Failing Bicon Implants. How would you treat?

This 60 y/o female presented to my office with chief complaint of “loose tooth”. Upon closer examination implant and abutment (together) tooth #9 keeps popping out. Implants (Bicon) are 10 years old. Patient medical history is emphysema due to smoking and mitral valve prolapse. Poor bone quality around implant #5 yet no mobility. Tooth #11 has 2+ mobility. Occlusion is collapsed and traumatic. Patient admits to bruxing. Patient unhappy with previous dentist and wants to fix her teeth. Where do I start?


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17 Comments on Failing Bicon Implants. How would you treat?

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Steve
3/5/2015
Thank you for posting this case. It is really interesting to see Bicon implants perform in this way... My comment to this case would be that all the implant-retained restorations lack the hemispherical base of the abutment (which is very important!!). Obviously, the dental technician was unaware of the pros and cons of the system and obviously the restoring dentist did not assess the lab work before fitting it... Despite this, the implants in the lower left six, and upper left four and five look nice... Restorative speaking, I would suggest you start with the reconstruction of the lower teeth, by raising the bite and have as a referral point in the upper jaw the upper left canine (which seems to have maintained most of its tooth structure). After the lower is finished, you might proceed with the restoration of the upper jaw! Really nice case, I would love to see the end result!
CRS
3/6/2015
Although I don't use Bicon implants I don't think that the failure can be blamed on just the implant. This patient is not a great candidate but ten years is pretty good all things considered. I'd remove the hopeless maxillary teeth with site preparation for four locators and an implant retained palate less denture. If the implants can be retrofitted for locators and the ones with half bone loss cut off and buried since removing them with the deep threads will cause a lot of bone destruction. I don't know what is possible with this system, but I like to graft prior to implant placement vs using a small implant. This patient can't be expected to maintain a fixed prosthesis and would probably be happier with the esthetics of a full denture.
andrew
3/10/2015
Hi CRS, I am interested in your comment that 10 years is considered pretty good in terms of lifespan for the implants. In general, what lifespan do you tell your patients who choose to have implants (given all things considered and in an ideal situation)?
CRS
3/11/2015
In medicine, there are no guarentees, for some reason as dentists we feel that we have to guarentee and warrantee everything. In orthopedics the average lifespan of a hip prosthesis is ten years, then the surgeon goes a "revision" and puts in a new one if needed. Lots of factors here. Based on my experience I tell patients, implants can last twenty years based on the research but success rates are quoted after the first year when the implants are fully integrated and restored. Another benchmark is 8 years out when we start seeing peri implantitis, the bacteria are still in the mouth! What I do think is important is setting the implant up for success, good bone support with grafting and soft tissue, good occlusion and oral hygiene maintenance. Here is a personal note root canals usually last 10-15 years, crowns around twenty. A deciduous tooth left in situ as a spacer lasts up to age 25-30. If a patient lives long enough the wisdom teeth will need to be removed due to perio or decay.These are general guidelines based on my experience as an oral surgeon. Telling a patient an implant will last a lifetime is a sales pitch! Of course there are always outliers and the patient's natural tooth if it can be reasonably saved is always best, coming from someone with a livelihood pulling teeth and placing implants. I hope these humble guidelines will help you in your treatment planning discussions with your patients. I think that the high bar set in dental school is very important when pursuing excellence in learning technique, and I personally strive for it on every case. But giving patients more realistic guidelines is more practical . Good luck and thanks for the question!
PeterFairbairn
3/10/2015
Bicon are a great system with innovative and well tested ( invented by Driskell in 78 ) but require special skills in the anterior zone and here placement in this zone is not ideal to fulfil to optimal results . As for the bone loss in the premolar , host factors may be the main cause . As to solution removal is more difficult as need to trephine out ( not screw in type ) . But that is what is needed with re-graft and new placement but a challenging case esthetically Good luck Peter
Dr Joseph Connolly
3/10/2015
I don't believe that Bicon Implants have a higher failure rate than other systems. If I had to pick 2 contraindications to Implant placement , one would be smoking and the other would be uncontrolled Diabetes. If the Patient wasn't willing to stop smoking and to demonstrate improved Periodontal Health, I would be hesitant to initiate another complex Dental Treatment Plan.
David levitt
3/10/2015
First of all, Steve do you work for bicon? Could you please explain in greater detail the hemispherical base concept. I use bicon(and several other systems) and not heard of this. Perhaps I call it something else. I agree this is a good over denture case. The Bicons can be converted with locators. You should remove the hopess bicuspid (#5?) implant and the lateral incisor implant as well. You can preserve the bone. Remove the restoration (simple with a twisting motion of a forcep). Then remove the threads down to the minor diameter, and finally trephine the remainder. You will need to place a 6mm length in #3. You didn't provide X-ray of 14 area but the goal is two anterior and two posterior implants minimum wit locators.
Steve
3/11/2015
Thank you David for your feedback. The answer is no, I do not work for Bicon... It happens that my academic background allowed me to research a bit and play a bit more with various implant systems (since 2002...). One of Bicon's innovations is relied upon the design of their abutments. The hemispherical base (I do not know how else should I call it, sorry!!!!) of the abutment provides excellent support to the underlying soft tissues and bone contributing to a remarkable emerrgence profile. The hemispherical base should not be trimmed by the lab and the margins of the crown have to be far away from the implant well. According to my opinion, this is why Bicon implants do not suffer from bone loss around their threads (bone modification?). The few times that I saw Bicon implants fail, it is always the design of the abutment... And this is consistent with the X-rays of this case! I totally agree with CRS that ten years is a LONG time... Thank you again for your feedback David.
Tom
3/17/2015
The hemispherical base as it is actually called, is the key to solid prosthetic work on Bicon implants. Besides providing an emergence profile and supportive base for the actual crown, it also helps to stimulate the bone during load (Wolff's law) thus, in many cases, resulting in bone gain. It needs to be a hemisphere and it needs to be as close to the bone as possible. The ideal width of the hemispherical base for a molar for instance should be 6,5 mm or more. I agree that in this case host factors are most likely at play but I must say that I see less problems with Bicon implants and peri-implantitis compared to other systems, but of course, that is my personal experience. Bicon truly is a great system to work with, but every party involved and especially the dental lab technician needs to know exactly what they are doing. Just follow the protocol!
Devin Savage
3/11/2015
This is a train wreck type of case. I agree that you should start with getting the lower fixed up. Bicon implants are very resilient. You can remove the abutment and crown, place a plastic plug and bury them for an indefinite period. They recover very nicely. I have also used the shoulder and also even a fin as the crown margin. You can do this because there is no screw to allow the passage of bacteria to travel down the threads. In this way it Bicons seem to be more resistant to failure due to infection. When you remove the hopeless ones, cut them off at bone level and either trephine out or just use a chisel or a gouge. Consider converting the upper to an overdenture. -Devin
Ashwath M Gowda. BDS., DD
9/25/2017
"I have also used the shoulder and also even a fin as the crown margin. You can do this because there is no screw to allow the passage of bacteria to travel down the threads. In this way it Bicons seem to be more resistant to failure due to infection". ************************** This, the above quote, seem to be a bit irrational. Bicon's restorations; Implant "well" and the corresponding "post" of the abutment are being created with a 1. precisely machined 2.5 degree MORSE TAPER, (I am not sure if it is 1.5) 2. which (the tapers) upon "proper assemble/ing" results in a mechanical cold weld at their interface that is impermeable to micro organism. 3. Such a seal maintains and prevents bacterial invasion, migration along and or localization of microbes, because of ABSENCE of any form of mechanical micro-space between the surface interfaces of the fixtures. Now, Using the "shoulder and also the fin" as a "crown margin" ..... impossible & impractical!!!!!! Here is why, A. Once the Bicon implant is integrated, there is no clinically practical and mechanically possible means for recording and duplicating the bevel and or the fin part of the fixture. B. Even, if in case, one other implant fixture be used as an analog over the lab bench for the prosthesis (crown) fabrication, C. The crown/bevel interface in the mouth would be a perfect "iatrogenic" microbial pouch and or a "bacterial reservoir". D. Bicon's bevel is designed for attachment of soft tissue and or migration of crestal bone on to it, when a "mechanical & bio-physiologically favorable" configuration is being created by the clinicians. I realise this post is nearing three years old, but I am tempted to respond as I did. Open for comments, questions and constructive criticism. Ashwath M Gowda. DDS.
Laz S
3/11/2015
I have seen more problems with Bicons (placed) by others than any other implant system. One guy came in once with 4 placed by one of their oral surgeon speakers. 3 of 4 had failed, including 2 with pariapical lesions!!!! This lady has severe bruxism - should definitely be checked for sleep disordered breathing. Must be ruled out and if present treated. Extract and graft entire upper arch - teeth and implants. Graft using Mike Pikos techniques and then place 8 Astra implants. I hate that dentsply bought Astra, they were great. But I have Astra's out there for 15 years in tough situations with 0 (zero) bone loss. Amazing - Ive used every major system and none have had the resilience of Astra. No- I don't speak for them or get paid. Aden have been promising as well.
Steve
3/13/2015
I would like to see some of these failing Bicon cases Laz S!!! I dare make the null hypothesis that all of them would have had issues with the restoration on top of them (lack of ovate base of the abutment, once again...!). Astra along with Ankylos are systems that rely upon the conical connection between the implant and abutment (which was first introduced by Driskell in '78 as correctly posted by PeterFairbairn)! These three systems (Bicon, Astra, Ankylos) can provide a very predictable outcome! I agree with your opinion about the Astra system! I like it very much! But it is so similar with... BICON!!!! Thank you all for your input guys!!!!
Dr. Will J
3/12/2015
I read these comments for my best learning and CRS has offered much wisdom. Steve is right too, the ovate base is better with Bicon for the immersion profile and implant health. I see your case as an excellent over denture for best predictability and esthetics. I agree with all the responses For how to handle the existing Bicons. You have a plethora of over denture attachments choices with the Bicons, too. Be sure to "price-in" the needed fee for your extensive time, skill, Care, & judgement for such a challenging patient. If you do, then your patient will appreciate your good dentistry, and you will enjoy helping!
Steve
3/13/2015
Thank you Dr Will J!!
CRS
3/13/2015
Thanks for the feedback, you are also wise!
John L Manuel, DDS
3/18/2015
The last several years' Bicon reports are considering load from the spherical abutment base, to fibrous tissue, is loading the bone atop the cylinder as a possible mechanism for the increased bone appearing in the area over time. Some of their research is on their site via video. On another thread... Not to become a broken record, I'd advise you carefully interview this patient about Bisphosonates and related drugs over the last 10 years at least. Those broad bands of acellular radiopaque tissue, and the abrupt horizontal break there remind me of some Drug Induced Osteonecrosis of the Jaw. At the least, a biopsy should be taken of that area.

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