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AchievingSuccess WithSmall-DiameterImplants

Category: Prosthodontics Created: Thursday, 08

January 2015 20:16 Written by Paresh B. Patel, DDS

INTRODUCTIONIt is without question that dental implants areone of the most successful additions to moderndentistry. With a success rate of greater than 95%,the root form implant should be considered torestore any edentulous area. However, when weare presented with the need to manage a highlyresorbed ridge, significant issues for the surgeonand restorative team arise if only the use of astandard body implant (3.7 mm or larger) isconsidered. These issues can be anatomical,medical, financial, or restorative.

Anatomical challenges are closely associated withhow much residual alveolar ridge remains(quantity) and also its density (quality). These cansometimes be overcome with additional surgicalprocedures such as ridge expansion, blockgrafting, and other hard- and soft-tissueprocedures. If these solutions are not accepted,the use of a much less invasive procedure shouldbe considered, such as the small-diameterimplant (SDI) (also referred to as the miniimplant).

SDIs have been around in their FDA-approvedform since 1997 and share similar surfacetexture, coatings, and titanium grade to theirlarger counterparts. Most implant manufacturersnow have added SDIs to their system. These SDIsnow are available in one- and 2-piece versions aswell as crown and bridge prosthetic options.

Medical challenges should be addressed byutilizing the most minimally invasive surgicalplan. The incorporation of 3-D cone beam (CB)technology is rapidly increasing and can allow forpresurgical planning to avoid mandatorygrafting. A CBCT surgical guide can be created todeliver the implant into the bone with a flaplesstechnique reducing surgical trauma. This may bea prudent solution for patients with systemicconditions who are unable to tolerate lengthyhealing times. It is important to note that a CBCT-based surgical guide is much different that aprosthetic guide that is based on a pan x-ray anda stone model.

Restorative challenges are usually themanagement of restricted restorative space in themesial-distal or buccal-lingual direction. This hasalways posed a high-risk problem in the aestheticarea. Too wide of an implant will create potentialfor bone and/or soft-tissue loss. Convergent rootscan also preclude the use of a standard bodyimplant. In these cases, an SDI may allow for theplacement of the implant and still allow properbone support, soft-tissue space, and properspacing from adjacent tooth roots.

SDIs can be used to retain maxillary ormandibular dentures. Due to reduced surfacearea, it is recommended to utilize 4 SDIs in themandible and 6 SDIs in the maxilla. The residualridge should be of Misch Type I or II to ensure asuccessful case. If the SDI selected is of a one-piece design, then immediate loading must beaddressed. Primary stability should be at aminimum of 30 Ncm on all the implants and astable tissue supported denture should bedelivered. The implants should also be placed asparallel as possible to minimize off-axis loads.

CASE REPORTSCase 1: Multiple Unit Fixed RestorationsDiagnosis and Treatment Planning—A 54-year-oldfemale presented in general good health with ahistory of diabetes. She had progressively lost herteeth during the past 15 years, with the last ofthem being extracted about 5 years ago. She wasunhappy with her existing dentures due to poorretention and difficulty with eating. Both ridgeswere examined and found to be moderatelyatrophic (Figures 1 and 2). A CBCT scan was taken(iCAT FLX) with the dual-scan protocol tofacilitate a prosthetically driven treatment plan(Figures 3 and 4).

Figure 1. (Case 1) Pre-opmaxillary ridge.

Figure 2. Pre-opmandibular ridge.

Figure 3. iCAT FLX TxPL (maxilla).

Figure 4. iCAT FLX Tx PL(mandibular).

Figure 5. Mandibularsurgical guide.

Figure 6. Maxillarysurgical guide.

Figure 7. Maxillarysurgical guide seated.

Figure 8. Mandibularsurgical guide seated.

Figure 9. Implant motorand pilot drill.

Figure 10. LOCATOROverdenture Implant(LODI) System (ZESTAnchors) fully seated.

Figure 11. TheLOCATOR attachment(ZEST Anchors) wassecured on the upperarch.

Figure 12. LOCATORattachments on thelower arch.

Figure 13. FitTest (QuickUp System [VOCOAmerica] materialswere placed.

Figure 14. FitTest wasallowed to set and showthe relief areas to becreated.

Figure 15. Relief wellsin maxillary prosthesis.

Figure 16. Relief wells inmandibular prosthesis.

Figure 17. iCAT FLX postscan.

Due to the height and width of the remainingbone, 6 SDIs would be placed in the maxilla and 4SDIs in the mandible to support overdentures.The SDIs selected for this case were of a 2-piecedesign with a LOCATOR attachment (LOCATOROverdenture Implant System [LODI] [ZESTAnchors]). The low profile of the attachmentwould allow for a less obtrusive denture and avariety of retentive inserts. After the treatmentplan was approved by the patient, surgical guides(Anatomage) were ordered (Figures 5 and 6).

Clinical Protocol—On the day of surgery, thesurgical guides were tried in to verify stabilityand fit (Figures 7 and 8). A single 1.6-mm pilot bitwas used to create the osteotomies through thesurgical guide in the maxilla using an implantmotor (Aseptico AEU7000) with copious irrigation(Figure 9). The pilot guide was removed and theLODIs were inserted and carried to depth (Figure10). All 6 SDIs were confirmed to have at least 30Ncm of torque, and the LOCATOR attachment wassecured (Figure 11). This protocol was duplicatedon the lower arch (Figure 12). To ensure that theexisting dentures would fit passively over theSDIs, FitTest (Quick Up System [VOCO America])material was placed and allowed to set, showingwhere relief areas would need to be created(Figures 13 and 14). Once the relief was complete,the process was repeated until a verified passivedenture could be obtained (Figures 15 and 16).The dentures could then be soft relined (Ufi Gel[VOCO America]). A final CBCT scan was taken(iCAT FLX) to ensure that all the SDIs were fullyencased in bone and no vital anatomicalstructures were violated (Figure 17).

Case 2: Single-Unit Fixed Prosthetics SDIs can be an excellent solution to support asingle crown in areas of reduced interdentalspace (less than 5 mm between adjacent teeth)where it would be impossible to place a largerimplant. These areas could be maxillary lateraland mandibular incisors. Case selection shouldhave a bone type of Misch I or II and off-axisocclusal forces should be minimized by designingthe single-unit crown to have implant-protectedocclusion. The use of a single SDI to support acrown much larger than a maxillary lateral is stillquite controversial.

Figure 18. (Case 2.) Pre-op photo showingmissing lateral.

Figure 19. Digitalperiapical (PA) (DEXIS)for mesiodistal width.

Figure 20a. A 1.8-mmpilot bit.

Figure 20b. Digital PA atinitial placement.

Figure 21. Initialplacement.

Figure 22. Komettitanium abutment bur.

Diagnosis and Treatment Planning—An 18-year-old young adult presented to our office aftercompletion of orthodontics several months prior.He had lost his retainer/flipper that also replacedhis missing upper lateral No. 7 (Figure 18). Adigital radiograph (Platinum [DEXIS]) was takento see the position of adjacent roots, and itconfirmed an extremely narrow mesio-distalspace (Figure 19). It was decided to utilize a one-piece, 3.0-mm diameter crown and bridge SDI (i-Mini [OCO Biomedical]). The decision to use thisbrand was due to the i-Mini’s aggressive threaddesign that allows for compression and fixationof the implant in Type II bone.

Clinical Protocol—A 1.8-mm pilot bit in theAseptico handpiece was used to carefully createthe initial osteotomy (Figure 20a) and anotherdigital radiograph was taken to confirm a parallelpath between the adjacent roots (Figure 20b). Afinal 2.4-mm osseoformer was used to preparethe bone, and the one-piece SDI was inserted(Figure 21). After final depth was reached, theprosthetic head of the implant was shaped forinterarch space with a high-speed handpiece(KaVo) and a titanium abutment prep bur(Komet) (Figure 22). A conventional vinylpolysiloxane (VPS) impression (Take 1 Advanced[Kerr]) was taken using light- and heavy-bodymaterials. The case was then sent to our dentallaboratory team for the fabrication of amonolithic zirconia crown (BruxZir [GlidewellLaboratories]) (Figure 23).

Case 3: Multiple Unit Fixed RestorationsMany of the same principles of utilizing an SDIfor single-unit fixed restorations should beembodied when applying their use for multiple-unit fixed restorations. All fixed units should besplinted together to help dissipate force andminimize any micromovement. In function, theocclusal loads can be distributed over themultiple splinted SDIs. This reduces thefunctional load on any one SDI and increases thebone-to-implant contact. For full-arch cases, it isprudent to increase the number of SDIs in orderto reach the desired surface area to preventimplant overload.

Diagnosis and Treatment Planning—A 62-year-oldfemale presented with the chief complaint ofdifficulty chewing and keeping her dentures inplace. The patient stated she had been wearingthe full upper and lower dentures for 15 years.The clinical exam revealed a healthy appearanceto the edentulous tissue (Figure 24). The patientstated that her experience with dentures hadmade her unhappy and self-conscious with heroverall appearance; so much so that she wantedto have “fixed teeth.” A medical history reviewrevealed the patient had had a previous heartattack and continued the use of Plavix, ananticoagulant medication. The patient was alsodiabetic, controlled with medication.

To minimize surgical trauma and to increase theefficiency of implant-guided surgery, a flaplesstechnique was to be employed for implantplacement. A CBCT scan (iCAT FLX) was taken fortreatment planning and fabrication of a surgicalguide. Upon completion of the CT scan, it wasevident that the residual ridges were highlyresorbed and would require the use of SDIs oradditional surgical procedures to accommodatestandard body implants. To keep within ourconcept of minimally invasive dentistry, multipleSDIs were prescribed to support the full-archrestorations.

The treatment plan options were discussed withthe patient and the final decision was made andapproved by the patient. CBCT surgical guides(Materialise) were made for upper and lower full-arch implant placement.

Figure 23. Monolithiczirconia restoration(BruxZir [GlidewellLaboratories]).

Figure 24. (Case 3). Pre-op maxillary ridge.

Figure 25. Maxillarysurgical guide.

Figure 26. Mandibularsurgical guide.

Figure 27. Initialosteotomy.

Figure 28. Handinsertion of an OCOBiomedical implant.

Figure 29. OCOBiomedical SDIs (lowerarch) fully inserted.

Figure 30. OCOBiomedical SDIs (upperarch) fully inserted.

Figure 31. Final iCATFLX scan.

Figure 32. iCAT slice.

Figure 33. Finalfull-arch prosthesis.

Figure 34. Final full-archupper and lower prostheses.

Clinical Protocol—The patient presented on herappointed day with no changes made to her dailymedication regimen. Infiltration with localanesthetic was administered. The surgical guideswere tried in to ensure proper fit and stability(Figures 25 and 26). The surgical guides wereretained, and a 1.8-mm pilot drill was used ineach site to full length. The guides were thenremoved, and an immediate photograph wastaken to illustrate the minimal amount of traumato the implant surgical sites (Figure 27). Each SDI(3.25-mm ERI [OCO Biomedical]) was started byhand to one half depth (Figure 28), and thentaken to full depth using the Aseptico surgicalmotor. With the exception of the posterior upperright site, all sites accepted a 2-piece 3.25 x 12 mmin the maxilla and 3.25 x 10 mm in the mandible(Figures 29 and 30). A post-implant placement CTscan (iCAT FLX) was taken; it demonstratedparallel placement in the panoramic view veryclosely resembling what was treatment planned(Figure 31). In addition, the 3-D slice view showedthat the implants were fully encased in bone,away from the nerve canal and engaging thecortical plate for maximum stability (Figure 32).Solid abutments (OCO Biomedical) were placedand torqued to 30 Ncm. Full-arch impressions ofthe duplicated dentures were taken with a VPSmaterial (Take 1 Advanced). The impressionswere then delivered to the lab team and full-archfixed bridges were fabricated for finalcementation (Figures 33 and 34).

CLOSING COMMENTSWith the use of guided surgery and SDIs, morepatients can undergo implant surgery to achievetheir desired goals to have teeth. SDIs, along withminimally invasive dentistry, are an idealtreatment solution to consider when standard-body implants are not feasible without additionalprocedures.

Dr. Patel is a graduate of University of NorthCarolina at Chapel Hill School of Dentistry andthe Medical College of Georgia/AmericanAcademy of Implant Dentistry Maxi Course. He isthe co-founder of the American Academy of SmallDiameter Implants and is a clinical instructor atthe Reconstructive Dentistry Institute. He hasplaced more than 2,500 mini implants and hasworked as a lecturer and clinical consultant onmini implants for various companies. He can bereached at pareshpateldds2@gmail.com or viathe Web site dentalminiimplant.com.

Disclosure: Dr. Patel reports no disclosures.

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