Mini Dental Implants

03/05/23 1

Minidental Implants Minidental Implants The MDI Sendax SystemThe MDI Sendax System

Professor Ninian Peckitt Professor Ninian Peckitt FRCS FFD RCS FDS RCS FACCSFRCS FFD RCS FDS RCS FACCS

Oral and Maxillofacial Surgeon / Facial Plastic SurgeonOral and Maxillofacial Surgeon / Facial Plastic Surgeon

03/05/23 2

Clinical AreasClinical Areas

Denture StabilisationDenture Stabilisationand and

ConversionConversion

03/05/23 3

Dental StatusDental Status

13% Edentulous5.2 million 12% 17% 18% 12%

Market Summary

03/05/23 4

Dental StatusDental Status

21 teeth = functional dentition21 teeth = functional dentition

17%17%

6.8 million6.8 million

Market Summary

03/05/23 5

Missing Anterior TeethMissing Anterior Teeth

96% anterior upper96% anterior upper

21 teeth21 teeth

87% lower anterior87% lower anterior

Market Summary

03/05/23 6

DenturesDentures

16% of dentate adults 16% of dentate adults

wear dentureswear dentures

8 million8 million

U.K. Denture MarketU.K. Denture Market(6.8 million Adults 17%)(6.8 million Adults 17%)

20% Market Share20% Market Share@ £1500 /unit @ £1500 /unit

Market Summary

03/05/23 7

Patient AffectPatient Affect

61%61%

27%27%

Market Summary

03/05/23 8

Denture ProblemsDenture Problems

41% denture problems41% denture problems

26% eating difficulties26% eating difficulties

Market Summary

03/05/23 9

Attitude to CostAttitude to Cost

Market Summary

03/05/23 10

Value PerceptionValue Perception

Market Summary

03/05/23 11

Private PracticePrivate PracticeMarket Summary

03/05/23 12

Mini Dental ImplantsMini Dental Implants

Maxilla

Mandible

Crown and Bridge

03/05/23 13

Mini Dental ImplantsMini Dental Implants

 Implant – titanium alloy or other implantable material

Implant Dimensions (<2.5mm diameter)

Fused Abutment (for additional strength)

Atraumatic Placement (minimal surgery)

Crestal anaesthesia (no regional block)

Transmucosal placement (no flaps)

Implant placement with (a single pilot hole of defined size) e.g. <1.5mm

Immediate Loading

Demonstrable cost benefit analysis

Specific

ation

Specific

ation ss

IndicationsIndications

1. Immediate stabilisation of a fixed or removable prosthesis

2. Transitional stabilisation of prosthesis (during conventional implant “no-load” healing period)

3. Immediate support for compromised natural teeth (Periodontal Disease / Endodontic Problems)

4. Interim abutment for failing fixed or removable prosthesis

5. Orthodontic anchorage applications

6. Compatible with all existing implant systems

7. Provisional repair of a broken prosthesis

IndicationsIndications

System ComponentsSystem Components

MDI Max Square Head

TransitionalLaboratoryAnalogue

Housing

Shims

Implant EngineeringImplant Engineering

MDI 1.8mm diameter

MDI Max 2.2 mm diameter

Available in 10, 13, 15, 18mm lengths.

Implant and abutment are a single unit.

O-Ball and Flat Head abutment designs.

High-Strength Titanium Alloy construction.

Implant EngineeringImplant Engineering

Unique self-tapping thread design.

Anti-rotational flat on implant thread surface.

Implants are surface etched.

Implant packaged for efficient delivery.

Metal Housing and O-Ring packaged separately

Titanium AlloyTitanium Alloy

(Titanium, 6 Aluminum, 4 Vanadium)(Titanium, 6 Aluminum, 4 Vanadium)

62.5% Higher tensile strength

than the strongest commercially pure, Grade IV CP titanium.

Tensile StrengthTensile Strength

Titanium AlloyTitanium Alloy vs. vs. Pure TitaniumPure Titanium

75 70 65 60 55 50 45 40 35 30 25

Patient GroupsPatient Groups

Medical: Minimal Surgery in nearly all groups

Financial: Low cost

Anatomical: Atrophic ridges

Bruising with Flap Surgeryconventional implant placement

ContraindicationsContraindications

Medical Psychiatric DiseaseChronic Facial Pain SyndromesHistory of Infected EndocarditisRheumatic Fever – not necessarily

Surgical Severe Jaw AtrophyGrade 4 Bone Density – not necessarilyHeavy OcclusionGross Dental SepsisImmediate Tooth replacement

Anaesthesia – Crestal Infiltration

No surgical flap required

No osteotomy site created

Only one drill required

Self-tapping mini-implants

Immediate loading

Multiple restorative options

Surgical PrinciplesSurgical Principles

Implant PlacementImplant Placement

Create Pilot Hole

Insert Implant (Finger Driver)

Tighten with Thumb Wrench

Seat with Ratchet Wrench

Impression or Reline

Peel off labelslot, size, and catalog number. Add to a patient’s chart for tracking

The Implant PackageThe Implant Package

The MDI Implant suspended from a plastic cap in the glass vial. Once the pouch is opened the vial can be placed in a surgical tray awaiting implant insertion.

The Implant PackageThe Implant Package

The MDI Implant can be carried to the mouth utilizing this cap.

Implant Delivery SystemImplant Delivery System

1.1mm drill1.1mm drill

Pilot Drill Pilot Drill This is the only drill necessary

Hole depth is usually

one third to one half the length

of the chosen implant

Step 1Step 1Pilot DrillPilot Drill

Step 2Step 2Implant Insertion ProcedureImplant Insertion Procedure

Use plastic cap and housing to deliver implant

Implant may also be delivered by the finger driver

Insert implant into pilot opening

Rotate clockwise with downward pressure

Rotate until firm bony resistance is felt.

Implant Removed from VialImplant Removed from Vial

Plastic Cap with Implant Plastic Cap with Implant

Plastic Cap with Implant Plastic Cap with Implant

Finger Driver MethodFinger Driver Method

Finger Driver MethodFinger Driver Method

Finger Driver MethodFinger Driver Method

Implant LocationImplant Location

Step 3Step 3Winged Thumb WrenchWinged Thumb Wrench

Winged Thumb WrenchWinged Thumb Wrench

Winged Thumb WrenchWinged Thumb Wrench

Thread the implant until it becomes difficult to turn.

If no significant resistance is met prognosis is poor the site lacks the required density for predictable success.

Step 4Step 4Ratchet WrenchRatchet Wrench

The Extension may be useful when the clinician is attempting to access an MDI implant between two natural teeth.

Use of Ratchet WrenchUse of Ratchet Wrench

Use in small, carefully controlled increments. If great resistance is encountered pause momentarily between turns. This will allow the bone to adjust to the implant.

The finger on the top of the ratchet wrench ensures control of the ratchet and ensures correct seating of the implant

Use of Ratchet WrenchUse of Ratchet Wrench

Seated ImplantsSeated Implants

Ideal length of final seating should allow abutment head to protrude from tissue. No threads should be visible.

Prosthetic TechniquesProsthetic Techniques

Seated ImplantsSeated Implants

Transferring Abutment PositionTransferring Abutment Position

Indelible Pencil

Wash

Wax (Chrome Cobalt Wax Pattern best)

Soft Liner

Custom Putty Jig (Peckitt)

A soft liner impression within the denture of the MDI O-Ball abutments.

Transferring Abutment PositionTransferring Abutment Position

Four Abutment ImpressionsFour Abutment Impressions

Abutment Location on DentureAbutment Location on Denture

Pencil marks on the denture reveal exact locations for Housings

5mm Openings5mm Openings

5mm Openings5mm Openings

Customised Putty StentCustomised Putty StentPeckittPeckitt

Aids positioningAids positioning• Implants• housings• duration 33%

Block Out ShimsBlock Out Shims

Block Out Shims 9mm in length. Prevent the acrylic locking to abutment

Cut to a length so that only O-Ball is exposed.

Block Out Shim PositioningBlock Out Shim Positioning

Each abutment is lubricated to prevent any acrylic lock on.

Block Out Shim PositioningBlock Out Shim Positioning

O Ring HousingsO Ring Housings

O Ring HousingsO Ring Housings

O Ring Housings are placed over ball abutments

O Ring HousingsO Ring Housings

Chairside relineChairside reline

Clean denture

Mix cold-cure acrylic

Fill abutment holes

Wait - until acrylic does not run

Seat denture

Close lightly in occlusion

Allow acrylic to polymerize

Chairside relineChairside reline

The cleaned and dry denture is filled with cold-cure acrylic and allowed to polymerise until it is not runny. The denture is then seated and the patient is instructed to close lightly in centric occlusion

Finishing ProceduresFinishing Procedures

Remove elastomeric shims

Trim flash

Fill any minor voids or discrepancies

Finish denture borders and polish

Perform final occlusal equilibration.

It is important that the shims are always removed. The denture is relieved of flash and any voids are filled.

A reline procedure and occlusal equilibration completes the process. The patient is then instructed in denture placement, removal, and oral hygiene.

Removing Block Out ShimsRemoving Block Out Shims

Dentures with O-Rings in PlaceDentures with O-Rings in Place

OutcomeOutcome

Recall and MaintenanceRecall and Maintenance

ACCESS™ Toothbrush

Plaque removal procedures

Cleaning denture housings

Modification of retention (New O-Rings)

Review placement and removal

Time for a new denture??

ACCESSACCESS™™ Toothbrush Toothbrush

MDI CassetteMDI Cassette

03/05/23 70

0

100

200

300

400

500

Outcome MDI Implants (Sendax)Mini Dental Implant Center New York

Outcome @ 4 yearsPresented to FDA

1996 - 2000 166 406 11

Patients Implants Failed Implants

2.7%2.7%Crestal Bone Loss < 1% / yrCrestal Bone Loss < 1% / yr

79,000 Implants79,000 Implants1999-20021999-2002

Failure 1%Failure 1%Data sourceData source

IMETC Quality AssuranceIMETC Quality Assurance

03/05/23 71

• History:History: Medical – Dental

• ExaminationExamination

- Sepsis / Perio Status / Occlusion

• InvestigationsInvestigations

- OPT / Lat Chin / P/A’s Bone Density - I.D. Nerve / Sinus Status - Implant Sites / Selection / Templates - Study Models / Crown Bridge - Putty Jig / Suck Down Splint

• Prosthetic EvaluationProsthetic Evaluation

- Existing / Conversion- New Prosthesis

Case PlanningCase Planning

03/05/23 72

Case PlanningCase Planning

InvestigationsInvestigations

OPT / Lat Chin / P/A’s Bone Density

I.D. Nerve / Sinus Status

Implant Sites / Selection

Templates

Computer Planning

03/05/23 73

Case PlanningCase Planning

No No engagementengagement

03/05/23 74

Conventional Dental Implant GuidelinesConventional Dental Implant Guidelines

Fixed Full Arch ProsthesesFixed Full Arch Prostheses

Minimum implants Maxilla

Minimum implants Mandible

03/05/23 75

Conventional Dental Implant GuidelinesConventional Dental Implant Guidelines

Fo/Fo OverdenturesFo/Fo Overdentures

Minimum implants Maxilla

Minimum implants Mandible

03/05/23 76

MDI Sendax GuidelinesMDI Sendax Guidelines

Fo/Fo OverdenturesFo/Fo Overdentures

Minimum implants Maxilla

Minimum implants Palateless Option

Minimum implants MandiblePeckitt 2003Peckitt 2003

03/05/23 77

Dental Implants and Nerve InjuryDental Implants and Nerve Injury

Conventional Dental ImplantsConventional Dental Implants

Nerve Injury thought to mirror that of wisdom tooth removalNerve Injury thought to mirror that of wisdom tooth removal

1.5%1.5%

Flap Surgery Implant Placement

03/05/23 78

Dental Implants: 2 Stage PlacementNeurology Status

Ellis: J. Prosthetic Dent 1992

Persistant Parasthesia 13%

Normal Neurology, 87%

Normal Persistant Parasthesia Total

Nerve InjuryNerve Injury

266 patients266 patients

Stage 160%

17%Stage 2

03/05/23 79

Dental Implants: 2 Stage PlacementNeurology Status: Site of Parasthesia

Ellis: J. Prosthetic Dent 1992

Lip41%

Chin29%

Gingiva21%

Tongue9%

Lip Chin Gingiva Tongue 266 patients266 patients

Normal Routine88%

Disadvantageous 5%

Nerve InjuryNerve Injury

03/05/23 80

Mini-Implants and Nerve InjuryMini-Implants and Nerve Injury

Zone 1Zone 1

Mini Implant Technique - less likely unlikely to injure nerve

- No Flap- Single Stage technique

Zone 2Zone 2

Mini-Implant Flapless Technique – less likely to injure

- lingual nerve- Nerve to mylohyoid

03/05/23 81

Mini-Implants and Nerve InjuryMini-Implants and Nerve Injury

Zone 2Zone 2

Mini-Implant Flapless Technique – inferior alveolar nerve injuryMini-Implant Flapless Technique – inferior alveolar nerve injury

- calibrate magnification of OPT settings

- template selection of implant length

- Simplant 8 Computer Planning

- crestal anaesthesia

- angulation of implant

03/05/23 82

Criteria for SuccessCriteria for Success Albrektsson et alAlbrektsson et al

implant - immobile when tested clinically

radiograph – no evidence of peri-implant radiolucency

vertical bone loss <0.2 mm annually after 1year of service

an absence of :

pain Infection neuropathies / parasthesia / violation of the mandibular canal

successful abutment systemsuccessful abutment systemPeckitt 2003Peckitt 2003

successful superstructuresuccessful superstructure

03/05/23 83

Outcomes Outcomes

Crown & Bridge Outcome 10 years 15 years

Bridge Survival 87% 69%

Meta-Analysis of fixed partial denture (bridges) survival: Prostheses and abutments

Scurria M et al - Journal of Prosthetic Dentistry 1998 79;.4, 459-464

Failure after 15 years – Dental Caries abutments

Crown & Bridge

03/05/23 84

Dental ImplantsDental Implants

Implant Abutment Loosening / Fracture

5 to 45% of cases

highest during the first year of function

Reduced by preloading abutment / prosthetic screws

Still a fairly common problem

Nonlinear contact analysis of preload in dental implant screwsSakaguchi R.L. - Borgersen S.E.June 1995

Int. Journal of Oral and Maxillofacial Implants - Vol. 10 No. 3 pp 295-302

MDI SendaxMTI Monorail

Bicon Q-Implants

03/05/23 85

Informed ConsentInformed Consent

Treatment Contract

Existing Condition

Treatment Options / Choice

Success Rates / Complications

Terms of Postoperative Care

Funding Arrangements

Complication Management

No Absolute Guarantees

03/05/23 86

Informed ConsentInformed ConsentTreatment Contract

ComplicationsComplications

Poor Bone Density Knife Edge Ridge Pain Infection Chrome Cobalt Dentures

Fractured Implant Denture Fenestration New Denture Provision Nerve Injury Implant Loss

A strategy should be agreed with respect to lost implantsA strategy should be agreed with respect to lost implants

03/05/23 87

Case ProtocolCase Protocol

Case Selection and Case Selection and Contract

Local Anaesthesia techniqueLocal Anaesthesia technique

MDI TechniqueMDI Technique

Antibiotic CoverAntibiotic Cover

AnalgesiaAnalgesia

Oral Hygiene Oral Hygiene

Keep Prosthesis in 3 daysKeep Prosthesis in 3 days

Review at 1 weekReview at 1 week

Mandatory AuditMandatory Audit

03/05/23 88

Case StudiesCase Studies

MDI Sendax ImplantsNinian Peckitt

FRCS FFD RCS FDS RCS

03/05/23 89

The Palateless Upper DentureThe Palateless Upper Denture

6 MDI Max Implants

Courtesy: http:// www.imtec.com

03/05/23 90

Fo/Fo Bimaxillary Case – 2 hoursFo/Fo Bimaxillary Case – 2 hours

Courtesy: Dr Anthony Coyne BDS

F/FPalateless

03/05/23 91

Immediate Hybrid OverdenturesImmediate Hybrid OverdenturesCourtesy: Dr Norman Andrews BDS MGDS RCS

Fo/-

03/05/23 92

Immediate StabilityImmediate Stability

Courtesy: Dr Anthony Coyne BDS

Lower Overdenture F/FoLower Overdenture F/Fo

03/05/23 93

Excellent RetentionExcellent Retention

Courtesy: Dr Anthony Coyne BDS

Lower Overdenture F/FoLower Overdenture F/Fo

03/05/23 94

Courtesy: Dr Norman Andrews BDS MGDS RCS

03/05/23 95

03/05/23 96

03/05/23 97

03/05/23 98

03/05/23 99

03/05/23 100

Patient Comment @ 1 monthPatient Comment @ 1 month Patient SatisfactionPatient Satisfaction

• Like he has his own teethLike he has his own teeth

• Retention ExceptionalRetention Exceptional

• Post op Pain – Mild toothachePost op Pain – Mild toothache

• Analgesia – 24 hoursAnalgesia – 24 hours

• Eating improvedEating improved

• Taste food “as it really is”Taste food “as it really is”

• Appearance is very goodAppearance is very good

03/05/23 101

Hybrid SystemsHybrid Systems

Dental ClearanceImmediate bicon 13 11 21 23 Immediate MDI 45 43 42 46

Loss bicon 13 23; MDI 36

03/05/23 102

Hybrid SystemsHybrid Systems

03/05/23 103

Hybrid SystemsHybrid Systems

03/05/23 104

Hybrid SystemsHybrid Systems

03/05/23 105

Hybrid SystemsHybrid Systems

03/05/23 106

Best Practice in ProstheticsBest Practice in Prosthetics

03/05/23 107

Crown and Bridge SalvageCrown and Bridge Salvage

Suck down splint

Courtesy: http:// www.imtec.com

03/05/23 108

Crown and Bridge SalvageCrown and Bridge Salvage Courtesy: Dr Norman Andrews BDS MGDS RCS

03/05/23 109

Crown and Bridge SalvageCrown and Bridge Salvage

Outcome

03/05/23 110

Crown and Bridge SalvageCrown and Bridge Salvage Courtesy: Dr Norman Andrews BDS MGDS RCS

03/05/23 111

Crown and Bridge SalvageCrown and Bridge Salvage

Outcome

Courtesy: Dr Norman Andrews BDS MGDS RCS

03/05/23 112

Crown and Bridge SalvageCrown and Bridge Salvage

03/05/23 113

Crown and BridgeCrown and BridgeCourtesy: http:// www.imtec.com

03/05/23 114

Telescopic CrownsTelescopic CrownsCourtesy: Dr Anthony Coyne BDS

03/05/23 115

Telescopic CrownsTelescopic CrownsCourtesy: Dr Anthony Coyne BDS

03/05/23 116

Courtesy: Dr Norman Andrews BDS MGDS RCS

Telescopic CrownsTelescopic Crowns

03/05/23 117

Maxillary AtrophyMaxillary Atrophy

Computer PlanningComputer Planning

Defensive Incisions

Sinus Lift

Nasal Floor Lift

Anterior Alveolar Augmentation

Transitional Stabilisation

Delayed Mini-Implant Placement

03/05/23 118

Maxillary AtrophyMaxillary Atrophy

Courtesy: Dr Javid Khan BDS

03/05/23 119

Maxillary AtrophyMaxillary Atrophy

3 weeks3 weeks

03/05/23 120

Maxillary AtrophyMaxillary Atrophy

Transitional Stabilisation @ 3 weeksTransitional Stabilisation @ 3 weeks

03/05/23 121

Maxillofacial ApplicationsMaxillofacial Applications

Gunshot Wound

Engineering Assisted SurgeryEngineering Assisted Surgery™™

03/05/23 122

Customised Cutting JigCustomised Cutting JigEngineering Assisted SurgeryEngineering Assisted Surgery™™

03/05/23 123

Mandibular OsteotomyMandibular OsteotomyEngineering Assisted SurgeryEngineering Assisted Surgery™™

03/05/23 124

OutcomeOutcomeEngineering Assisted SurgeryEngineering Assisted Surgery™™

03/05/23 125

Lower OverdentureLower OverdentureCourtesy: Dr Norman Andrews BDS MGDS RCS

Engineering Assisted SurgeryEngineering Assisted Surgery™™

03/05/23 126

Lower OverdentureLower Overdenture

Registration

Engineering Assisted SurgeryEngineering Assisted Surgery™™

03/05/23 127

F.I.R.S.T.F.I.R.S.T.™ System™ System

Fabricated Implant Restorations and Surgical TechniqueFabricated Implant Restorations and Surgical Technique

Immediate tooth replacement

MDI Implant and fabricated Restoration

Model Surgery from Dental Cast

Surgical Template

100 F.I.R.S.T. restorations to date

No failures – Todd Shatkin (personal communication)

1048 MDI Implants1048 MDI Implants3.5 year outcomes3.5 year outcomes

(1 third cases Crown & Bridge)97.65% Success Single tooth

98% Multiple teeth

ReferencesReferences

03/05/23 128

Mini Dental Implants: Principles and Practice, by Victor Sendax

Chapter 7: An Oral and Maxillofacial Surgeon’s Role in Advanced MDI Therapeutics: Engineering Assisted Surgery™, MDIs in Functional Reconstructive Surgery within Great Britain and New Zealand Venues.

Publisher: Mosby © 2013. ISBN-10: 1455743860 ISBN-13: 978-1455743865

03/05/23 129

Thank you for your attentionThank you for your attention