Bicon molar implant placement: too deep to restore?

I’m not sure of the exact drilling protocol for bicon- but this x-ray screams at me from my phone. Yes- it’s incredibly deep - looks 3-4 mm sub-Osseus. No reason to ever to something like this- ever. Your angulation is way off- your drill obviously was deflected mesially by your technique. Your placement is way off- and this doesn’t look like a socket so I’m not sure how you ended up here. I wouldn’t want this in my mouth. My advice is do not restore, remove and place more ideally. Make a surgical guide, do something to achieve a better outcome next time.

yes.

Do yourself a big favour and use a stent even for a single tooth placement. It will help you no end. This one is a definite remove and re-do

Best advice would be to remove the implant ASAP. Let heal. Take an implant residency with lots of hands-on. Then try again! Good luck.

Its too deep and I do not think (could be wrong) they make an abutment that has a long enough neck to bring it supracrestal to be able to put a crown on it. Additionally, its angled which will further complicate restoration. best as others have state remove it ASAP and place a longer implant that is vertical in the center of the space with the platform 2mm subgingival

that is the problem about the bicon implants.if you do your osteotomy deeper than it should be, you get into a problem. if i were you i would take it out and do it once again by changing the axe of the implant.

Since I’ve never done a bicon implant I am just curious how does nor remove an implant that has no screwed in interface?

I haven't used Bicon but placement looks way too mesial and deep. I am concerned about damage to 20 during removal which would probably involve a trephine. Do others have thought on potential difficulty for removal?

WHY ?.......there is so much available bone........ you could have used a normal sized implant...now you have a problem... it is certainly too deep to properly restore.... I hope for your sake it is not fully integrated.

I have been placing bicon implants for the last 4 years. Go to their website and review all the xrays posted. They have custom abutments, and since no screw or cement, you will find it easy to restore, and I am sure there will be no issues. Contact Bicon and they will gladly reassure you that you and the pt will be fine. DO not remove the implant. Bicon implants are different, and at times better due to the way the abutment and the implant work. Just my thought.

I agree with above , Contact Bicon. I have restored Bicons similarly placed with success.

The above posters that think that is restorable must be smoking something

No matter how many people will tell you this is restorable, are you satisfied with your work? Is it what you want in your mother's or sister's mouth? Will this haunt you every time your patient comes in for a recall? We do make mistakes. And try to correct them. And learn from them. Take the whole re-do as a learning process. Invest time on this patient and you will come out a better surgeon.

I also agree with Frank as to how I practice dentistry . To remove this implant would cause a huge defect . I suggested contacting Bicon to get a longer abutment Below is a 10 year follow up on a case I inherited. Note the dense bone growth along the abutment . The restoration on #31 is a provisional.

Sorry I wasn't able to post radiograph

When doing implant surgery ALWAYS after pilot drill put a pin in the pilot hole and take a PA to check angle and position, then if it looks good proceed if it doesnt readjust the position and angle and take another PA With this particular case we can see it wasnt an immediate placement so why wasnt it placed in the center of the space and why is the angle so off?

DR. YOU ALREADY KNOW THE ANSWER. THERE IS NO IDEAL WAY TO RESTORE THIS.

I have placed and restored Bicon implants-for years. This is perfectly restorable. With a two dimensional radiograph we can not tell the exact depth of placement. Those of us who have placed hundreds of implants in posterior mandible understand that the buccal crest is usually more apical than the lingual crest. So if you place the implant “at crest” based on the lingual bone,which is a common rookie mistake, the implant has several threads exposed (above bone) in the facial. It would look good on a periapical radiograph but it would be a very poor placement when evaluated on a CT -scan. When you uncover this implant you will see that it is not more than 1 mm or 2 apical to the facial crest. This is consistent with published research on Bicon implants. For those who want to know, a Bicon implant is removed with a threfine slightly larger than the implant, which in this case has the potential to do serious damage to the adjacent teeth. Do not remove this implant, restore it using an abutment with a long shaft and following the conventional bicon protocol.

I am not familiar with Bicon but I would imagine that you can restore this successfully. I am not sure how you can get to the head of the implant if it is buried. Do they use healing abutments to develop soft tissue? If this is totally buried and you go back to take and impression, how do get an impression coping onto the implant? If you can get an impression coping, then a lab can make a custom abutment with a crown.

Bicon works well at 3 mm sub-crestal, using the extended , spherical based abutment. In fact, bone often grows past the abutment interface and around the spherical base. As to angulation, it is angled to erupt midway in the restoration space. I understand that those trained in different designs could see this as a problem, it it’s not. How is it that a Maxillary all on four is fine with four extremely angulated imlamts, but a Bicon aimed 15 degrees to emerge in the center of the available space is a travesty? The implants ate placed with a black synthetic rod extending to near the surface, so uncovering is no problem. The Titanium transfer jig just slides down thru this tunnel to allow the analog attach,ent location to be poured into the model. No other screws, nor jigs are necessary. A solid titanium abutment blank is available to be custom milled if a standard abutment won’t fit . In this case, it looks to me like an extended length standard abutment could be trimmed to allow a final crown to draw clear of obstruction. Having shared this, I personally aim and plan for an implant in line with the crown draw vector, although that may not be parallel to adjacent teeth.

The Implant is way too far subcrestal. whoever said it could be the angle of the x ray beam is wrong. There is no way projection geometry would throw off the pic that much. Now a CT scan would definitely tell you, but there is no question that this implant is WAY to far sub crestal as well as being off angle. Is it possible to restore this? Maybe? But anyone who says is it fine and go for the restoration is wrong. Ask them if they would want this implant in this position in their mouth? My guess no. Why not start out with a better overall position. Long term it will be much better. We all make mistakes. None of us are perfect. Anyone who places implants that has never had a problem probably has not placed that many. Neil Zachs, Periodontist, Scottsdale AZ

One point to mention here is implant abutment connection. Only bicon having pure bacterial seal connection. Since there is no hex, abutment can place in 360 degree position and easily restoarable. Many are scared about this deep placement is because of bone loss after abutment placement. This will not happen with bicon. Regarding such deep placement is may be a accidental fall of implant into a osseous defect( bone void) which couldn't find in the opg or iopa. With bicon extended post and bacterial seal connection we can easily restore this case without any fear of bone loss.

The depth and angulation Can subject the prosthetic to two things: 1. Pseudo pocket (a long junctional epithelium vulnerable to pocketing or recession ) depending on the pre existing biotype . 2. Implant fracture , is very possible , specifically that the prosthetic space is relatively big.

The situation here need to look at in 3 phases of Implant restoration. The implant placement phase, abutment level or restoration phase and the long term survival phase The implant phase The Bicon system protocol is to place the implant 2- 3 mm sub crestally in contrast to most of the screw system. This implant in discussion is deeper by 1-2mm than the ideal. Now the deeper placement of this implant is a blessing in disguise and covers any possibility of implant fracture in the future. The bone protects the implant from fracture. If implant has to fracture the bone has to fracture first. With functional load, by the principle of wolf's law the quality and quantity of bone improves and the implant gets secured with time and function with Bicon system. Yes, the angulation of this implant placement could have been better and the subsequent restoration as well would have been easier. Abutment phase & long term Survival phase The next issue fracture of abutment. Breaking or fracture of 2.5 or 3.0 mm abutment of Bicon implant is never reported in any clinical situations so far, in 30 years. The implant used here is a 2.5mm well and a 2.5 mm abutment will be used. Now the immobile abutment implant junction with Bicon system, with 100% bacterial seal protects and improve the bone and soft tissue around implant with time and functional load. Now issue will be restoring this implant for someone who are not used to the plateau system and cold-welded abutments in Bicon, especially for someone who uses a screw system other than Bicon on regular basis who places it at bone level, and such systems make abutments for the bone level placements and makes it impossible to restore if placed deeper. And the micro-movements in implant abutment junction can cause bacterial contamination deeper to crestal bone and subsequent clinical problems. Someone who knows the Bicon system can restore it easily with the versatile abutment available with the implant system. In short, meticulously know the implant system and use the system conscientiously for the challenging clinical systems one may come across. For an argument point, an ideally placed implant or any other implant system could have been as well worked, but it does not mean this implant cannot be restored or it will fail in future. The angulation of this implant placement could have been better and the depth could have been an ideal 2- 3 mm deeper to the crest. But, then all this discussion would have not happened. For me the versatility of the system is to help you with 100 % possibilities to restore and retain a marginally or significantly misplaced implant. That is a big advantage. But a routine negligence and clinical errors should be avoided whenever possible by adapting standard operating protocols. To err is human, and to forgive divine. Thanks BICON

do not remove the implant insted custamise the abutment and restore.

It appears there is plenty of bone for a conventional placement. Don’t understand the rationale for the deep placement. If it’s integrated then is will be destructive to remove. If it fails it will be pretty easy to get an expert to dispute it. I don’t think Bicon implants were designed to be placed that way so the company won’t have your back. Some patient’s biology will tolerate anything some won’t. Rolling the dice here. I can fault you as an operating “Surgeon” you may be faulted for seeking advice on an implant blog of posters with varying credentials and experience. Should have made the call at placement but I don’t have the details. Good Luck time will tell.

Please don't listen to Anyone who tells you that this is perfectly ok to restore. The implant is WAY too far sub osseous. Aside from the off angle and the fact that it is too far mesial, if it even can be successfully restored, the crown to implant size ratio will be SO skewed at what appears to be almost 2:1 if not more Neil Z Periodontist

Please take a look at the Radiographs above of the Bicon at 10 Years. Note it has not had any issue of C/R ratio. The research on CR ratio was based and teeth and extrapolated to implants. There has been additional bone up to the base of the abutment and above the platform. About 10 years ago the Nobel Tri lobe implant was popular . Have you seen bone grow above that platform?

Every artist uses different tools and palates. As I read the comments it’s amazing how quickly this degrades into a pissing match of why my system is better than your system. Meantime NO ONE can or still has answered my original question. Assuming this implant is non ideal. HOW DO YOU REMOVE A BICON IMPLANT? Especially one that has integrated. I’ve had a couple of referrals from GP’s that perfed the inside of the well trying to drill out a fractured stem. Short of a trephine I can’t get these out. Anyone have another alternative? If someone asked me to trephine this case out I’d respectfully pass and suggest a bridge.....

With my great respect for the past posts of “CRS”, I am surprised to see his above comment. For one thing, Rainier Urdaneta has many years of publishing long term, detailed research on Bicon Implants and is a voice worth the attention. As for me, I have a hard time understanding how so many who represent themselves as “implant specialists” have not taken the time to review Bicon history, research, placement and prosthetic protocols, etc.. While perhaps only intended as helpful advice, the off the cuff remarks of those not schooled in the Bicon System can cause unnecessary doubts in both the Dental community and the community of patients. Much of the research and protocol is posted on the Bicon site, and the 2017 book, “The Bicon Implant - a Thirty year perspective” is available through Quintessence Piblishing or Bicon, the perusal of which will shed some much needed light on the subject of comparing different implant systems accurately. As a side note, the initial poster did not show a pre-operative radiograph, so one wonders if there was a premolar root in the placement position. If one is looking at a ridge width which is compatible without grafting, by placement in the pre-existing socket versus more centralized placement in conjunction with grafting procedures, then it is an “informed patient” decision which path to take. Of course, we’d all prefer an implant orientation along the anticipated load vector and compatible with restoration insertion path as well as existing adjacent teeth. The Bicon Short implant presents a valuable option in high risk areas, as well as avoiding having to having to graft every non-ideal implant site. It is not the answer to every problem, but neither are the alternative systems. Please become more knowledgeable about this system before making sweeping proclamations. Thanks, John

Do decide if removal is possible we eould need: 1-Knowing how long has the implant been in place? How stable was it? (might be in very soft bone and have slipped. 2-CBCT: if the buccal plate is thin removal migyht be done through an opening in cortical plate. Alos CBCT allows toevaluate proximity of mental nerve. The idea of making a bridge and leaving the implant in place has its merits. Finally,getting advice from a savy doctor in your neihgborhood would be good. A forum like this wil be a good brainstorming and all ideas are welcome. But in the end you need a reliable advice from a qualified person.

I have the same question as DrG . Wouldn't a removal cause significant damage to bone structure and potentially 20? Is leaving it in and trying to restore the lesser of two evils? The distance from 20 is a little more than 1 mm. 2 mm would be preferred. Again, I don't know Bicon but want to focus the conversation on the 3 possibilities and which option presents the best outcome given a sub-optimal depth and angle: 1) Remove - is trephine the only solution and is it worth the damage 2) Restore - chance of failure and damage to adjoining structure 3) Bridge - and deal with potential failure of bridge later Thoughts?

I have been placing Bicon dental implants for years. for this case in particular,I would say it's restorable but you and Bicon lab will have a hard time restoring it. the reason behind that is few years ago the company discontinued any abutment with an extended post including the temporary one. the abutments that are available now with just 1 or 2 mm post from the implant platform to the hemispherical base and they recommend it to be large. they claim that the extended post is associated with bone loss which I didn't see in all my cases so far even with the one with 5mm in length. I contact the company several times to discuss this issue and to return back the old way but no body contact me . so what happened now. when I placed the implant 2 or 3 mm below the crest then the final abutment with the large hemispherical base will come 1 or 2 mm from the implant top.that means you have to trim the the bone from the top of the implant up to the crest to accommodate the large hemispherical base. and it means in your case all the bone above the implant has to be removed. I don't understand what is the purpose of doing that if no body complain. you wont be able to get the old abutment with the nice extended post that will help you restore the case I hope they return the old stuff so we can all enjoy the system as before. Now if I place the implant I just do it 1 mm sub crestal and of course no immediate they don't have custom abutment .they customize the abutment so it's trial and error so for me no deep placement until we get the extended post or the transition of the abutment from the implant will be smooth. this is the only concern.it's a great system but the restoration this way has to be user friendly like before. I will post a deeply placed case of mine when they have the extended post and you will see how your case will be restored easily from the first attempt.hope that will help.

I understand Mohamed’s initial resistance to Bicon’s keeping the spherical base at it’s historical distance (on non-extended abutments) on the extended length abutments. Please note that they do offer extended abutments, but extend above the normal hemispherical structure in a matching diameter. This is most likely due to their research demonstrating consistent post-placement bone growth above the abutment/implant interface when the spherical base is retained in that closer position. For those not familiar with the “pre-prepped” Bicon abutments, just picture a crown prep sitting atop a solid shaft which has a spherical base just above the taper which inserts into the implant receptacle. Of course, a screw attachment abutment could be used if desired. If one desires some custom abutment, a solid titanium alloy blank can be purchased and milled to spec.

The author of the post contradicts himself. He sees that the implant is NOT inserted “optimally” but he is asking for advice if it is possible to restore it "optimally". The implant integrated well. Leave it as is and try to restore without charging the patient for surgical and prosthetic procedures.

Curious how you decided to go with Bicon short implant in this case. I am researching Bicon as I have some cases with little available bone and welcome all input. I have no opinion on this case but obviously compared to a routine implant surgery I would question the surgical technique/placement of implant.

"The enemy of good, is better"! Do as Dr. Rainer Urdeneta says. He's done wonderful research, and probably has forgotten more than most of these guys ever knew.

+1 Dr Urdaneta

The good thing about this site is the opportunity to see all cases the bad and good.any one who is posting a case he or she is seeking advice and recommendation from our colleagues so over criticism will be an obstacle to see those cases. what you can do with Bicon dental implant system you cannot do it with the other system. this is a fact. it's not an invitation to place the implant improperly but if this case could be corrected restoratively,why not. Dont remove the implant if it is fully integrated.if you do so you will harm the patient. lessons to learn 1- use a surgical stent or M-D guide or any tool to position the implant right 2-whenever in doubt,remove the implant on the spot before integration,it's not a crime 3- use the measuring tool for the depth positioning of the implant.if your osteotomy is deep use the inserer/retrival tool to position the implant 1 to 2 mm past the crest regardless of the actual depth you have 4- finally, try to stick with 6mm length implant . no need to use even 8mm especially with Bicon

I'm posting a case of mine to show how forgiving the Bicon system is 6 years in function ,delayed immediate (4 weeks after the extraction),5x6 mm.the implant was placed in the distal socket + it's relatively deep.with other system you are going to have a hard time restoring the case and it will carry a mesial cantilever as well the post used is the extended post that I like but it is discontinued now which will make the restoration of the similar case very hard look at the nice tissue response and the amount of bone gain around the post feed back is greatly appreciated

at the time of implant placement

3 weeks after the uncovery

X-ray at 3 weeks after the uncovery

look at how deep is the implant

current x- ray for the abutment/Crown

and finally look at the crown and the tissue response

Thx for posting that case, Mohamed. In addition,before the implant package is even opened, one can place one of the blank expansion plugs and x-ray to confirm position - both depth and angulation. Should the implant seem too deep, some bone graft can be placed in the bottom of the preparation, then checked to be certain the final implant will be in correct position. Also, Bicon is one of the few implants that allows changing the angulation AFTER the insertion by packing bone graft somewhat like uprighting a fence post. Their reamers have end cutting, or side cutting (double blade), or side cutting single blade hand reamers that allow one to restrict the enlargement to only 1/4, 1/3, 1/2, 3/4, or all of the cross sections so one can avoid cutting into vital structures by only placing the blank portion against ares where cutting is not desired.

I should add that the selected cutting side option is in the final hand preparations, not motorized reamers.

well said john .this is exactly what I'm doing .of course at the beginning we went far from Ideal but by time we master the system.I read your comment on the discontinuation of the extended post. I know they did the change based on researches but to me it increase the toughness of the restorative part. in the past I used to do only one time trimming but now I have to trim at the uncovery time and one more time at the delivery time .that is pain to the clinician and the patient .all my cases with extended post has no issues with the surrounding bone whatsoever.imagine a large base emerge right from the implant and flaring up.if you have much room mesio distally what about the buccolingual dimention.I believe when the restoration is easy ,simple and user friendly for the clinician that will bring more clinician to the system. the only thing that I wish to be done like any company when they upgrade the system is to keep the parts and the abutments for the clinician who would love to continue with the old version instead of complete discontinuation exactly like old branemark system. is it better than the most recent well researched dental implant system? No but I would like to use it.this is an example.

Please don't ignore the overhang on the distal of #20....