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Mini Dental Implants A Presentation
byTariq Idris
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Topics• History of Dental Implants• Role of Mini Implants• Cases• Complications
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Topics• Future trends• Medico-legal issues• Practicals: Surgical and Prosthetic
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Aims/ Objectives• To appreciate the choices available
to the patient• To understand the scope of mini implants• To understand their limitations and Pitfalls
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To gain an insight into the techniques employed
Aims/ Objectives
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Current Options for the Edentulous
Complete Dentures
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Current Options for the Edentulous
Overdentures Retained by Implants
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Current Options for the Edentulous
Bridgework Supported by Implants
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Option 1:A Denture.• Low cost/Simplicity but difficulties
when faced with:
• Little/ no ridge
• No retention/ resistance
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Option 1:A Denture.• Sore spots/ constant Easing
• Aesthetic Compromise
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Consequently:• Looseness
• Pain/ ulceration
• Lack of Confidence
• Difficulty with eating
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• “ It makes me gag”• “ It hurts when I chew”• “ I can’t taste my food”• “ I hate it !” • “ I take it out to eat”
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Anti-Ageing
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Mini Dental Implants(MDI’s)• Over 20 year history• No long term studies• Some early studies:
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Mini Dental Implants(MDI’s)
Currently 4 years of Datashowing only 2.1% loss.
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Mini Dental Implants(MDI’s)Historically used as temporary or
transitional implants to secure
Temporaries whilst conventional implants were undergoing healing phase
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Mini Dental Implants(MDI’s)Now some FDA approved
for long term use for fixed and removable protheses.
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MDI Features• Implants are Surfaced Etched• Self-tapping Thread Design• High-Strength Titanium Alloy Material• Integrated Abutment
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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
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Current Designs
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Titanium Alloy(Titanium, 6Aluminum, 4Vanadium)
62.5% Higher tensile strength thanthe strongest commercially pure,
Grade IV CP Titanium
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10
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30
40
50
60
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TitaniumAlloy
CP Titanium
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Advantages of Mini Implants• Minimally invasive surgery• Cost effective• Immediate loading• Suitable for Resorbed Ridges
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Advantages of Mini Implants• Minimal post-op Discomfort• Can be used on almost all ridges•Can be performed by the patients
general dentist
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Is this the End of Conventional Implants?
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NO!!!!MDI’s are an alternative to dentures,
bridges and conventional implants
in certain situations
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NO!!!!They are often a third way
in between dentures
and more complex implant treatments
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NO!!!!The Patient will end up with a different
product
compared with conventional implants
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The most important thing is to give the patient the Choice
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Many patients who would not consider
conventional implant treatment due to:• Fear of complex surgery• Timescale of treatment: up to 2 years• Cost
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• Limited bone availability: do not want grafting
• may proceed with mini dental implants
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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
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Patient Selection Criteria• Who is a candidate for
MDI?• Difficulty wearing
lower denture!!! etc.
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Patient Selection Criteria• Cannot tolerate a palate on upper• Anatomically
compromised• Patient wants to feel
more confident, etc.
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Are MDI’s Good for everyone?• Medically Compromised ? • A wider range of Patients can be treated • No incision in most cases
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Are MDI’s Good for everyone?• Low morbidity• Low infection• Non-invasive
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Are MDI’s Good for everyone?• What about patients taking steroids?• Contraindicated for most implants,
but can be done with MDI
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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
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Are MDI’s Good for Everyone?
• Anatomically Compromised ?
• Many patients do not have adequate bone
support to accept the large size of conventional implants.
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Are MDI’s Good for Everyone?
• Anatomically Compromised ?
• MDI’s can be used in almost any ridge and on patients with severe alveolar ridge resorption.
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Are MDI’s Good for Everyone?• Fewer visits to the dental surgery• Can be performed by the General Dentist
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Are MDI’s Good for Everyone?
Financially Compromised ?• Fewer visits to the dental surgery• Can be performed by the General Dentist
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Mini Dental Implants
Their biggest application is in the stabilisation of Complete lower dentures.
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Mini Dental Implant Diagnosis and Treatment Planning
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Treatment Plan• Occlusal Dynamics• Oral Hygiene• General health/ medical history• Psychological/ social status• Aesthetics: smile line• Anatomy
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Anatomy
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Anatomical Considerations• Mandibular Nerve• Mental Nerve• Sub- mental artery
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Anatomical Considerations• Maxillary Sinus• Nasal Sinus• Other teeth/ roots
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Bone Quality and Quantity • Rate Density - 1,2,3,4• 1 - Very dense bone: difficult surgically• 2 - Moderately dense bone
Classic Mandibular Bone
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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
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Assess the Bone• Height • Width• Shape• Angulation
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Assess The Bone• Using Ridge Mapping, Radiographs,
CT scans,• Sectional Radiographs, Scanora,etc
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1 - Radiographic Planning
Panoramic X-RayAssists in planning Implant placement
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1 - Radiographic PlanningPencil radiograph in region of canine
and 1st premolaranterior to mental nerve canal
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1 - Radiographic PlanningPencil radiographand in region of
lateral incisor Region
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Implant Placement Procedure
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2 - Mark Denture and Transfer
• Using the pencil marks made on the radiograph as a guide, mark DRY denture heavily with skin marker.
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2 - Mark Denture and Transfer
Next DRY Patient’s arch and place denture
in mouth.
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2 - Mark Denture and Transfer
You may darken transfer spots with marker for
APPROXIMATE placement of implants.
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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%
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4 - Create Pilot HoleFirst Palpate to assess
the Angulation of the Ridge.
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4 - Create Pilot HoleAfter measuring depth, drill pilot
hole with a tapping motion using saline
irrigation.
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4 - Create Pilot HoleDrill depth according
to bone density evaluation.
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5 - Implant Insertion
Do not contaminate the implant surface
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5 - Implant Insertion
Insert implant into pilot opening
through gingiva to bone: take care not
to trap tissue
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5 - Implant Insertion
Rotate clockwise with downward
pressure
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6 - Finger Driver
Continue insertion of implant with finger
driver until firm bony resistance is again
met. met.
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6 - Finger Driver
Then follow with winged thumb
wrench SLOWLY, again until firm bony
resistance is met.
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7 - Ratchet Wrench
If bone is extremely dense use of ratchet wrench is needed.
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7 - Ratchet Wrench
SLOW incremental turns will allow full
insertion without snapping of the
implant.
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7 - Ratchet Wrench
Pressure should be applied downward on the ‘head’ of the
ratchet during insertion.
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7 - Ratchet Wrench
If VERY HEAVY resistance is noticed,
back implant out
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7 - Ratchet Wrench
and make pilot hole deeper. DO NOT
force ratchet or implant may snap at
neck.
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8 - Complete Insertion
Complete the insertion of all implants.
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8 - Complete Insertion
Insert implants completely so that no
threads are supragingival.
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8 - Complete Insertion
Check primary fixation with torque wrench
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Postoperative X-ray
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Denture Placement and Prosthetic Technique
Phase 3
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Denture Placement and Prosthetic Technique
Positioning should be close to original plan, make holes in denture
with lab bur on premarked locations.
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Denture Placement and Prosthetic Technique
Place housing abutments on implant
o-balls.
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Denture Placement and Prosthetic Technique
Try-in denture for full seating.
Use fit checker
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Denture Placement and Prosthetic Technique, (cont.)
Fill holes in denture with implant housing
attachment resin.
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Denture Placement and Prosthetic Technique, (cont.)
Protect exposed implant head to prevent
engaging undercut.
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Denture Placement and Prosthetic Technique, (cont.)
Place denture on o-ring housings and have patient bite gently using previous
registration to seat denture and hold for
setting of resin/acrylic.
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Denture Placement and Prosthetic Technique, (cont.)
Remove denture and assess security of housing in denture.
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Denture Placement and Prosthetic Technique, (cont.)
Add flowable resin (light cured), cold cured acrylic or cyanoacrylate if loose..
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Denture Placement and Prosthetic Technique, (cont.)
Trim excess material and smooth tissue surface of denture to avoid sore spots.
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Denture Placement and Prosthetic Technique, (cont.)
Also shorten boarders of denture.
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Post Operative Instructions• Prescribe analgesics• Ice Applications• Warm saltwater• Wear Denture for 24 hours• See patient next day
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24 Hours Later• Adjust denture• Most likely there will be adjustments• Some will have denture sores
developing• Adjust spots and check occlusion
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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.
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Case Presentations
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Case 1
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Case 2
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Lateral Case
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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
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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:
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MDI’s aren’t Voodoo• Primary fixation• Oral health• No/ limited micro movement• Biomechanics
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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.
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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
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Partial Cases
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Complications• Fracture: instruments/ implants• Lateral forces• Pain/swelling• Fracture of prosthesis• Housing loosening• Wear: O ring; implant head
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Broken Drill
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Broken Drill
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Broken Drill
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Consent• Principles• A process- not a
form• Clear and honest• Documented• Avoid jargon
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Consent Issues
No/ limited data/ studies: HistoryNew to UK: New to you.
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Risks• Surgical and Prosthetic: • Non-integration, • Fracture, • Infection,
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• Damage to nerves (paraesthesia) and adjacent teeth
• Sinus perforation • Case abandonment • Bone loss
Risks
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• Fracture of Prosthesis, • Oral Hygiene issues • Need for maintenance / check up’s.• No Assurances of Success/ Longevity
Risks
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Consent: Operator Issues• Suitable training• Suitable experience• Competence
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91.8% 92.9% 100.0%98.8%
0%10%20%30%40%50%60%70%80%90%
100%
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%
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Future Trends• More research, more research, more
research
• Greater range of sizes
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Future Trends• Development of design for individual
crowns
• Orthodontic Applications
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24 Hours Later• Adjust denture• Most likely there will be adjustments• Some will have denture sores developing• Adjust spots and check occlusion
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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.
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SummaryPatient arrives with a loose lower denturePatient leaves 2 hours later with a stable
prosthesis
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SummaryNo flap
No suturesImmediately loaded
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Other Applications?• Transitional – during the healing phase
of conventional implants• Salvage cases• Retention of Partial Dentures
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Concerns with the following issues:• Insufficient fixation in Type 2, 3 and 4
bone• The marginal overhang?• Potential overloading• Long term durability• Retention
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Address concerns/ difficulties• Fracture• Durability• Surface Area• Emergence Profile/ Overhang• Poor Quality Bone
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Range of Larger SizesAll self tapping.
• 2.3mm• 2.8mm• 3.3mm• 3.8mm• 4.3mm
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Improved Abutment for Crowns
With a Hygienic Crown Margin
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The New Mini/ Midi Implant• Increased Surface Area: comparable
with conventional implants• Improved Strength• Improved Retention• Improved Fixation
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Assess the Bone• Height • Width• Shape• Angulation
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Assess The Bone• Using ridge mapping, radiographs,
CT scans,• Sectional radiographs, Scanora,etc
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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
bone
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Ridge Expansion/ Compression• Established over 30 years ago• Scientifically valid• Involves opening the ridge and
displacing it
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• Creates a Series of microfractures• Heal readily especially if stable
and with periosteum intact
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Expansion and CompressionPhenomenomTM
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Simultaneous Expansion and CompressionProducing Improved Primary Stability
Particularly Suitable for Type 2 and 3 Bone i.e. Maxilla
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Expansion and Compression• Smooth and Progressive• Improves surrounding bone quality• Creates a wall of dense bone around
the implant• Improves the fixation ( torque check)
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Aseptic Technique
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Missing laterals
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A Denture had Been In place for over 20 years.
Ridge Mapping revealed 2mm Width
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The Finished Restorations
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Measured Ridge Expansion
Pre-op 2mm Post op 4mm
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Deciduous Teeth
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Implants Placed
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Crowns in Place
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Natural Contours
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Lower Incisor
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Implant Insertion
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Implant in Site
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Fixation Checked 30Ncm
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The Post is Prepared
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Crown Fitted
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Scientific Principles• Biocompatibility• Implant Surface• Implant Site• Surgical Technique
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Scientific Principles• Undisturbed healing phase• Biomechanics• Prosthetic Success
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Principles ExaminedBiocompatibility:
Titanium Alloy well established as a biocompatible implant material
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Principles ExaminedImplant Surface:
Implant is a threaded screw etched and blasted
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Principles ExaminedImplant Site:
Placement site is always improved by ‘Osteo- Expression’
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Simultaneous Expansion and CompressionProducing Improved Primary Stability
Particularly Suitable for Type 2 and 3 Bone i.e. Maxilla
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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
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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
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4. The Surgical TechniqueFlapless Surgery
• Maintains keratinised tissue which act as a physical barrier to plaque invasion
• Lower incidence of surgical complications
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5. Undisturbed Healing/Immediate Loading
• Dependent on good fixation > 25Ncm• Micromovement less than 100 microns• Controlled Load
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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
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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
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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
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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
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Related ResearchG. E Romanos Journal of Oral implantology
vol30.no 3.2004.‘Present status of Immediate Loading of
Oral Implants’
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Related ResearchSeveral ConditionsPrimary Stability
Sufficient Bone QualityElimination of Micromovement
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Related Research
‘Implant design makes a significant contribution to the initial stability’
‘A screw threaded design with a rough surface is recommended’
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Related Research3.5mm by 14mm implant equivalent
surface to multirooted teethRecommended techniques to improve
bone density
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6. Biomechanics• Avoid Bruxists• Avoid Molars• Splinting to other implants• Occlusal Protection• Controlled Diet/ Bone Training
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Prosthetic Factors• Ultimate simplicity: no extra components• Conventional impression techniques• Conventional Crown fabrication• No internal joints/ screws• Conventional cementation
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Stable Gap Free Interface1Year Post Op
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Simple Reconstruction
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Factors Contributing to Success• Minimal Surgical Trauma• Improved Bone to Implant Contact• Improved Fixation• Improved Peri implant Bone quality• Controlled Occlusal Load
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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
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Using MDI in your practice• Patient Satisfaction• Your Satisfaction• Staff Involvement• Financially Accepted• Financially Rewarding• Minimal Outlay
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How can MDIs affect my Practice?• Emotional Satisfaction• Patient Relationships and Referrals• Financial Freedom• Personal and Family time
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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
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The EndThe End