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IMPLANT FOCUS

SIMON ALLUM

VISITS

GEOFF PULLENS
PRACTICE IN

KNIGHTSBRIDGE
DISCUSS THE

TO

BICON

IMPLANT

Simon Allum BDS graduated from Guy's Hospital in 1982. He is an experienced lecturer in the use and application of implants in private dental practice. He runs an implantology referral clinic in Darlington, County Durham

Geoff Pullen qualified from Kings in 1981. He tells me that he took up dentistry as a last minute decision with no previous history in the family. After 18 months in practice Geoff set off to the University of Southern California on the urging of Ian Gainsford, the Dean of Kings at that time and self-funded his DDS. He says, My trusting parents remortgaged their house so I could go. On returning to the UK, he took up an associate position in the West End of London, working with Harold Prieskel in private practice. He recalls that in 1985 Harold Prieskel and a small group of others were the first group from the UK to travel to the Brnemark clinic in Gothenburg. I vividly remember having a debrief with Harold over a cup of coffee. He told me hed seen something that would change the course of dentistry forever. Later that same year, Geoff left Harold with the conviction that he could succeed in private practice in his own right. I set up shop in rented rooms in Knightsbridge - 12 patients followed me! I slowly established myself - made a load of mistakes - but it has worked out well for me in the end! Later in 1985 Geoff himself visited the Brnemark clinic and he has been working with implants ever since. Im more a crown and bridge guy than a surgeon, so when I started I had a colleague from Ireland place

the implants for me. It was exciting stuff and in those days we felt a deal of pioneering spirit. Cases were often complex to restore and not always profitable, but this seemed the price to pay for the experience gained. In the late eighties, the prosthetic components were poor. The standard components from Nobel were OK for research patients, but they didnt cut much ice with the demands

of private practice. The aesthetics were just too clumsy. So, after just one case using the standard stuff, I started using 3i for my rehab work. We managed to achieve some pretty nice results. Things went along like this for 10 years - wed try to get more and more sophisticated with the treatment plans, using the implant option more and more. There were highs and lows, good successes interspersed with the occasional spectacular failure and sometimes implant loss - well you expect that from time to

Figure 1: 11 Devonshire Place (WC1), undergoing refurbishment inside and out on the day I visited

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Figure 2: Geoff Pullen

Figure 3: Geoff Pullen and assistant, Gemma, at work

time, and you can cope with it when implants fail before the restoration is complete. But if you have to change tack when the technical work has started, you often have an upset patient and an overhead you hadnt budgeted for. But the worse things were the disappointments with the aesthetics and the heartbreak of failed component parts. Remaking cases, removing broken components, screws, and even implants. The solutions to
Figure 4: The finned BICON implant. Cut away illustrates the 1.5 locking taper abutment connection

these problems were coming thick and fast from the manufacturers, but they usually were a redesign or yet more technology. The 2,000 torque driver that hit the market to combat abutment screw problems on external hex fixtures was a classic case.

GEOFFS BICON

INTRODUCTION TO

Id had a bad month. One of my collaborating surgeons had sent me a patient with an upper central incisor implant ready to restore. But there was a problem - the healing abutment hed placed was the wrong size. Weeks of careful treatment to the soft tissue bed were wasted, and the aesthetics were ruined. Then, shortly after that headache, I had another problem with a big bridge - at first I couldnt keep the abutment screws tight - and then the patient came in with two broken implants. This cutting edge stuff was beginning to impact on the well-being of my patients, the meagre profits of my fledgling practice and my own mental health. Something had to change - and radically. As luck would have it I was having lunch with my Irish surgeon colleague, whod originally placed my early Brnemark implants. Like all surgeons who limit their practice, Nick had been hearing similar stories to mine from his referring dentists. Implants were the way to go, but the restorative

side was fraught with difficulty. So hed looked around for a more forgiving implant and had come up with the BICON implant. The BICON implant is a twopiece implant, designed by an engineer, consisting of the finned implant fixture and a solid titanium abutment that can be prepared if required, just like one would a natural tooth (Figure 4). The implant itself has a circular well, which is tapered and corresponds exactly to the taper on the abutment post. When the two pieces are tapped together, considerable force is required to separate them: this design feature is called a taperlock and is an established connection concept used in engineering. BICON has no screws, no hexes and, no complex kit for implanting or restoring. Starting with BICON was very inexpensive. On first view I was taken by an X-ray of multiple posterior units un-splinted. Now these implants had been around with this design since 1985 and had been designed to stand alone as single units - something that screw retained implants struggled to do until much later. Not only that, the design hadnt changed: they rotate 360 offering enormous prosthetic flexibility and optimum aesthetics. And that was essentially it. My mind was made up to try these Bicon implants and theyve been so successful Ive not placed
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IMPLANT FOCUS

Figure 5: Geoff had placed implants at 6 5 4 3 bridge were fitted on the day of surgery

four months

Figure 6: Forceps used to rotate and remove temporary abutments from the fixtures

previously. Temporary abutments and immediate temporary acrylic

another type of implant for the past six years. Very early on I shared my thoughts with Clive Debenham the only other of my colleagues to admit to me he was having misgivings about the screwretained implant restorations that he was working with. So Clive and I decided to go to Boston (the headquarters of the Boston Implant Corporation - BICON) to watch Norm Shepherd, the then chief surgeon at Bicon, place over 20 implants a day, to meet Vin Morgan, a general dentist and President of Bicon, and to become more and more enthused every day that passed. The influence of Vin Morgan, as a general dentist, in recognising the need for a GDP friendly system, and steering all product development with that in mind, has been invaluable to BICONs worldwide success. Now Clive and I both spend our days treating many more implant patients than most of our

colleagues in UK, having fun in our practices and showing colleagues the techniques that we use to provide reliable and predictable implant treatments. Geoff is a very easy-going and relaxed person to talk with, and this comes across in the overall ambiance of his practice. For my own part, I had been looking forward to this visit because having looked through the product information and seen one of the companys training videos I realised that there were some quite unusual and very interesting and intriguing features about the BICON system that seemed to make good sense - if they worked predictably and offered longterm stability. I was aware that BICON have been advertising the system quite extensively over the past few years, but hadnt particularly taken notice of them in the past, not regarding them as a mainstream system. They are not a particularly high profile

company in the realms of published data, and when I spoke with Geoff about this he acknowledged this point, but assures me that papers are coming through, whereas much of the data on the performance of the system in the past has been largely anecdotal seemingly largely due to the history of the development of the company - a topic which I do not have the space to go into in any detail here. Having had the experience of looking at all manner of implant systems in some detail, I initially found the BICON design concept intriguing and could see the sense in it. Perhaps one criticism in the design was that I felt a little disappointed that the system still uses coated surfaces (implants being available in machined, HA coated and TPS) where many other companies appeared to be moving onto treated surfaces and also appear to be backing these surfaces with a growing evidence base (e.g. Osseotite/TiOblast/SLA

etc). However, I liked the concept of the abutment design which is a little reminiscent of the Ankylos abutment - except that all BICON abutments are manufactured in solid titanium with no screw components. My personal experience is that where solid titanium abutments are in use elsewhere (e.g. the new Astra direct abutment system, and the ITI solid abutment system) they generally offer simplicity, strength and reliability, as well as a very compact abutment (due to the lack of an abutment screw hole through the axis) allowing for an optimum thickness of porcelain for aesthetic considerations on the final restoration. The Taperlock connection is said to give a bacterial seal between components and the design also offers the possibility of cementing crowns to the abutment extraorally before the abutment is fitted - to ensure that there are no issues with subgingival excess cement. I felt that only potential sticking point

Figure 7: Solid titanium abutments were customised in the laboratory and replica dies fabricated. Duralay pick-up copings were constructed and are shown seated on their respective abutments Figure 8: The working model partially disassembled illustrating components

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Figure 10: The completed pick-up impression Figure 9: Each abutment has been aligned in the mouth using the laboratory-made temporary acrylic bridge as a jig. The abutments were tapped into position and the Duralay copings have been fitted ready for the pick-up impression

with this design is that you must have complete confidence in the strength, reliability and durability of the Taper-lock abutment connection. So I asked Geoff whether it ever lets him down and whether he feels that there is a risk of component wear over time. Well, firstly, let me say that one beauty of the system is that the abutment is either on or off its never loose - so there is no significant wear occurring between loose components working against each other. With external hex fixtures if a screw becomes loose the patient may eventually come and see you with a soft tissue problem and tell you that they have become aware of an increasing problem over a matter of some weeks. By the time you eventually see that patient there

could be a combination of hard and soft tissue loss and the hex on the top of the implant could be well-worn. We have never had a case where a posterior abutment has come out. Very occasionally we get an anterior abutment come out. Where this does happen it is because we have missed something - perhaps the occlusion isnt quite right or the patient is a bruxist. Failing abutments are not something that give me a headache in my practice. In the very rare instance where an abutment connection fails, the patient invariably gets in touch straight away and there is nothing to deteriorate in the mouth. Perhaps they may initially be a little irate with my receptionist, but by the time they get to see me they are more concerned about whether

this is a problem that I can sort out. Once I have identified the problem, and explained the way forward for them, they are fine. I would rather have that situation than someone come in with a loose screw under a restoration that I would have to strip down. I watched Geoff carry out work on a couple of patients. The first was a restorative case where Geoff planned to change abutments from the temporary immediately loaded abutments to the definitive abutments (Figures 5 to 12). The original abutments had been fitted down finger-tight and Geoff expected them to be relatively easy to remove. However, since fitting them they had been subject to some occlusal loading under the immediate temporary bridge and they took a fair amount of effort with good-sized forceps to rotate them and break the seal on the locking taper - illustrating just how well these components go together (Figure 6). The second case was

scheduled for surgery. Geoff placed two fixtures in the lower left quadrant. The fixtures come in 8mm, 11mm, and 14mm lengths, but Geoff only uses the 8mm and 11mm fixtures (Figure 13), preferring to compensate for length by using increased width where possible (the need to use the longest possible fixture is a myth). Implant diameters of 3.5mm, 4mm, 4.5mm, 5mm and 6mm are available. Geoff mainly chooses the TPS fixtures, with the occasional HA fixture in poor quality bone. There are a few novel concepts involved in the surgical phase. For aesthetic restorations, Geoff prepares the osteotomy to 3mm depth beyond the length of the fixture. The implant is pushseated into the full depth of the prepared site, a small plug is fitted into the abutment well of the implant, and then the 3mm of osteotomy above the implant is filled with autogenous bone slurry. Geoff tells me that the

Figure 11: The definitive bridge was fitted subsequent to my visit

Figure 12: Radiograph of fixtures at 6 5

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crestal levels on radiograph may settle at or above the abutment connection, but because of the reduced diameter of the abutment stem (as compared to the implant itself) bone above the periphery of the implant will maintain height along with the soft tissues as long as there is a good volume of bone around the fixture itself. One very novel idea to me was that the Bicon protocol is to prepare the final osteotomy using an engine driven reamer at only 50rpm without irrigation. This I had to see and when I did I saw that the osteotomy was prepared slowly and atraumatically. One benefit of this was that each time the reamer was removed from the site, its flutes were filled with a great-looking bloody cancellous bone slurry that Geoff could easily collect to infill the site after implant placement or use for the augmentation of other sites (Figure 14). This bone slurry looked better than the anaemic-looking mush that I usually collect from my own bone traps once it has been well-washed through with saline from the physiodispenser pump. About once a month, GDPs

To contact Geoff Pullen Telephone 0207 7061264, 0r email him at pullenteeth@btinternet.com

Figure 13: Geoff only uses the shorter 8 and 11mm fixtures, although 14mm fixtures are also available

attend Geoff s practice to see him work and get an initial idea about implantology using the Bicon system. Geoff also offers teaching on other days with more of a one-to-one emphasis and he also mentors and offers support and advice over the phone to other BICON users. There are currently around 80 Bicon users in the UK - and the number is growing all the time. On the day I visited Geoff s practice, it was in somewhat of a state of disarray - being decorated and renovated by the landlords, both inside and out. However, although the building is now renovated throughout, Geoff has very recently relocated the practice, incorporating it into part of his home in nearby Bayswater. I asked him how he felt about the prospect of working and living on the same premises. I feel

fine - dentistry is all around me its what I do, and I feel very comfortable with that. I have worked in Devonshire Place for ten years now and Im really looking forward to a change and the challenge of setting out a new working environment. PD

For an information pack on the Bicon system contact Sue Hood, UK administrator, Bicon Marketing Ltd, Tel: 01473 829299. You can email Bicon at noscrews@bicon.co.uk or visit www.bicon.co.uk

Figure 14: Bone slurry is efficiently collected in the flutes of the final final osteotomy reamer at 50rpm without irrigation

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