Palatal Mini-Implants to Increase Retentionand Stability of Implant-Retained Maxillary

Overdentures: A Case ReportCamilo Machado, DDS, MS,* Guillermo Chacon, DDS, MS,† and Eliana Sanchez, DDS, MS‡

Maxillary edentulous patientshave been successfully treatedwith osseointegrated implants

using various approaches includingimplant-supported fixed dental prostheses,implant-retained maxillary completeremovable dental prostheses,1 andfixed partial dental prostheses. Thefixed implant-supported dental pros-thesis has been used for �20 years. Ithas lost popularity because the design ofthis restoration needs to provide oral hy-giene access around the abutment cylin-ders which creates an esthetic problemin the maxilla for patients with severeresidual ridge resorption and a highsmile line.2 The implant-retained maxil-lary complete removable dental prosthe-sis is a treatment option that gives thepatient retention that is not achievedwith conventional complete removabledental prostheses, and often providesimproved functional and estheticresults.2,3

Osseointegrated implants havebeen successfully used for orthodonticanchorage for �20 years.4–7 The useof the mid-sagital palatal suture to os-seointegrate anchorage devices fororthodontic purposes was first re-ported by Block and Hoffman8 in1995, since then it has shown satisfac-tory results with no implant mobilityor dislocation after loading the im-

plants with orthodontic forces.6,7,9,10

Histomorphometric evaluation has in-dicated that all the implants servingfor orthodontic anchorage have beenwell osseointegrated despite the pro-longed application of orthodonticloading.9

Clinical research shows that thethickest vertical bone volume (6–9mm average) of the mid-sagital sutureis at the level of the first premolar7

lending sufficient bone support forsmall diameter implant placement.10,11

This clinical case documents thesuccessful use of mid-palatal mini-implants as an extension of orth-odontic anchorage to gain accessorysupport and retention for a maxillarycomplete removable dental prosthe-sis. This is achieved by placing 2implants in the canine areas and 1mini-implant in the mid-palatal su-ture establishing a triangular design.

CASE REPORT

A 40-year-old male patient pre-sented with localized moderatechronic periodontitis in the maxilla

and generalized severe chronic peri-odontitis in the mandible. He waswearing a maxillary partial removabledental prosthesis with clasps. Compre-hensive extraoral, intraoral, and radio-graphic evaluations were performed.The extraoral and intraoral examina-tions did not reveal any significantfindings. The temporomandibularjoints were asymptomatic.

The treatment plan included extrac-tions of all existing teeth, placement of 2conventional cylinder implants in themaxillary canine areas and 1 mini-implant in the mid-palatal suture estab-lishing a triangular design. As well, 2implants were placed in the canineareas of the mandible. Fabrication ofan implant-retained maxillary com-plete removable dental prosthesis andan implant-retained mandibular com-plete removable dental prosthesis wascompleted.

Preliminary impressions weremade with irreversible hydrocolloidmaterial (Jeltrate Dentsply/Caulk Mil-ford, DE) to fabricate maxillary andmandibular interim prostheses before

*Assistant Professor, Restorative and Prosthetic Dentistry,College of Dentistry, The Ohio State University, Columbus, OH.†Residency Program Director, Oral and MaxillofacialSurgery, College of Dentistry, The Ohio State University,Columbus, OH.‡Assistant Professor, Primary Care, College of Dentistry, TheOhio State University, Columbus, OH.

ISSN 1056-6163/08/01704-402Implant DentistryVolume 17 • Number 4Copyright © 2008 by Lippincott Williams & Wilkins

DOI: 10.1097/ID.0b013e31818c49d0

Maxillary edentulous patientshave been successfully treated withimplant-supported fixed and remov-able dental prostheses. The fixedimplant-supported dental prosthesishas been used for �20 years. It haslost popularity because the design ofthis restoration requires special ac-cess for oral hygiene around theabutment cylinders creating an es-thetic quandary in the maxilla. Theuse of the mid-sagital palatal su-

ture to osseointegrate anchorage de-vices for orthodontic purposes hasshown satisfactory results. This clin-ical case documents the successfuluse of mid-palatal implants as anextension of orthodontic anchorageto gain accessory support and reten-tion for a maxillary complete remov-able dental prosthesis. (ImplantDent 2008;17:402–407)Key Words: conventional implants,mini-implant, template

402 PALATAL MINI-IMPLANTS TO INCREASE RETENTION AND STABILITY • MACHADO ET AL

surgery. Lateral view and panoramicradiographs were taken to determinethe availability of bone height and theposition of anatomical structures.Maxillomandibular relationship records(face bow and occlusion record) weremade and a diagnostic tooth arrange-ment was made to determine implantpositions. The radiographic evaluationshowed sufficient bone height in themid-palatal suture to place a mini-implant 6 � 3.3 mm (The StraummanCompany Waltham, MA) at the levelof first premolars. Based on the clini-cal and radiographic evaluations a de-cision was made to place 2 screw-typetitanium implants of 15 � 4.5 mm(Straumman) in the maxillary canineareas, and 15 � 4.5 mm (Straumman)in the mandibular canine areas (Figs.1 and 2).

The surgical procedures weredone in 3 different appointments.Based on the patient’s chief complaintat the first appointment all the man-dibular teeth were extracted, mandib-ular contouring was performed, andmandibular interim prosthesis wasplaced. For the second appointment a

maxillary surgical template (TriadVLC Dentsply Trubyte York, PA) wasfabricated with the preplanned loca-tion of the implants, distally to thecanines. Local anesthesia lidocaineHCl 2% and epinephrine 1:100,000(Lignospan Standard, Septodont, NewCastle, DE) was used to anesthetizethe canine area and the palate. Theextractions of the maxillary canineswere performed by placing the surgi-cal template into the mouth to markthe implant locations. A pilot drill wasapplied through the template, after thatthe mucosa was removed using apunch blade, and the standard surgicalprotocol for placing the selected im-plant system was followed, 2 implantswere placed distal to the canine sock-ets. Following the same technique themini-implant was placed in the mid-sagital suture at the level of the firstpremolars and a maxillary interimprosthesis was delivered (Fig. 3, A andB). For the third appointment a periodof 6 weeks was allowed for healing ofthe mandible before taking alginateimpressions and to fabricate a surgicaltemplate with the preplanned locationof the mandibular implants in the ca-nine areas and 2 implants were placed(Fig. 3, C and D). After a 6-monthperiod allowed for osseointegration,findings revealed no implant mobilityand normal peri-implant soft tissueconditions. Then maxillary and man-dibular overdentures were fabricatedfollowing a standardized technique.

Straumann locator attachments wereused to fix and stabilize the prosthesesto the implants. At the follow-up ap-pointments the prostheses showedgood stability and retention and thepatient was completely satisfied after1 year.

DISCUSSION

Longitudinal prospective studiesof implant-retained complete remov-able dental prostheses have shown ahigh success rate (�94.5%) of im-plant stability in the edentulous man-dible12 loading 2 implants, and only72.4% in the maxilla loading 2 to 6implants.13,14 Most of these failureshave been due to inferior bone qual-ity and bone resorption.

Apparently, there is a general con-sensus that a minimum of 4 implants isnecessary to the success of a maxillaryimplant-retained complete removabledental prosthesis.15 To accomplish thistreatment most patients receive bilat-eral maxillary sinus lift augmentationprocedures.16

CONCLUSION

The aim of this case report was toshow an alternative treatment for eden-tulous patients, which benefits them byreducing the number of implants placed.It eliminates the need for sinus lift aug-mentation. This application within themaxilla requires the use of 2 conven-

Fig. 1. Panoramic radiography shows the im-plants placed in canine areas in the maxillaand in the mandible.

Fig. 2. Lateral view shows the mini-implantplaced in the mid-palatal suture.

Fig. 3. A, Surgical template with triangular design for maxillary implants. B, Maxillary implantsplaced. C, Surgical template for mandibular implants. D, Implants placed in the mandible.

IMPLANT DENTISTRY / VOLUME 17, NUMBER 4 2008 403

tional cylindrical implants and one mid-palatal mini-implant.

Disclosure

The authors claim to have nofinancial interest in any company orany of the products mentioned in thisarticle.

ACKNOWLEDGMENTS

The authors acknowledge Strau-mann Company for providing the im-plants and prosthetic attachments.

REFERENCES

1. Karabuda C, Yaltirik M, Bayrakter M.A clinical comparison of prosthetic compli-cations of implant-supported overden-tures with different attachment systems.Implant Dent. 2008;17:74-81.

2. Lewis S, Sharma A, Nishimura R.Treatment of edentulous maxillae with os-seointegrated implants. J Prosthet Dent.1992;68:503-508.

3. van der Bilt A, van Kampen FM,Cune MS. Masticatory function with man-dibular implant-supported overdenturesfitted with different attachment types. EurJ Oral Sci. 2006;114:191-196.

4. Turley PK, Kean C, Schur J, et al.Orthodontic force application to titaniumendosseous implants. Angle Orthod.1988;58:151-162.

5. Odman J, Lekholm U, Jemt T, et al.Osseointegrated implants as orthodonticanchorage in the treatment of partiallyedentulous adult patients. Eur J Orthod.1994;16:187-201.

6. Wehrbein H, Merz BR, Diedrich P, etal. The use of palatal implants for orth-odontic anchorage. Clin Oral Implants Res.1996;7:410-416.

7. Bernhart T, Vollgruber A, GahleitnerA, et al. Alternative to the median region ofthe palate for placement of an orthodonticimplant. Clin Oral Implants Res. 2000;11:595-601.

8. Block MS, Hoffman DR. A new de-vice for absolute anchorage for orthodon-tics. Am J Orthod Dentofacial Orthop.1995;107:251-258.

9. Wehrbein H, Merz BR, HammerleCHF, et al. Bone-to-implant contact oforthodontic implants in humans subjectedto horizontal loading. Clin Oral ImplantsRes. 1998;9:348-353.

10. Wehrbein H, Merz BR, Diedrich P.Palatal bone support for orthodontic im-plant anchorage—A clinical and radiologi-cal study. Eur J Orthod. 1999;21:65-70.

11. Lee JS, Kim DH, Park YC, et al. Theefficient use of midpalatal miniscrew im-

plants. Case report. Angle Orthod. 2004;74:711-836.

12. Ahn M, An K, Choi J, et al. Imme-diate loading with mini dental implants inthe fully edentulous mandible. ImplantDent. 2004;13:372.

13. Jemt T, Chai J, Harnett J, et al. A5-year prospective multicenter follow-upreport on overdentures supported by os-seointegrated implants. Int J Oral Maxillo-fac Implants. 1996;11:291-298.

14. Bergendal T, Engquist B. Implant-supported overdentures: A longitudinalprospective study. Int J Oral Maxillofac Im-plants. 1998;13:253-262.

15. Sadowsky SJ. Treatment consid-erations for maxillary implant overdentures:A systematic review. J Prosthet Dent.2007;97:340-348.

16. Fugazzotto P, Vlassis J. Report of1633 implants in 814 augmented sinus ar-eas in function for up to 180 months. Im-plant Dent. 2007;16:369-378.

Reprint requests and correspondence to:Camilo Machado, DDS, MSCollege of DentistryThe Ohio State University305 West 12th Avenue, 191 Room3001-S, P.O. Box 182357Columbus, OH 43218-2357E-mail: machado.6@osu.edu

Abstract Translations

GERMAN / DEUTSCHAUTOR(EN): Camilo Machado, DDS, MS, Guillermo Chacon,DDS, MS, Eliana Sanchez, DDS, MS. Korrespondenz an:Camilo Machado, DDS, MS, zahnmedizinische Fachhochschule(College of Dentistry), staatliche Universitat Ohio (The OhioState University), 305 West 12th Avenue, 191 Room 3001-S,P.O. Box 182357, Columbus, OH 43218-2357. Tel.: 614-247-8408, Fax: 614-292-9422. eMail: machado.6@osu.eduPalatinale Mini-Implantate zur Verstarkung des festenSitzes und der Stabilitat von Implantatgehaltenen Zahn-brucken im Oberkiefer: Eine Fallstudie

ZUSAMMENFASSUNG: Patienten mit zahnlosem Oberk-iefer wurden erfolgreich mit Implantatgestutzten festensowie herausnehmbaren Prothesen behandelt. Die festenImplantatgestutzten Zahnprothesen finden seit mehr als 20Jahren Anwendung. Inzwischen hat diese Behandlung-salternative an Popularitat verloren, da diese Art der Gebi-sswiederherstellung einen besonderen Zugang hinsichtlichder Mundhygiene um die Stutzzahnzylinder im Oberkiefer

erfordert. Die Verwendung von mittig-sagittalem palatinalemFaden zur Osseointegration von Ankervorrichtungen fur kief-erorthopadische Zwecke weist zufrieden stellende Ergebnisseauf. Dieser klinische Fall dokumentiert die erfolgreiche Ver-wendung von mittig-palatinalen Implantaten als Erweiterungvon kieferorthopadisch eingesetzten Ankervorrichtungen, umdaruber zusatzliche Stutze und weiteren Halt fur einekomplett herausnehmbare Zahnprothese im Oberkiefer zuerhalten.

SCHLUSSELWORTER: mini-implantat, deckprothese

SPANISH / ESPAÑOLAUTOR(ES): Camilo Machado, DDS, MS, Guillermo Chacon,DDS, MS, Eliana Sanchez, DDS, MS. Correspondencia a:Camilo Machado, DDS, MS, College of Dentistry, The OhioState University, 305 West 12th Avenue, 191 Room 3001-S,P.O. Box 182357, Columbus, OH 43218-2357. Telefono:614-247-8408, Fax: 614-292-9422. Correo electronico:machado.6@osu.edu

404 PALATAL MINI-IMPLANTS TO INCREASE RETENTION AND STABILITY • MACHADO ET AL

Miniimplantes palatales para aumentar la retencion y esta-bilidad de sobredentaduras maxilares retenidas con implan-tes: Informe de un caso

ABSTRACTO: Los pacientes sin dientes en el maxilar hansido tratados exitosamente con protesis dentales fijas y re-movibles apoyadas con implantes. Las protesis dentales fijasapoyadas con implantes se han usado durante mas de veinteanos. Han perdido popularidad porque el diseno de estarestauracion requiere acceso especial para la higiene oralalrededor de los cilindros pilares creando un problema es-tetico en el maxilar. El uso de una sutura palatal mediosagitalo mediano para la integracion osea de dispositivos de suje-cion con propositos ortodonticos ha demostrado resultadossatisfactorios. Este caso clínico documenta el uso exitoso deimplantes palatales medios como una extension de la sujecionortodontica para lograr el apoyo y la retencion adicional deuna protesis maxilar dental removible completa.

PALABRAS CLAVES: miniimplante, sobredentaduras

PORTUGUESE / PORTUGUÊSAUTOR(ES): Camilo Machado Cirurgiao-Dentista, Mestreem Ciencia, Guillermo Chacon Cirurgiao-Dentista, Mestreem Ciencia, Eliana Sanchez Cirurgia-Dentista, Mestre emciencia. Correspondencia para: Camilo Machado, DDS, MS,College of Dentistry, The Ohio State University, 305 West12th Avenue, 191 Room 3001-S, P.O. Box 182357, Columbus,OH 43218-2357. Telefone: 614-247-8408. Fax: 614-292-9422. e-Mail: machado.6@osu.eduMini-Implantes Palatais para Aumentar a Retencao e aEstabilidade de Sobredentaduras Maxilares Retidas por Im-plantes: Relato de Caso

RESUMO: Pacientes desdentados maxilares foram tratadoscom sucesso com proteses dentarias fixas e removíveis su-portadas por implantes. A protese dentaria fixa suportada porimplante foi usada durante mais de vinte anos. Ela perdeupopularidade porque o projeto de restauracao exige acessoespecial para higiene oral em torno dos cilindros de suporte,criando uma perplexidade estetica na maxila. O uso da suturapalatal medio-sagital para osseointegrar dispositivos de anc-oragem para objetivos ortodonticos mostrou resultados sat-isfatorios. Este caso clínico documenta o uso bem-sucedidode implantes medio-palatais como extensao da ancoragemortodontica para obter suporte e retencao acessorios para umaprotese dentaria maxilar removível completa.

PALAVRAS-CHAVE: mini-implante, sobredentadura

RUSSIAN /������: Camilo Machado, ������ ����������,������ ������ ����� ����, Guillermo Chacon, ����������������, ������ ������ ����� ����, Eliana

Sánchez, ������ ����������, ������ ������ ���������. ����� ��� ���������� : Camilo MachadoDDS, MS, College of Dentistry, The Ohio State University,305 West 12th Avenue, #191 Room 3001-S, P.O. Box 182357,Columbus, OH 43218-2357. ������: 614-247-8408,����: 614-292-9422,����� ��������� ���:machado.6@osu.edu������� �� ��� �-��������� ����������� ������ ������������������������� ������ �� ��� ��������, !-��������� �� ���������. "����� �� ����������: ������ ������

�#$%&#. �������� � �������� ������ �������������� �������� ������ � ������� �������������� � ������� ������ ������� ,����������� �� ����������. ��������� �������������, ����������� �� ����������,����������� � � ���� � ������ ��. !�� ������������������, ��� ��� ����������� "��� ������������� ������� ���������� ������� �����#��� ���� ����������� ������ ����������������� �������������, ��� �� ������������ ����� "���������� ����� ��������.$������ ���� ������-���������� ������ � ��� �������������� ������� ������������� ����������������� ���� ��� ��� �� ������������������. %����� ���������� ��������� �� ���� �������� ������� ���������������� ��������� ������ � ����� ������������������� ������� ������������� � ������������ ������������ ����� � �������� �� ������������� �������� ������� ������������� .

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TURKISH / TURKCEYAZARLAR: Camilo Machado, DDS, MS, Guillermo Chacon,DDS, MS, Eliana Sanchez, DDS, MS. Yazısma icin:Camilo Machado, DDS, MS, College of Dentistry, TheOhio State University, 305 West 12th Avenue, 191 Room3001-S, P.O. Box 182357, Columbus, OH 43218-2357ABD. Telefon: 614-247-8408, Faks: 614-292-9422. e-posta:machado.6@osu.eduImplantla Yerinde Tutulan Maksiler Overdenture’lerin Ret-ansiyon ve Stabilitesinin Arttırılması icin Damakta MiniImplantlar: Bir Olgu Raporu

OZET: Maksiler dissiz hastalar, implant ile desteklenen sabitve hareketli dental protezler ile basarıyla tedavi edilmektedir.Implant ile desteklenen sabit dental protezler yirmi yıldanfazla bir sureyle kullanılmaktadır. Ancak, bu restorasyonuntasarımı, abutman silindirleri etrafında oral hijyen icin ozel

IMPLANT DENTISTRY / VOLUME 17, NUMBER 4 2008 405

erisimi gerektirerek maksilada estetik bir sorun yarattıgından,populerligi azalmıstır. Ortodontik amaclarla ankraj aletlerininosseoentegrasyonu icin orta sagital damak suturunun kulla-nımından tatmin edici sonuclar alınmıstır. Bu klinik olgu, tamhareketli maksiler dental protezler icin aksesuar destegi ve

retansiyon saglamak uzere orta damak implantlarının ort-odontik ankrajın bir uzantısı olarak basarıyla kullanımınıgostermektedir.

ANAHTAR KELIMELER: mini implant, overdenture

JAPANESE /

CHINESE /

406 PALATAL MINI-IMPLANTS TO INCREASE RETENTION AND STABILITY • MACHADO ET AL

KOREAN /

IMPLANT DENTISTRY / VOLUME 17, NUMBER 4 2008 407

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