straight. However, just by putting the black healing plug and cutting it, and a little bit of pushing motion as we’re cutting the black healing plug, push the implant, and it tipped it. So just pay attention to it. One very easy way is to put a guide pin. Don’t engage it very tightly. Just make sure that it’s still straight. Take it out gently. Cut your plug outside. Put it in with a very smooth perio probe. Okay? We’ll take a few minutes and introduce to you our newest sibling here. Now, Dr. Chuang will talk to this at length. He has told us, after reviewing our data, that the survival rate of this fat boy implant is comparable to the other implant, the longer ones, or the so called long ones. So that’s given us a lot of confidence, and we’ve been using it very, very successfully for now the past eight years. The five by six millimeter implant is the newest addition. Soon, we will have a four and a half by six, I’m told. We’ll see. Five by six millimeter implant is quite a bit different, would you say? In the sense that the shoulder no longer had the little groove that you see in the other, the four and a half, the five, and the six millimeter implants. The other, the five by eight, five by eleven implants. The other difference, from the six by five point seven especially, is this slow taper. This means that not four of the fins are touching the wall. Three of them are touching the wall at five millimeters, plus the shoulder. So does that mean that this implant is less stable? It can be. However, there is a major difference from all of the other implants. The five by six, the top or apical fin, is slightly wider than any of the other implants. The other implants have a top or apical fin, fin width of approximately four millimeters. The five by six has slightly over four and a half. That means quite a few things clinically, but mainly, it means that when you put it in place, you will have to use the implant to mill itself in. Because otherwise, it will just snag, and you will end up with an implant sitting above your osteotomy, especially because you are probably drilling in just enough bone to get it in. Okay? And then in the bottom of the five by six implant, there is a donut cut. There is actually another piece that’s a little bit higher. This kind of negative imprint of a donut is approximately one millimeter deep, and one millimeter across. It just adds two extra walls for lateral stability. And I know you will hear about the effect of this later on in the talk about the finite element analysis of this implant. So a clinical illustration, this implant is relatively new. And in cases like this one, where the teeth actually read the book and decided to be right over the mental foramen, and then patient who decided that, you know, I paid enough for the bridge, it will take care of itself, you end up with situations where you remove the bridge, and whatever is left of the prosthesis, and the root, and the distal abutment, and you’re left with a very, very shallow bone. In this case, one trick you can use is try to drill towards the lingual slightly, because you can run out of bone very fast. Angle it slightly lingually and just stay shallow. If you need to to drill, in other words, you’re not gonna stay within the socket itself, make sure you know exactly how deep the socket, because that’s your best indication of where the mental foramen is. Bicon technique, we all know it. Paralleling pins, then going through the reamers. You’ve all probably seen the new medium length reamers. They work great for the distal mandible. Finishing it up sequentially, going up to five, correcting the socket, making sure you have a floor. It’s obvious, isn’t it? And then you can introduce the implant with the inserter retriever, which is recommended. And if you have a little bit of extra depth, such as in the distal socket, you don’t have to mill it too much. You can just introduce it with the black healing plug and carrier, place it into place. And this is what I’m alluding to, that placing the black healing plug with just a smooth perio probe will allow you to avoid having to move the implant, to cut it, or to retrieve the inserter, such as the endodontic reamer. You will maintain the exact preliminary position you put it in, and it won’t move on you. Just graft some bone, close the area, in this case my preference is for a collagen plug, and just let it heal. And this is what we have. Just clearing the mental foramen. Thank you.