Mini Dental Implants A Presentation by Tariq...

Mini Dental Implants A Presentation

byTariq Idris

Topics• History of Dental Implants• Role of Mini Implants• Cases• Complications

Topics• Future trends• Medico-legal issues• Practicals: Surgical and Prosthetic

Aims/ Objectives• To appreciate the choices available

to the patient• To understand the scope of mini implants• To understand their limitations and Pitfalls

To gain an insight into the techniques employed

Aims/ Objectives

Current Options for the Edentulous

Complete Dentures

Overdentures Retained by Implants

Bridgework Supported by Implants

Option 1:A Denture.• Low cost/Simplicity but difficulties

when faced with:

• Little/ no ridge

• No retention/ resistance

Option 1:A Denture.• Sore spots/ constant Easing

• Aesthetic Compromise

Consequently:• Looseness

• Pain/ ulceration

• Lack of Confidence

• Difficulty with eating

• “ It makes me gag”• “ It hurts when I chew”• “ I can’t taste my food”• “ I hate it !” • “ I take it out to eat”

Anti-Ageing

Mini Dental Implants(MDI’s)• Over 20 year history• No long term studies• Some early studies:

Mini Dental Implants(MDI’s)

Currently 4 years of Datashowing only 2.1% loss.

Mini Dental Implants(MDI’s)Historically used as temporary or

transitional implants to secure

Temporaries whilst conventional implants were undergoing healing phase

Mini Dental Implants(MDI’s)Now some FDA approved

for long term use for fixed and removable protheses.

MDI Features• Implants are Surfaced Etched• Self-tapping Thread Design• High-Strength Titanium Alloy Material• Integrated Abutment

MDI Features(at the moment!)

• 1.8 – 2.2 mm diameter• Available in 10 to18 mm lengths• Implant and abutment are a single unit• O-Ball and Square Head abutment

designs

Current Designs

Titanium Alloy(Titanium, 6Aluminum, 4Vanadium)

62.5% Higher tensile strength thanthe strongest commercially pure,

Grade IV CP Titanium

TitaniumAlloy

CP Titanium

Advantages of Mini Implants• Minimally invasive surgery• Cost effective• Immediate loading• Suitable for Resorbed Ridges

Advantages of Mini Implants• Minimal post-op Discomfort• Can be used on almost all ridges•Can be performed by the patients

general dentist

Is this the End of Conventional Implants?

NO!!!!MDI’s are an alternative to dentures,

bridges and conventional implants

in certain situations

NO!!!!They are often a third way

in between dentures

and more complex implant treatments

NO!!!!The Patient will end up with a different

product

compared with conventional implants

The most important thing is to give the patient the Choice

Many patients who would not consider

conventional implant treatment due to:• Fear of complex surgery• Timescale of treatment: up to 2 years• Cost

• Limited bone availability: do not want grafting

• may proceed with mini dental implants

Mini Dental Implants• They are ‘consumer friendly’• They widen the market of prospective

patients• They require less investment of time

and money from the Dentist due to their relative simplicity

Patient Selection Criteria• Who is a candidate for

MDI?• Difficulty wearing

lower denture!!! etc.

Patient Selection Criteria• Cannot tolerate a palate on upper• Anatomically

compromised• Patient wants to feel

more confident, etc.

Are MDI’s Good for everyone?• Medically Compromised ? • A wider range of Patients can be treated • No incision in most cases

Are MDI’s Good for everyone?• Low morbidity• Low infection• Non-invasive

Are MDI’s Good for everyone?• What about patients taking steroids?• Contraindicated for most implants,

but can be done with MDI

Are MDI’s Good for everyone?• What about patients taking blood

thinners?• Less of a problem unless a flap is needed• Consult with Patient’s Physician

Are MDI’s Good for Everyone?

• Anatomically Compromised ?

• Many patients do not have adequate bone

support to accept the large size of conventional implants.

• Anatomically Compromised ?

• MDI’s can be used in almost any ridge and on patients with severe alveolar ridge resorption.

Are MDI’s Good for Everyone?• Fewer visits to the dental surgery• Can be performed by the General Dentist

Financially Compromised ?• Fewer visits to the dental surgery• Can be performed by the General Dentist

Mini Dental Implants

Their biggest application is in the stabilisation of Complete lower dentures.

Mini Dental Implant Diagnosis and Treatment Planning

Treatment Plan• Occlusal Dynamics• Oral Hygiene• General health/ medical history• Psychological/ social status• Aesthetics: smile line• Anatomy

Anatomy

Anatomical Considerations• Mandibular Nerve• Mental Nerve• Sub- mental artery

Anatomical Considerations• Maxillary Sinus• Nasal Sinus• Other teeth/ roots

Bone Quality and Quantity • Rate Density - 1,2,3,4• 1 - Very dense bone: difficult surgically• 2 - Moderately dense bone

Classic Mandibular Bone

Bone Quality and Quantity • 3 - Low density bone

Maxillary bone or soft mandibular spongy bone: modify protocol

• 4 - Very low density bonePoor candidate for MDI

Assess the Bone• Height • Width• Shape• Angulation

Assess The Bone• Using Ridge Mapping, Radiographs,

CT scans,• Sectional Radiographs, Scanora,etc

1 - Radiographic Planning

Panoramic X-RayAssists in planning Implant placement

1 - Radiographic PlanningPencil radiograph in region of canine

and 1st premolaranterior to mental nerve canal

1 - Radiographic PlanningPencil radiographand in region of

lateral incisor Region

Implant Placement Procedure

2 - Mark Denture and Transfer

• Using the pencil marks made on the radiograph as a guide, mark DRY denture heavily with skin marker.

Next DRY Patient’s arch and place denture

in mouth.

You may darken transfer spots with marker for

APPROXIMATE placement of implants.

3- Assess Vertical Bone Height :• MDIs are 10mm. - 18mm. Long• Less than 10 mm = Poor Candidate for

MDI• Use longest implant possible

Mandibular – 2/3 total height• Maxillary - 90%

4 - Create Pilot HoleFirst Palpate to assess

the Angulation of the Ridge.

4 - Create Pilot HoleAfter measuring depth, drill pilot

hole with a tapping motion using saline

irrigation.

4 - Create Pilot HoleDrill depth according

to bone density evaluation.

5 - Implant Insertion

Do not contaminate the implant surface

Insert implant into pilot opening

through gingiva to bone: take care not

to trap tissue

Rotate clockwise with downward

pressure

6 - Finger Driver

Continue insertion of implant with finger

driver until firm bony resistance is again

met. met.

6 - Finger Driver

Then follow with winged thumb

wrench SLOWLY, again until firm bony

resistance is met.

7 - Ratchet Wrench

If bone is extremely dense use of ratchet wrench is needed.

7 - Ratchet Wrench

SLOW incremental turns will allow full

insertion without snapping of the

implant.

7 - Ratchet Wrench

Pressure should be applied downward on the ‘head’ of the

ratchet during insertion.

7 - Ratchet Wrench

If VERY HEAVY resistance is noticed,

back implant out

7 - Ratchet Wrench

and make pilot hole deeper. DO NOT

force ratchet or implant may snap at

8 - Complete Insertion

Complete the insertion of all implants.

Insert implants completely so that no

threads are supragingival.

Check primary fixation with torque wrench

Postoperative X-ray

Denture Placement and Prosthetic Technique

Phase 3

Positioning should be close to original plan, make holes in denture

with lab bur on premarked locations.

Place housing abutments on implant

o-balls.

Try-in denture for full seating.

Use fit checker

Denture Placement and Prosthetic Technique, (cont.)

Fill holes in denture with implant housing

attachment resin.

Protect exposed implant head to prevent

engaging undercut.

Place denture on o-ring housings and have patient bite gently using previous

registration to seat denture and hold for

setting of resin/acrylic.

Remove denture and assess security of housing in denture.

Add flowable resin (light cured), cold cured acrylic or cyanoacrylate if loose..

Trim excess material and smooth tissue surface of denture to avoid sore spots.

Also shorten boarders of denture.

Post Operative Instructions• Prescribe analgesics• Ice Applications• Warm saltwater• Wear Denture for 24 hours• See patient next day

24 Hours Later• Adjust denture• Most likely there will be adjustments• Some will have denture sores

developing• Adjust spots and check occlusion

24 Hours Later

• Instruct to wear denture as much as possible over next week and to call if there is a problem.

• See patient in three days and one week post-op.

Case Presentations

Case 1

Case 2

Lateral Case

Immediate Loading• Introduced by Linkow in the 60’s• Well established in the mandible• Not yet in the maxilla• Primary stability greater than 30 Ncm• Micro movement 50-150 microns

MDI’s aren’t Voodoo• Its what yoodoo that counts.• How many implants do you need to

restore a full jaw?• The principles of Osseointegration still

apply:

MDI’s aren’t Voodoo• Primary fixation• Oral health• No/ limited micro movement• Biomechanics

Other Applications?• Transitional – during the healing phase

of conventional implants• Salvage cases• Retention of Partial Dentures• Fixed Crown and Bridge? BEWARE!• Single tooth - Lateral incisors with mild

occlusal forces. Lower incisors.

Other Applications?• Distal abutment - Free end saddle

replacement of removable partial dentures???

• One implant per root if possible• 2 for each molar (minimum)• 1 for each anterior tooth

Partial Cases

Complications• Fracture: instruments/ implants• Lateral forces• Pain/swelling• Fracture of prosthesis• Housing loosening• Wear: O ring; implant head

Broken Drill

Consent• Principles• A process- not a

form• Clear and honest• Documented• Avoid jargon

Consent Issues

No/ limited data/ studies: HistoryNew to UK: New to you.

Risks• Surgical and Prosthetic: • Non-integration, • Fracture, • Infection,

• Damage to nerves (paraesthesia) and adjacent teeth

• Sinus perforation • Case abandonment • Bone loss

• Fracture of Prosthesis, • Oral Hygiene issues • Need for maintenance / check up’s.• No Assurances of Success/ Longevity

Consent: Operator Issues• Suitable training• Suitable experience• Competence

91.8% 92.9% 100.0%98.8%

0%10%20%30%40%50%60%70%80%90%

Implant Efficacy

1-85 86-170 171-255 256-340

Chronology of Implant Placement

Implant Efficacy as a Function of Chronology of Implant Placement

LossSuccess

Implant Placement

Order1-85 86-170 171-254 255-340 Totals

Successes 78 79 85 84 326

Losses 7 6 0 1 14*

Percent Success

91.8% 92.9% 100.0% 98.8% 95.9%

Future Trends• More research, more research, more

research

• Greater range of sizes

Future Trends• Development of design for individual

crowns

• Orthodontic Applications

24 Hours Later• Adjust denture• Most likely there will be adjustments• Some will have denture sores developing• Adjust spots and check occlusion

24 Hours Later• Instruct the Patient to wear denture

as much as possible over next weekand to call if there is a problem.

• See patient in three days and one week post-op.

SummaryPatient arrives with a loose lower denturePatient leaves 2 hours later with a stable

prosthesis

SummaryNo flap

No suturesImmediately loaded

Other Applications?• Transitional – during the healing phase

of conventional implants• Salvage cases• Retention of Partial Dentures

Concerns with the following issues:• Insufficient fixation in Type 2, 3 and 4

bone• The marginal overhang?• Potential overloading• Long term durability• Retention

Address concerns/ difficulties• Fracture• Durability• Surface Area• Emergence Profile/ Overhang• Poor Quality Bone

Range of Larger SizesAll self tapping.

• 2.3mm• 2.8mm• 3.3mm• 3.8mm• 4.3mm

Improved Abutment for Crowns

With a Hygienic Crown Margin

The New Mini/ Midi Implant• Increased Surface Area: comparable

with conventional implants• Improved Strength• Improved Retention• Improved Fixation

Assess the Bone• Height • Width• Shape• Angulation

Assess The Bone• Using ridge mapping, radiographs,

CT scans,• Sectional radiographs, Scanora,etc

Auto Advancing Technique• Similar Effect to Using Osteotomes• Implant is creating a channel by pushing

spongious bone to the side• Implant is intimately in contact with the

Ridge Expansion/ Compression• Established over 30 years ago• Scientifically valid• Involves opening the ridge and

displacing it

• Creates a Series of microfractures• Heal readily especially if stable

and with periosteum intact

Expansion and CompressionPhenomenomTM

Simultaneous Expansion and CompressionProducing Improved Primary Stability

Particularly Suitable for Type 2 and 3 Bone i.e. Maxilla

Expansion and Compression• Smooth and Progressive• Improves surrounding bone quality• Creates a wall of dense bone around

the implant• Improves the fixation ( torque check)

Aseptic Technique

Missing laterals

A Denture had Been In place for over 20 years.

Ridge Mapping revealed 2mm Width

The Finished Restorations

Measured Ridge Expansion

Pre-op 2mm Post op 4mm

Deciduous Teeth

Implants Placed

Crowns in Place

Natural Contours

Lower Incisor

Implant Insertion

Implant in Site

Fixation Checked 30Ncm

The Post is Prepared

Crown Fitted

Scientific Principles• Biocompatibility• Implant Surface• Implant Site• Surgical Technique

Scientific Principles• Undisturbed healing phase• Biomechanics• Prosthetic Success

Principles ExaminedBiocompatibility:

Titanium Alloy well established as a biocompatible implant material

Principles ExaminedImplant Surface:

Implant is a threaded screw etched and blasted

Principles ExaminedImplant Site:

Placement site is always improved by ‘Osteo- Expression’

Simultaneous Expansion and CompressionProducing Improved Primary Stability

Particularly Suitable for Type 2 and 3 Bone i.e. Maxilla

Advantages of the Self Tapping Tapered Design

• Avoids drilling the bone/ minimal risk of overheating

• Progressive expansion and condensation more controlled than using osteotomes

• Less need to sedate the patient

4. The Surgical TechniqueFlapless Surgery

• In use for over 30 years by many surgeons: Tatum, Hahn, Roberts, etc

• Maintains the periosteum which provides the blood supply

• Chanavaz J Oral Implantol 1995;21:214-219

4. The Surgical TechniqueFlapless Surgery

• Maintains keratinised tissue which act as a physical barrier to plaque invasion

• Lower incidence of surgical complications

5. Undisturbed Healing/Immediate Loading

• Dependent on good fixation > 25Ncm• Micromovement less than 100 microns• Controlled Load

Related research•Immediate Load Of Single Tooth Implants

in the Anterior Maxilla: 100% success attributed to good fixation 32Ncm.

•Maintenance of Crestal Bone and excellent soft tissue contours attributed to lack of

second stage surgery. Lorenzoni

Related Research:‘ A delayed healing process can cause

psychological, social, and speech and/ or function problems’

Eliminate discomfort and inconvenience of 2nd surgery: sutures, infection, etc

Related Research:‘One method for decreasing the risk of

surgical trauma is to have more vital bone in contact with the implant’

Proposed Protocol 45 to 60 Ncm for placement

Misch et al

Related ResearchTestori: BIC at 4 months 64% for

immediately loaded compared with 39%Piatelli: Early loaded implants showed

better quality of bone although similar BIC for the 2 groups

Related ResearchG. E Romanos Journal of Oral implantology

vol30.no 3.2004.‘Present status of Immediate Loading of

Oral Implants’

Related ResearchSeveral ConditionsPrimary Stability

Sufficient Bone QualityElimination of Micromovement

Related Research

‘Implant design makes a significant contribution to the initial stability’

‘A screw threaded design with a rough surface is recommended’

Related Research3.5mm by 14mm implant equivalent

surface to multirooted teethRecommended techniques to improve

bone density

6. Biomechanics• Avoid Bruxists• Avoid Molars• Splinting to other implants• Occlusal Protection• Controlled Diet/ Bone Training

Prosthetic Factors• Ultimate simplicity: no extra components• Conventional impression techniques• Conventional Crown fabrication• No internal joints/ screws• Conventional cementation

Stable Gap Free Interface1Year Post Op

Simple Reconstruction

Factors Contributing to Success• Minimal Surgical Trauma• Improved Bone to Implant Contact• Improved Fixation• Improved Peri implant Bone quality• Controlled Occlusal Load

Personal Experience: Fixed Restorations• 18 months• Over 180 Placed following Protocols• Only 3 Lost: 2 Overloaded, 1 post

extraction• Expansion Measured Routinely• High degree of Satisfaction

Using MDI in your practice• Patient Satisfaction• Your Satisfaction• Staff Involvement• Financially Accepted• Financially Rewarding• Minimal Outlay

How can MDIs affect my Practice?• Emotional Satisfaction• Patient Relationships and Referrals• Financial Freedom• Personal and Family time

Pitfalls and Limitations• Do not over-promise• Do not overload• Not an excuse for an ill fitting denture• Beware with fixed crowns:forces,

cosmetics• New Generation Mini Implants

The EndThe End

Mini Dental Implants A Presentation by Tariq...

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