Transcript Mini Workshop PPT_1x

Staff Implant Surgeon
Confidential
Course Synopsis
 Teach general dentists how to manage the edentulous patient with small diameter
implants (“minis”)
 Identifying appropriate and ideal patients for the use of SDIs
 Learn treatment planning protocols
 Learn fundamental surgical implant placement techniques
 Learn restorative techniques
 Medical management of at risk patients
 Management of peri-, intra- and post-operative complications
 Use of cutting edge technologies to minimize risk and frustration to the clinician
 Hands-on workshop designed to allow practical application of newly acquired didactic
training
Course Objectives
 Recognize patients most appropriate for implant treatment
 Develop appropriate treatment plans and present them to patients
 Adeptly perform the conventional surgical placement of implants, both






flapped and flapless
Apply 3D imaging modalities to develop surgical guides
Describe and manage the restorative challenges of edentulous patients
Manage the potential medical and surgical complications and risks
associated with implant therapy
More fully comprehend the anatomy of the edentulous patient,
particularly as it applies to implant surgery
More effectively communicate the benefits of implants to patients
Understand marketing and financial strategies for putting implant
dentistry into a successful practice
Earliest known example of a dental implant was retrieved from a
female mandible skull at a Mayan excavation site in Honduras
dating back to 600 AD
-It was initially believed to have been placed posthumously as
was often the practice of the Egyptians, but has since been
theorized that it was placed during the woman’s lifetime
-There was evidence of bone compaction around the implants
*Wikipedia
1952: Per-Ingvar Branemark begins to study bone healing
and regeneration on rabbit tibias
-When he attempts to retrieve the titanium cylinders he
has embedded in the tibias, he discovers that the bone has
literally adhered to the titanium
-He coins the term “osseointegration”
-In 1965, he places the first dental implant in a patient
-At the 1978 Toronto Conference, the world is introduced
to Branemark’s titanium dental implant.
*It is currently estimated that 8% (approx. 31 million) of the U.S.
population is edentulous in one or both arches, and that number is
expected to nearly double in the next 15 years (1)
*For patients over the age of 75, the incidence of edentulism is 44% (1)
*In 2011, the first of the Baby Boomers will reach 65 years of age
According to Gordon Christensen, 90% of denture wearers are
unhappy with the fit of their dentures (2)
(1) Dene L, NYSDJ, April 2010
(2) GC 2007 lecture, St. Paul, MN
It is further estimated that 2/3 of Americans has one or
more missing teeth*
*AAID Website
*The more educated the patient, the less likely to
be missing teeth
*The higher ones income, the less likely they are
to have full or partial edentulism
*Women tend to have a higher incidence of
edentulism than men, ironically likely due to
their greater likelihood to seek out dental care
sooner
*West Virgina (48%) and Kentucky (44%) are #1 and #2,
respectively, for highest percentages of edentulism (1)
*Hawaii has the lowest incidence of edentulism at 16% (2)
(1) Kentucky Legislative Research Commission (2000)
(2) NIDCR/CDC DOCDRC
*Poor denture retention
*Self-conscious in public to eat, speak, laugh, etc
*Often stay at home for fear of embarrassment and lack of
confidence in the fit of their denture
*Unable to afford conventional implants and restorative options
*Not candidates for conventional implants for medical reasons
or lack of sufficient available bone
*Seek out a dental professional only when the frustration and/or
pain from their existing denture becomes too much to bear
Among those patients who are completely
edentulous (1):
-89.6% wear dentures in both arches
-96.8% wear only an upper denture (for maxillary
edentulism only)
-80.6% wear only a lower denture (for mandibular
edentulism only)
(1) Redford et. al 1996
*Much more confident and self-assured, both in themselves and
their denture
*More social and outgoing
*Immediate improvement in the quality of their lives
*Very appreciative of the dentist/surgeon who gave them this
renewed outlook on life and refer family and friends
*Requires only the application of a skill set you, as a dentist,
already possess
*Start-up cost is vastly less than other treatment options
*The surgical and restorative components are kept in house
*Maximizes your per hour income
*Patients see an almost immediate improvement in the quality
of their life
*Very low morbidity
*Quickly develop a large referral base, which can lead to a
myriad of other procedures and patients with other needs
They are identical to conventional diameter implants, with the
exception of being smaller in diameter:
-2.2mm, 2.5mm, and 3.0mm
-Have a one-piece design
Indicated for:
-Long term use in Complete Denture Stabilization
-Short term use to stabilize dentures prior to placement of
conventional diameter implants (“Bridging”)
*In 1997, the FDA approved minis for long-term use (1)
*Success rates ranging from 94.2-97% have been reported (1)
(1) Hoos JC, ineedce.com, April 2011
*Limited quantity of bone in the posterior mandible
*Financial constraints precluding conventional implants and hybrid
dentures or crown and bridge
*Complex medical conditions that would make certain patients at
higher risk for conventional flapped implant surgery
*Need for additional pre-prosthetic surgeries that are either
contraindicated or which the patient does not wish to undergo
*Patients who desire an option that allows them to leave with a
denture the same day and/or with greater stability and retention
*Can also be used as a bridge towards conventional diameter implants
*Medical or surgical issues
*Active infection in planned implant sites
*Insufficient quantity or quality of bone to achieve favorable
initial stability
*Mandible: 97% (overall) (1)
*Maxilla: 91% (overall) (1)
*When used in (2):
CLD: 95%
CUD: 83%
Lower RPD: 93%
Upper RPD: 92%
(1) Robert Strober, DDS
(2) Shatkin TE et al. Compendium 2007
Slide that shows a lit review for the success of minis
Slides to compare and contrast ours with 3M, Zimmer, Atlas
*Complete package for one low, fixed price:
-4 Mini Implants in the sizes of your choice
-Overdenture
-Surgical Drill
-O-ring housings
-Analogs
-Model work
-Dedicated, knowledgeable staff of implant technicians available to
help you throughout your mini implant overdenture case
Insert GL Image of the Mini OD package
As demonstrated by the research of Atwood (1957)
and Tallgren (1972), the alveolar bone undergoes
atrophy and resorption following extraction
-On average 4mm of width lost in the first year,
upto as much as 6.1mm, 50% within the first 3
months*
*Dentistry Today Feb 2011
*Decreased mastication efficiency
*GI issues
*Difficulty with speech (99%)
*Poor retention (62%)
*Lower denture discomfort (63%)
*Contemporary Implant Dentistry Misch CE, 2007
The Anatomy of the Edentulous
Mandible
 Review of the 4 types of bone
 Inferior Alveolar Nerves
 Mental Foramina
 Superior and Inferior borders/cortices
 Symphysis
 INSERT IMAGE OF A REGULAR PAN
Types of Bone
D1:
 -Almost entirely cortical in nature
 -1250 or greater Hounsfield Units
 -Primarily found in the anterior/symphyseal region
 -Least vascular and most dependent on the periosteum for its vascular and
nutritional needs
 -Greatest Bone-to-Implant Contact (BIC)
 (Insert Image of D1 bone and PAN with D1)
D2:
 -Composed of thick crestal bone with intermediary coarse trabecular bone
 -850-1249 Hounsfield Units
 -Primarily found in the anterior and posterior mandible
 -Excellent BIC and abundant intrinsic vascularization
 -Ideal for implant placement
 (Insert Image and PAN of D2)
D3:
 -Composed largely of porous cortical bone and fine trabecular bone
beneath
 -350-849 Hounsfield Units
 -Primarily found in the anterior and posterior maxilla and occasionally the
posterior mandible
 -Highly vascular and porous which aids in osseointegration but is usually
slower to osseointegrate and has reduced initial stability compared to D1 and
D2 bone
 (Insert Image and PAN of D3)
D4:
 -Composed primarily of fine trabecular bone and an often complete absence
of cortical bone
 -<350 Hounsfield Units
 -Primarily found in the posterior maxilla
 -Least favorable BIC and extra care must be taken in drilling the osteotomy
Inferior Alveolar Nerves
 *Must be extremely cognizant of its location relative to
planned implants
 -Not usually a consideration when dealing with
overdentures
Mental Foramina
 The objective with an overdenture that is retained by SDI is to keep the
planned implants (usually 4) anterior to and within the intraforaminal space
 -Placing the most distal implants 7mm anterior to the mental foramen will
ensure a sufficient safety margin
 **Misch has shown that for any patient, the average distance between mental
foramina is always 44-46mm
 Therefore: the easiest rule of thumb is to measure 5mm distal from the center
of the mandible on either side for the first 2 implants and then an additional
10mm distal to those implants for the 3rd and 4th implants.
 -Doing so will ensure even spacing of the implants and place you 7mm anterior
to the mental foramina bilaterally
Inferior Border of the Mandible
 Must maintain a distance of 3mm from the apex of the
mini implant to the most inferior aspect of the inferior
cortical border
 Insert image of PAN with a graphic showing the 3mm
buffer
Comprehensive Medical and Dental History
It is imperative to get as comprehensive a medical history as possible
-Review their MH with them after they have completed it
-Also obtain a thorough surgical history (even though SDI are relatively
atraumatic and non-invasive, there still exists the potential for complications
and an understanding of how a specific patient has responded to surgery in
the past can be invaluable in managing any situations that arise)
There are certain conditions which are of particular
concern when dealing with potential implant candidates:
-Diabetes
-Uncontrolled HTN
-History of H/N CA with XRT
-Use of bisphosphonates
BLOOD GLUCOSE (FOR IDDM AND NIDDM):
*BGL: 70-120 mg/dl before meals and under
140 mg/dl within 2 hours of eating
*A1C: <6.0% is normal; For diabetics: <7.0% is
well-controlled; >8.0% indicates very poorly
controlled
*Normal: <120/80
*Pre-Hypertension: 120/80-139/89
*Hypertension: >=140/90
*Would recommend to defer any surgical procedures with BP of:
>180 Systolic
>105 Diastolic
*Would recommend defer any invasive (flap, extraction) surgical
procedures with BP of:
>160 Systolic
>100 Diastolic
*First reported by Mark in 2003 (1)
*Defined as: “exposed bone in the maxilla or mandible that fails to heal within 8
weeks in a patient receiving/has received a systemic BPN and who has not
received local radiation therapy to the jaws” (2)
*Incidence: true number not known, but estimates:
-IV: 0.8-30% (probably around 8%) (2)
-Oral: 0.015% (2)
*3 million individuals worldwide have had IV BPN therapy and 13 million women
in US alone are on Oral BPN (2)
(1) Marx RE, AAOMS, Sept 2003
(2) Matthew I, TODS Meeting
*94% of all BIONJ are due to IV, only 6% due to oral
*According to Marx, mean duration of use before onset of
necrosis is 3 years and is dose and time dependent
*C-Terminal Telopeptide (CTX) Levels (Picogram/ml):
>100 pg/ml: HIGH RISK
100-150 pg/ml: MODERATE RISK
>150 pg/ml: MINIMAL RISK
Insert Images of BIONJ
*Perform any planned procedures 2-3 weeks prior to
starting XRT
*ORNJ greatest with >4000 cGy
*Defer any elective treatment for at least 3-12 months after
XRT completed
*Study Models
*Bite Registration (if indicated)
*Set of Full Mouth Radiographs (if indicated)
*Panoramic Radiograph
*Intra-Oral Photos
*CBCT scan (if available and indicated)
*Determine how long the patient has been edentulous
*How old is their denture or other prosthesis if they have one?
*What is their chief complaint?
*What treatment options have they considered or tried in the
past?
*What has worked for them? Are there any treatment options
they are opposed to having done?
*What are their expectations for implants and implant-retained
dentures?
Once all the relevant medical and dental information has been
gathered, the next step is to assess the data and determine the
patient’s suitability for implants
-One of the benefits of SDI is that virtually any patient with an
edentulous mandible would benefit from and is suitable for
their placement
It is strongly recommended that you select and treat a minimum
of 10-20 ideal patients before attempting more complex cases
*No medical or surgical contraindications
*Edentulous mandible
*4-5mm of buccolingual alveolar width in the planned implant
sites
*Flat crestal ridge with no undercuts or osseous irregularities
*Alveolar ridge height of at least 13mm
*Sufficient keratinized, attached gingiva (3-4mm)
*Occluding against an edentulous maxilla restored with a
complete denture
Image of a PAN with the ideal mandible
*Determine the radiographic testing required:
-PAs<PAN<CBCT
-PAs are essentially non-diagnostic for the purposes of implant site selection; they
are indicated only for localized, low tech analysis of pathology in the planned site
*Perform visual inspection of the ridge to appreciate any significant defects or tori
*Manually palpate the ridge lingually and buccally so as to obtain a mental image
of what the ridge looks like and any undercuts that may be present
*Measure the buccolingual width to ensure at least 5mm of width to accommodate
the 2.2mm diameter implant, while maintaining at least 1.5mm of buccal and
lingual bone around the implant
*Determine the location of the mental foramina and the middle of the symphysis
*Inspect the status of the gingiva in the planned sites
-Confirm adequate keratinized tissue
-Determine the thickness of mucosa and tissue overlying the
planned sites
-Absence of any lacerations, ulcerations, or other soft tissue
injury
*Confirm there is no active infection or other pathology in the
planned implant sites
*Inspect the trabeculation patterns of the bone to determine the
viability of the bone, particularly in diabetic and
bisphosphonate users
*Verify the location of the mental foramina and the
intraforaminal distance
*Confirm you have at least 13mm of alveolar height to ensure the
apex of the implant is at least 3mm from the inferior border
*5.4mm or less of D1/D2 Bone: 2.2mm implant
*5.5mm or more of D1/D2 Bone: 2.5mm implant
*6mm or more of D3 Bone: 3.0mm implant
*Best to avoid D4 bone
*When using a PAN by itself, direct measurement of the ridge
height can be performed
-Must take into account the Distortion Percentage of your
PAN machine
-If unsure of the DP, then assume it to be 125% and factor this
into your final measurement
*When using a CBCT scan, a direct measurement can be made
of the ridge in all dimensions or exported to a third party DTP
software to virtually place an implant and fabricate a surgical
guide if desired
*Must be taken into account when selecting your implant
length, otherwise you may not have as much bone available as
you predict
Example:
You determine you have 13mm to the inferior border of the
symphysis. If you have a 125% distortion and don’t allow for it,
you might actually only have less than 10mm available.
13mm – (13x.250)=9.75 a 10mm could not be safely placed
Insert slide with the PAN implant overlay that shows the 125%
distortion
*If you want to ensure the most accurate placement of the implants,
whether it be for restorative purposes to ensure parallelism, or if there
is concern about proximity to anatomical structures, digital treatment
planning (DTP) can be completed and even surgical guides can be
fabricated to achieve the highest accuracy
Insert images of the DTP packages
Surgical Protocol
*Thoroughly review the planned procedure and the risks versus
benefits with the patient
*If possible, provide them a video demonstrating the procedure,
from the placement of the implants to the relining of their
denture to the final restoration
*If indicated, provide the patient with the appropriate preoperative medication prescriptions
*Review their medical history and be aware of any changes in their conditions or
medications
*Review the planned procedure, answer any last minute questions, and obtain
verbal and written informed consent
*Obtain an accurate reliable Bite Registration of their existing dentures and then
remove their dentures
*Have patient rinse with 0.12% Chlorhexidine Rinse (Peridex) for a full minute
prior to beginning treatment
*Using an intra-oral marking pen or Thompson’s Stick mark the mental foramina
on the ridge crest
*Note the middle of the symphysis and measure 5mm to the left and right of it;
these will be the locations of the most anterior implants
*Measure an additional 10mm posterior from the first implants and mark them;
these will be the locations of the most distal implants
*Administer a small amount of local anesthetic only in the planned implant sites
*When placing the 2.2mm or 2.5mm implants, you will use the
1.5mm and 1.7mm diameter drills, respectively
-Drill to 1/3-1/2 of the implant length
*When placing the 3.0mm implant, you will use the 2.4mm
diameter drill
-Drill to at least 2/3 of the implant length, often to full length
*If performing Guided Surgery, confirm the fit of the guide, the
location of the planned implants, and the sleeve diameters
Insert Video of Osteotomes Being Drilled
*Grasp the implant carrier, being careful not to touch the sterile body of
the implant
*Deliver the implant to the pilot drill hole and begin the insert the
implant with hand pressure, being careful to minimize lateral forces
*Continue to hand torque the implant until the carrier separates from
the implant, then continue with the implant driver
*Final insertion and stability is achieved using the torque wrench;
rotate the torque wrench 90 degrees at 7-10 second intervals until only
the implant head is visible and the collar is embedded in the gingiva
*Final Torque: At least 35 Ncm, do not exceed 45 Ncm
*If the desired initial stability cannot be achieved, it is recommended to
use a shorter implant
Insert Video of Implants Being Placed
*Use of minis in the maxilla is similar to that of the mandible with a
few exceptions:
-The bone tends to be softer, generally D3 in quality; use widest
implant possible to maximize initial stability in soft bone
-Recommended to place 6 implants
-Must be aware of the proximity to the sinus in certain cases;
generally it is recommended to leave at least a 1mm safety margin
from the sinus but many implantologists prefer to perforate the
sinus a small amount to gain bicortical stability by using the bony
sinus floor
-When restoring, it is best to use a Progressive Load Strategy: the
palate is removed in stages, allowing the implants to absorb the
loading forces gradually; defer removal of the palate until the
implants have fully integrated and use only a soft reline
Insert Several Slides of a PAN with 6 Minis in Place
Insert Image of an Edentulous Maxilla with 6 Implants
*Usually only requires an NSAID for mild analgesia
Prosthetic Protocol
*Use Block Out Shims to completely conceal the necks of
the implants beneath their O-ball heads
-This prevents impression material from flowing under
the O-ball
*Snap a Mini Implant Impression Coping onto the head of
each implant
*If gingival tissue prevents full engagement of a coping
onto the implant, take an impression of the implant
without the use of the impression coping, or trim the
tissue
*Standard impression is taken (closed tray is preferred)
-Full Arch PVS is recommended
*Once the impression has fully set, carefully remove it
from the patient’s mouth
*Confirm that all the impression copings have been
transferred/captured in the impression
*This step can be performed either in your office or by
Glidewell Laboratories
*Align the squared neck of a Mini Implant Analog with the
squared opening at the base of the impression coping
*Press the analog into the coping until it snaps into
proper position
*Insert a lab analog into each coping and prepare the
impression to be used to fabricate a stone model
*A Soft Tissue Model is fabricated by the laboratory
(Insert Image of ST Model)
*A soft denture reline procedure is used when immediate
loading with the O-rings is contraindicated, as in the case
of a transitional prosthesis, or whenever the Inclusive
Mini Implants are placed in soft bone (such as the maxilla
or a Type III mandible)
*Approximately four to six (4-6) months after a soft reline,
the soft inner liner can be replaced with a hard pick-up of
the O-ring housings to increase the level of retention
*Relieve the patient’s existing denture to make room for
the implant heads. The positions of the implants can be
identified using a color transfer applicator, or by lining the
intaglio surface of the denture with impression or bite
registration material. An acrylic bur can then be used to
relieve the denture
*Lightly roughen the tissue-facing surface of the denture
with an acrylic bur, and degrease the surface with
isopropyl alcohol
*Apply the selected soft reline material onto the tissue-facing
surface of the denture
*Seat the denture in the patient’s mouth. Instruct the patient to
close with normal pressure into centric occlusion
*Allow the soft reline material to set
.
*Remove the denture from the patient’s mouth and trim excess
material with fine scissors or a surgical blade. Do not remove
the palate of a maxillary denture during this stage
*Instruct the patient to keep the denture in place for the first 48
hours following placement, to prevent gingival overgrowth
*A hard denture reline procedure is used to incorporate
the retention caps (O-ring Housings) that cover the
Inclusive Mini Implants in the patient’s final prosthesis
*This loading procedure can typically be performed
immediately after placement of the Inclusive Mini
Implants, provided primary stability and appropriate
occlusal loading are assured
*Primary stability is generally indicated when 35 Ncm of
torque resistance is achieved, with implants seated at the
appropriate gingival depth
*Mark the location of the implants on the intaglio surface
of the patient’s existing denture. This can be done using a
color transfer applicator, or by lining the intaglio surface
of the denture with impression or bite registration
material
*Relieve the denture to make room for the O-ring
housings. This can be done by creating a space for each
housing where marked (or by burring a full trough)
*Trim the blockout shims to the appropriate length in
order to completely mask the exposed neck of each
implant beneath the O-ball head. This is critical to
prevent pick-up material from flowing under the O-ball
*Place an O-ring housing on each mini implant, checking
for passive fit over the blockout shims
*Place the denture in the patient’s mouth, checking for
passive fit over implants and housings
*Apply a thin layer of adhesive on the intaglio surface of
the denture
*Place hard pick-up material directly onto the O-ring
housings and into the housing spaces (or trough) in the
denture
*Seat the denture in the patient’s mouth. Instruct the
patient to close with normal pressure into centric
occlusion.
*Allow the hard pick-up material to set
*Remove the denture and all blockout shims
*Trim and polish
*Instruct the patient to keep the denture in place for the
first 48 hours following implant placement, to prevent
gingival overgrowth
Insert Image of Mand Case Completed
Insert Image of Completed Max Case
*No SDI currently have FDA approval for crown and bridge
applications but they often are utilized for this purpose, either
for single unit cases or as anchors for short span bridges
*We do not endorse the use of the Inclusive Minis in C&B
*In those instances when they are utilized for this purpose, it is
often the case that multiple implants are used per tooth
*Recent study concluded that “Replacing a single, missing molar
with 2 narrow diameter dental implants might serve as a viable
treatment option providing good and predictable long-term
results.” (1) 50/66 used in mand; 16/66 in max and all were still
functional after 1 year
(1) ICOI Implant Dentistry Feb 2012
Insert Multiple Slides of PAs and Images of SDI Crowns
Insert Multiple Slides Showing Problems with SDI Crowns
Post-Operative
Complications
*Rarely have any post-operative complications:
*Possibly some bruising or swelling at the surgical site
-Bruising resolves on its own and swelling treated with antiinflammatories
*Mild to moderate bleeding especially for patients that are anticoagulated
-Usually tamponaded by the implant itself, or apply moderate
pressure with gauze
*Failure of implant(s) to osseointegrate
-Either remove the implant and replace with a wider, longer
implant in same area or place another implant in different
location
*Sinusitis
-Usually managed with antibiotic and antihistamine
*Sinusitis:
-Can occur commonly as a result of perforation or irritation of the sinus
lining (Schneiderian Membrane)
-Usually a temporary situation, and best managed with antihistamines and
antiobiotics
-For more severe or systemic sequalae, refer to the ER, OMS or ENT prn
*Other Infections (site specific)
-Very rarely occur, but when they do, must be managed aggressively and in a
timely manner
-Antibiotics prn; I&D prn; Removal of implant if suspected to be the direct
cause
*Generally would be into the sinus
-Depending on the size of the implant and the patient’s sinus
history, may be decided to leave it alone or may require a
Caldwell Luc Procedure to retrieve it
-But should be referred to OMS for evaluation to determine the
necessary course of treatment
-Displacement into the submandibular or sublingual space is
more ominous, and should be referred immediately to a
specialist
*The best offense is a good defense in this case
-Adhere to the drilling guidelines and intraforaminal boundaries
and should not have a problem
-Review the PAN and CBCT scan (if available) to help ensure you
are not near a major nerve bundle
-If sensory changes occur, it is most likely a bruising or
compression of the nerve, not a frank dissection
-Treatment with steroids often helps to relieve neuro issues or
removal of the implant if it is compressed
-A true dissection of the nerve would likely be permanent and
should be thoroughly documented and referred for an OMS or
neuro consult
Would be extremely rare but if it did occur, be
sure and seek immediate assistance from a
trusted OMS
The main concern in this situation would be injury to
anatomical structures in the floor of the mouth, such
as the lingual artery/vein or the submandibular gland
-For laceration of an artery and brisk bleeding, apply
bimanual pressure and gauze; if needed, consider
ligating the vessel or tamponading with bone wax
-For a truly emergent hemorragic situation, protect
the airway and refer immediately to a specialist or
EMS if necessary
 BREAK FOR LUNCH
*Thoroughly educate your staff (RDHs, DAs, Front Desk)
on the basic of minis
*Have educational videos and visual aids, models; patients
are very tactile and visual consumers
*Present 2 or 3 separate treatment plans; start with the
most comprehensive, expensive plan and then an
intermediate plan and by the time you arrive at the $25004000 mini option, it is even more appealing
 Commence Workshop for Afternoon
Obtain Images of Various Cases