Short-Term Objective and Subjective Evaluation of ...

Short-Term Objective and Subjective Evaluation of Small-Diameter Implants Used to Support and Retain Mandibular Prosthesis

| Continuing Education Exam #38

Robert Brandt, D.D.S., M.S., Scott Hollis, D.D.S., Swati Ahuja, B.D.S., M.D.S., Pradeep Adatrow, D.D.S., M.D.S., William Balanoff, D.D.S., M.S.

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Introduction Traditionally, 3.5 mm and larger endosteal root form implants have been used successfully to stabilize and retain both removable and fixed prostheses for edentulous and partially edentulous patients.1,2,3 Also, to insure a successful integration with the root form implant, immediate loading was originally not recommended. Instead, a period of time, usually about 4-6 months, was recommended for osseointegration before loading implants.1, 2 Delay in receiving final prosthesis leads to aesthetic, dietary and phonetic difficulties during the integration period.4 Another alternative in this situation has been to place smalldiameter implants in the healing phase to support and retain the transitional prosthesis.5, 6 It was observed, at times, that the small-diameter implants had effectively integrated and were difficult to retrieve.7, 8 Also, many patients who have been edentulous for a long period of time have significant ridge resorption and are left with thin atrophic ridges. It is difficult to place conventional implants in these patients without extensive grafting. Many patients thus reject the option for getting implants due to the increased cost of treatment. However, due to their size, small-diameter implants have been successfully placed in thin atrophic ridges without the need for grafting.9, 10 The small diameter implants requires minimal surgery time hence is economical for the patients. Thus, the use of small diameter implants as a definitive treatment alternative to regular size root form implants has became viable to stabilize removable and fixed prostheses.7, 8, 11-14

To date, there has been no study of the subjective and objective outcomes of

T D A EXAM #38

ABSTRACT Background: The introduction of small-diameter implants has provided dentists the means of providing edentulous and partially edentulous patients with immediate functioning transitional prostheses while definitive restorations are being fabricated. The successful use of these small-diameter implants for temporary stabilization of prostheses has led many clinicians to explore the option of using them as a definitive alternative, especially as the technique requires minimal time and also is economical for the patients. To date, there has been no study with multiple patients looking at both the subjective and objective outcomes of these small-diameter implants. Materials and Methods: Twenty-seven edentulous patients were enrolled in this study, seven of them were smokers. One-hundred and eight small-diameter (2.0 mm, MDL) implants were surgically placed in 24 edentulous mandibles. All implants were immediately loaded. The patients filled out a screening questionnaire and four subsequent questionnaires to test their satisfaction with the altered prosthesis at 6, 12, 18 and 24 months. The survival of the implants was also noted. Results: Smokers had an implant survival of 79%. Non-smokers had an implant survival of 100%. The results of the questionnaire indicated an overall satisfaction with the implant-supported prosthesis. Key Words: Small-diameter implant, Overdenture, Immediate load, Intra-Lock

these implants, therefore, the researchers embarked on a two-year clinical research project to test patient satisfaction and survival of the 2.0mm MDL small diameter implant (Intra-Lock System International, Boca Raton, Florida) with an immediate load protocol to retain and stabilize mandibular dentures. Materials And Methods Thirty-four (34) patients between the ages of 35 and 70 wearing comfortable complete dentures were initially screened, however only twenty-seven were accepted into the study. The inclusion factors used during the screening process were: 1. Patients had to be present for treatment and follow-up examinations according to the scheduled requirements of the

research project. 2. Patients had to be between the ages of 35 and 75 years. 3. Patients were selected regardless of sex, race, or ethnicity as suggested by NIH and FDA guidelines. 4. Patients had to be edentulous and must not have root pieces, deep undercuts, bony exostosis, or any oral pathology. Exclusion factors were: 1. Uncontrolled diabetes 2. Psychological disturbances 3. Existing malignancy, and must not be receiving immune suppressive therapy, such as radiation therapy, chemotherapy, or chronic steroid therapy 4. Advanced cardiovascular disease 5. Pulmonary disease

Journal of the Tennessee Dental Association • 92-1

6. Renal disease 7. Liver disease 8. Significant alcohol ingestion 9. History of treatment that involved the use of oral or intravenous bisphosphonates 10. Musculoskeletal diseases 11. Neurological diseases

Figure 1B - 1.5mm drill through cortical plate

Surgical Phase: Placement of Implants The appropriate length and diameter of the implants to be placed in the patients was determined via clinical palpation and calibrated panoramic radiographic examination. Local anesthesia was achieved by buccal and lingual infiltrations of the anesthetic solution in the region of the mental foramen. Bleeding points created by a periodontal probe marked the sites of implant placement. A tissue punch (Figure 1A) and a 1.2mm pilot drill were the only instruments required for the osteotomy of a 2.0mm diameter implant. The tissue punch was used to clear the tissue in the area of the osteotomy. The 1.5mm drill was used to break through the cortical bone to allow selftapping of the Mini DriveLock Implant. These drills were used at 600 rpm using light, intermediate pressure, with external saline irrigation. (Figure 1B). The osteotomy was accomplished through the overlying gingiva, without a tissue flap. The implant was placed with a hand-held driver. (Figures 2,3) The intra-Lock Mini Drive-

92-1 • Short-Term Objective and Subjective Evaluation of Small-Diameter Implants Used to Support and Retain Mandibular Prosthesis

Continuing Education Exam #38 |

Patients filled out a screening questionnaire providing information on how they felt about their dentures. The complaints focused on comfort, stability, and confidence. Of the eleven patients not accepted, three had existing abutment teeth, four had uncontrolled systemic diseases, and three needed remakes of their maxillary and mandibular dentures. By means of a panoramic radiographs it was determined that every patient accepted into the study possessed adequate bone quantity and quality for implant placement. Undergraduate students at the University of Tennessee fabricated all the dentures worn by these patients. During the surgical phase of the study, three patients failed to appear for their appointments, making the final subject count of twenty-four patients. Each patient signed a University of Tennessee Institutional Review Board approved consent form prior to implant placement. The protocol consisted of placing four MDL (Mini Drive-Lock) implants between the mental foramina in the mandibular anterior region. The lower denture was adjusted to accommodate the four O-ring metal housings in areas corresponding with the MDI implants. The metal housings were picked up in the lower denture using acrylic resin. The mandibular denture was immediately

Figure 1A - 2mm tissue punch to crest of ridge

loaded onto the four implants. Patients were recalled at 3, 6, 12 and 24 months to answer questionnaires and/or clinical and radiographical evaluation. The MDL small diameter implants used in this study were manufactured by IntraLock (Boca Raton, Florida). They are acid-etched titanium grade 23 implants, available in five different lengths (10mm, 11.5mm, 13mm, 15mm, and 18mm). A 2mm gingival collar is found on the 2.0mm implant. The MDL O-ring housing is designed to allow up to 20 degrees of implant divergence.

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Lock Implants are packaged in a sterile titanium cradle. This design allows for the implant to be removed from the vial and transported directly to the implant site. The transfer can be accomplished using the Mini Drive-Lock Implant Contra-angle Driver (MDLCAD) or the Mini Drive-Lock Ratchet Driver (MDLRD). The Mini DriveLock Implant Contra-angle Driver (MDLCAD) snaps over the o-ball and engages the square-driving feature. Once the implant is secure, it can easily be transported to the site and placed in osteotomy site. Once in position the contra-angle was set at 15rpm with a torque setting of 35Ncm and the implant was allowed to slowly self-tap into the cancellous bone. Once the handpiece stalls at 35Ncm, the contra-angle drive-lock driver is removed by lifting and separating it from the implant. The Mini Drive Lock Ratchet Driver (MDLRD) is placed in the ratchet wrench and attached to the implant in the same manner as the MDLCAD. Using small incremental turns, the implant is seated until the shoulder of the collar is flush with the height of the surrounding gingival. (Figure 4,5)

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Restorative Phase: Denture modification to pick up the attachments The position of the O-ball abutments were then transferred to the tissuebearing side of the lower complete denture via a dye impregnated marking stick. Those areas on the denture were prepared to make space for the O-ring and metal housing using a round acrylic bur. (Figure 6) The O-ring metal housings were then placed on each implant and marked to ensure adequate

Figure 2 - Implant placed with hand-held driver

Figure 3 -Hand-held driver

Figure 4 - Shoulder of ball flush with surrounding tissue

acrylic was removed. The patient was then asked to close into maximum intercuspation to evaluate their occlusion. Once a passive fit was achieved and the occlusion confirmed, the denture was cleaned and dried. The O-ball attachments were lubricated and the o-ring housings placed back on the implants. (Figure 7) Cold-cure acrylic was then placed in each recess and the denture was seated. The patient was asked to lightly close into maximum intercuspation and hold that position as the acrylic polymerized. The denture was then removed from the patient’s mouth, excessive material was trimmed, voids, if present, were filled and the denture was polished and delivered to the patient. (Figure 8) The patients were instructed not to remove the denture in the initial 24 hours. They were given instructions on placement and removal of the denture. Additionally, they were provided with a Chlorhexidine mouth rinse and a post-operative soft toothbrush to help clean around the implants. The patients were then scheduled for a one-week post-op visit. A total of 96 MDL IntraLock implants were placed in 24 patients. The patients were recalled at 3, 6, 12, and 24 months for clinical and radiographic evaluation and to fill out questionnaires regarding comfort and stability of their dentures. During each evaluation appointment, the patients were asked to complete a survey. The survey had four questions related to the fit and function of the lower denture. 1. How well can you bite with your present dentures after occlusal adjustments as compared with before


Figure 5 - Four implants placed in the mandible

implant placement? 2. Rate your satisfaction from your present dentures after implant placement as compared with before implant placement? 3. How secure do you feel with your present dentures after implant placement compared with your present dentures before implant placement? 4. How much have your present dentures, after implant placement, affected your speech compared with your present dentures before occlusal adjustments? Each patient was asked to grade each question using the following scale: 1 - Extremely poorer than before 2 - Considerably poorer than before 3 - Slightly poorer than before 4 - The same as before I got the replacement 5 - Slightly better than before 6 - Considerably better than before 7 - Extremely better than before.

Figure 6 - Mandibular denture relieved to facilitate passive implant connection

Results The results of the screening questionnaire indicated that the denture satisfaction prior to implant placement was 3.8 out of 7. The results of the questionnaires at 3 months, 6 months, 12 months and 24 months following implant placement indicate an overall satisfaction and improvement with the dentures. Only six of ninety-six implants were lost in the first 3 months. All the implants that were lost were placed in smokers (4 on one patient and 1 each on other two patients)

Conclusion None of the implants were lost after 6 months until 3 years. These results indicate a safe, effective and inexpensive method for adding implants to the treatment plan of complete mandibular dentures. The one concern is the high failure rate in smokers. Therefore, it is questionable to indicate these implants in smokers. Further studies using smalldiamenter implants as definitive implants need to be done both in smokers and non-smokers to confirm the findings of this study.

Discussion The combined satisfaction rating of 3.8 out of 7 shows dissatisfaction with the initial efficiency and stability of their complete dentures. The results of the questionnaires indicate that the patients were able to masticate and speak with added security after placement of 4 mandibular small-diameter implants.

Disclosure. None of the authors reported any disclosures.

2. Branemark PL, Hansson BO, Adell R, et al. Osseointegration Implants in the Treatment of the Endentulous Jaw: Experience From a 10-Year Period. Scand J Plast Reconstr Surg Hand Surg. 1977;2(16):1-132

Figure 8 - O-ring receptacles picked up in the denture with acrylic resin, excess resin removed

92-1 • Short-Term Objective and Subjective Evaluation of Small-Diameter Implants Used to Support and Retain Mandibular Prosthesis


Figure 7 - O-ring receptacles placed on implants

References 1. Adell R, Lekholm U, Rockler B, Branemark PL. A 15-Year Study of Osseointegrated Implants in the Treatment of the Endentulous Jaw. Int J Oral Surg. 1981;10(6):387-416

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3. Cochran DL, Morton D, Weber HP. Consensus Statements and Recommended Clinical Procedures Regarding Loading Protocols for Endosseous Dental Implants. Int J Oral Maxillofac Implants.2004;19(suppl):109–113 4. Ahn MR, An KM, Choi JH, Sohn DS. Immediate Loading with Mini Dental Implants in the Fully Ddentulous Mandible. Implant Dent 2004;13(4):367–372 5. Attar MS, el Shazly D, Osman S, el Domiati S, Salloum MG. Study of the Effect of Using Mini-Transitional Implants as Temporary Abutments in Implant Overdenture Cases. Implant Dent. 1999;8:152-158 6. Balkin BE, Steflik DE, Naval F. Mini Dental Implants Insertion with Auto Advance Technique for Ongoing Applications. J Oral Implantol. 2001;27:32-37 7. Christensen GJ. The ‘Mini’ Implant Has Arrived. JADA 2006;137(3):387–390 8. Christensen GJ. The Increased Use of Small-Diameter Implants. J Am Dent Assoc, Vol 140, No 6, 709-712 9. Bulard RA, Vance JB. Multi-Clinic Evaluation Using MiniDental Implants for Long-Term Denture Stabilization: A Preliminary Biometric Evaluation. Compend Contin Educ Dent 2005; 26(12):892–897 10. Mazor Z, Steigmann M, Leshem R, Peleg M. Mini-Implants to Reconstruct Missing Teeth in Severe Ridge Deficiency and Small Inter-Dental Space: A 5-Year Case Series. Implant Dent 2004;13(4):336–341

11. Coomfort, M.B.,, Chu, F.C. ,Chai, P. Y. P. WatT, T. W. Chow, . A 5-Year Prospective Study on Small Diameter Screw-Shaped Oral Implants, Article first published online: 12 APR 2005 12. Flanagan D. Implant-Supported Fixed Prosthetic Treatment Using Very Small-Diameter Implants: A Case Report. J Oral Implantol 2006;32(1):34–37 13. Griffitts TM, Collins CP, Collins PC. Mini Dental Implants: An Adjunct for Retention, Stability, and Comfort for the Edentulous Patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005;100(5):e81–e84. 14. De Leonardis, D Garg AK, Pecora GE, Andreana S. Osseointegration of Rough Acid-Etched Implants: One-Year Follow-Up of Placement of 100 Minimatic Implants. Int J Oral Maxillofac Implants. 1997;12:65–73

Robert Brandt, D.D.S., M.S., Professor, Department of Prosthetic Dentistry, University of Tennessee Health Science Center, College of Dentistry in Memphis, Tennessee. Scott Hollis, D.D. S., Assistant Professor, Department of Prosthetic Dentistry,

University of Tennessee Health Science Center, College of Dentistry in Memphis, Tennessee. Swati Ahuja, B.D.S., M.D.S., Assistant Professor, Department of Prosthetic Dentistry, University of Tennessee Health Science Center, College of Dentistry in Memphis, Tennessee. Pradeep Adatrow, D.D.S., M.D.S., Resident, Graduate Prosthodontic Program, University of Tennessee Health Science Center, College of Dentistry in Memphis, Tennessee. William Balanoff, D.D.S., M.S., Private Practice, Florida. Corresponding author: Dr. Swati Ahuja, Dunn Dental Building, 875 Union Ave., Memphis, TN 38103, [email protected]

Questions for Continuing Education Article - CE Exam #38


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1. The introduction of small-diameter implants has provided dentists the option of: a. immediate functioning transitional prostheses b. economical partial dentures c. orthodontic anchor use d. none of the above

4. What makes the small-diameter implants attractive to dentists for implementation: a. they are safe b. they are effective c. they are inexpensive d. all the above

2. The survival of implants in this study was: a. 100% for non-smokers b. 79% for smokers c. 75% for both smokers and non-smokers d. answers a and b

5. What was the greatest concern in using smalldiameter implants: a. they are too easily dropped b. they are difficult to place c. they have a high failure rate in smokers d. all the above

3. One advantage for using small-diameter implants is: a. they are more easily aligned b. they don’t integrate too quickly c. they may be used in atrophic ridges Publication date: Spring 2012. Expiration date: Spring 2015. d. all the above

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