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Mini Dental Implants- The Same Day Implants

Puneet Chopra,1 Priyanka Chopra,2 Harpreet Singh Grover3
preserving adjacent teeth. (13) In clinical situations where residual dentitions are healthy and there are no ABSTRACT systemic contraindications, dental-implant therapy may represent the highest standard of care for tooth The computer and medical worlds are both striving to develop replacement. smaller and smaller components. In similar fashion, The Mini Several different types of implants and restorations are Dental Implants represents a smaller version of the dental available. The problem is, many of them are expensive implant. and require a long recovery. The options depend upon Mini Dental Implants are titanium screws that replace the root of the amount of bone available, the patient's general a tooth. The ball shaped head and collar design can be used for health, and restoration preference. Three general both permanently cemented crowns and bridges as well as categories of implant diameters are available: the minisecuring full or partial dentures. When used for fixed or cemented implant (1.8 mm), the standard-sized implant (3.75 applications the prosthesis is cemented directly to the head of the mm) and the wide-body implant (6.0 mm), with all implant. As a revolutionary departure from routine dental implant sizes in between. Use of mini-diameter implants is methods, Mini Dental Implants are so narrow they are typically increasing. (4-13) inserted directly through the overlying gum tissue and into the Some implant companies have recognized the challenge bone underneath. Consequently the need to surgically cut and of minimal bone presence and made implants of a flap open the gum tissue, routinely required for standard smaller diameter (ranging from 3 to 3.5 mm). Although implant systems, is avoided in most Mini Dental Implant this change is only a slight reduction in diameter, it has applications. As a result, post-insertion patient irritation and allowed easier placement of root-form implants in the soreness is significantly reduced. maxillary lateral incisor area, mandibular anterior sites It is often possible to provide the complete mini implant service or in any area in which bone has shrunken. These in a single office visit. Because of the unique, minimally invasive procedure, the minute size of the implants, and the characteristic slightly smaller-diameter implants have been used placement area, the patient can enjoy a light meal an hour after widely and have been successful, in spite of allegations having the mini implants placed. that they would be too weak. With Mini Dental Implants, less bone is necessary, which is a great Mini Dental Implants are titanium screws that replace benefit for patients who have previously been told they would the root of a tooth. The ball shaped head and collar need bone grafts to receive any dental implants. Mini Dental design can be used for both permanently cemented Implants are surprisingly affordable, at a fraction of the cost of crowns or bridges as well as securing full or partial traditional implants. It is safe, biocompatible and provides an dentures. improved method of tooth replacement. MDI, the mini dental implant system, FDA approved Mini dental implants clearly represent an enormous breakthrough for the dental implant specialty as the most patient-friendly, costprocedure is available at a fraction of the cost of effective, proven dental implant system available today. traditional implants. Mini Dental Implants are constructed out of the same titanium alloy as the larger Key Words: Mini Dental Implants, endosseous, titanium size traditional implants. Since the mini dental implant is a solid screw, a traditional implant is hollow in the center, it can be around half the size of a regular dental implant and just as strong. Introduction With the growing marketplace for dental implants and the advent of new technologies, implant design Dental Implant therapy has been one of the most principles can affect success of immediately loaded significant advances in dentistry in the past 25 years. implants. In 2006, Wang et al. (14) provided a definition Endosseous dental-implant rehabilitation can provide based on a consensus from the International Congress partially or completely edentulous patients with of Oral Implantologists in which immediate loading was function and esthetics similar to natural dentition while described as a technique in which the implant preserving adjacent teeth. (13) In clinical situations IJCD JUNE, 2011 2(3) restoration is placed into functional occlusal supported 89 where residual dentitions are healthy and there areJournal of Contemporary Dentistry 2011 Int. no loading within 48 hours of implant insertion. systemic contraindications, dental-implant therapy may

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described as a technique in which the implant supported restoration is placed into functional occlusal loading within 48 hours of implant insertion. MINI DENTAL IMPLANTS Mini dental implants are sometimes referred to as MDIs or small diameter implants (SDIs) or narrow body implants (NBIs). The narrow diameter or mini-implants are endosseous implants made of titanium alloy and less than 3 mm in diameter. They were introduced commercially to the dental profession in the 1990s and were first used for transitional prosthesis support. (1516) Late in l997, Dr. Sendax collaborated about his mini implant theory and design concepts with a colleague, Dr. Ronald A. Bulard who wasalready manufacturing and marketing standard sized dental implants, abutments, and other dental products. These so-called "mini"-diameter implants have been used successfully as interim implants to support provisional prostheses, while larger-diameter implants were integrating into bone. When minis were used as interim implants, the intent was to remove the miniimplants when the larger-diameter implants were put into service. As might have been anticipated, when attempting to remove these interim mini-implants, practitioners found that they could not be removed, because they had integrated into the bone during the interim service period. The pull-out strength of endosseous implants may be based on the length rather than the diameter of the implant,(17) and histologic analysis has shown that mini implants undergo osseointegration comparable to that of larger-diameter implants.(18) These findings have led some clinicians to advocate the use of mini implants to support and/or retain definitive prostheses.(19-21) Some small diameter implants are used as anchors for orthodontic use and are called TADs or temporary attachment devices. These differ from the more common mini implants in that they are removed after they are no longer needed and orthodontic treatment is completed. DESIGN OF MINI DENTAL IMPLANTS The design variations allow for use of the implants in the different densities of bone found throughout the mouth. The body connects the tip with the prosthetic head and can be a parallel sided cylinder or a progressively tapered cone. Mini dental implants have a diameter of 1.8mm to 2.9mm and are available in various lengths. Multiple tip, thread, body and head designs are available across the category as well. Most tip designs are sharp or slightly blunted to provide self tapping ability of the implant through the medullary bone. It takes the form of a slim titanium rod with a retaining fixture that can be incorporated into a denture. The head of the implant is shaped like a ball: the retaining attachment contains a rubber O-ring that acts like a socket. This O-ring holds a denture in place by snapping over the ball on the top of the implant. This enables the denture to rest easily on top of the gum tissue. The ball shaped head and collar design can be used for both permanently cemented crowns or bridges, as well as securing full or partial dentures. When used for xed or cemented applications the prosthesis is cemented directly to the head of the implant. If the implant is to be used for a removable denture then a housing with a rubber gasket is attached to the acrylic denture and functions like a button that snaps on and off the implant. The denture sits snugly against the gums and is retained securely, allowing better chewing function and increased condence. Because of the unique procedure, the size of the implants, and the characteristic placement area, the typical MDI patient can enjoy a light meal an hour or so after having the mini implants placed. A denture patient who has had his or her prosthesis stabilized with MDI can remove and replace the denture easily after a little practice, and can then easily utilize good dental hygiene. Mini Dental Implants are available in four lengths, 10, 13, 15 & 18 mms.

Procedure
The procedure is quicker and also non-invasive than that for a normal implant. Due to their size, they can cause little or no discomfort and are placed gently in the jawbone. A small pilot bit is used to create the opening for the implant to be threaded into the bone. Due to the size of the implant, the dentist will use a small finger driver or screwdriver to help with the insertion. Ratchet wrench is used to secure the implant in place. Using such a minimally invasive procedure means the patient can heal faster, have less discomfort, and can use the implant much sooner. A regular implant is placed much differently. It requires a full flap of gum must be pushed back to see the bone. The bone is then removed with a series of burs to create space for the dental implant to be inserted. Most of this surgery can be avoided with a mini dental implant. Interim bis-acrylic composite crowns are fabricated with an indirect technique and cemented on the same day using provisional cement. The interim crown is kept out of occlusion, with minimal interproximal contacts. This approach is defined as nonfunctional immediate loading. (22) These interim crowns are meant merely for esthetics rather than function . The patient is provided with home care instructions and discharged. Ten days after surgery, the patient is recalled for evaluation. The definitive implant supported crowns are usually delivered within 2 weeks of surgery, which is considered to be immediate or immediate-delayed occlusal

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loading. (22) In 2006, Wang et al.(14) provided a definition based on a consensus from the International Congress of Oral Implantologists in which immediate loading was described as a technique in which the implant supported restoration is placed into functional occlusal loading within 48 hours of implant insertion. Furthermore, a distinction was made between the immediate restoration for aesthetic purposes, in which the restoration was placed out of occlusal contacts, and true immediate loading. When complications do arise with mini dental implants, the typical treatment is to move the mini implant to an adjacent spot. Because no bone is removed, the small opening in the gum closes and the body will fill in the defect with new bone. INDICATIONS Mini dental implants are much more than a solution for loose lower dentures. They can be used virtually anywhere in the mouth. They can have been used to: 1. Secure Upper and Lower Dentures 2. Replace a Single Missing Tooth 3. Replace Multiple Missing Teeth 4. Get rid of a Denture entirely and replace it with fixed Porcelain Crowns 5. Get rid of a metal partial denture Edentulous arches with minimal remaining bone in a facial-lingual dimension.(23) Many patients who have been edentulous for several years do not have enough remaining facial-lingual bone to place standarddiameter implants without grafting. It is possible to place some mini-diameter implants (1.8 mm) in bone that is as narrow as 3 mm in a facial-lingual dimension Removable partial dentures (RPDs), Kennedy Class I, II and IV. (23)When bilateral distal extension (Class I), unilateral distal extension (Class II) or anterior extension (Class IV) removable partial dentures are planned, it is common knowledge that the dentures will rock toward the respective edentulous areas when chewing. If at least 3 mm of facial-lingual bone and 10 mm or more of crestalapical bone are present in any of the edentulous sites, and mini-implants are placed, patient satisfaction is increased significantly. The partial denture rests on the small implants, retained and supported in various ways: denture soft liner, rubber "O" rings in housings or other special abutments. Rocking toward the edentulous areas is eliminated and denture retention is improved. Extra support and retention under fixed partial dentures (FPDs). (23)Occasionally, situations arise in which an FPD is planned that has questionable potential retention from natural teeth, and the patient has refused RPD treatment or grafting and standard implants. Mini-implants can be placed in the edentulous areas and used to support the pontic areas of the FPD. When an FPD becomes loose on one end, and the prosthesis can be removed from the other abutment without destroying it, the prosthesis often can be salvaged. A small-diameter implant is placed in the pontic area, a hole is cut in the underside of the pontic, the abutment retainers of the FPD are cleaned and roughened internally, and the FPD is re-cemented using the mini-implant as additional support and retention under the pontic. The ideal candidate is one in good general and oral health. The best candidates have healthy gum tissues that are free of periodontal disease since the miniimplants are intimately connected with the gum tissues and underlying bone in the mouth, according to the American Dental Association (ADA). Individuals with uncontrolled diabetes are poor risks. Exclusion criteria for patients were conservative: severe or recent cardiac pathology, severe hypertension, uncontrolled diabetes, or bleeding disorder, AIDS, any condition that seriously compromised bone healing potential or autoimmune response, intravenous bisphosphonates, heavy smoking, personality disorder or psychosis, substance abuse, and physician veto. Although limited mesiodistal edentulous spaces contraindicate the placement of standard diameter implants, mini implants would also normally be contraindicated in locations with heavy lateral occlusal contacts. ADVANTAGES / BENEFITS OF MINI-IMPLANTS: Shatkin et al (24) carried out a retrospective evaluation of 2514 MDI implants in 531 patients over 5.5 years with a mean duration of 2.9 years. MDI 2.4 and 1.8mm diameter implants were placed to support removable full and partial upper and lower dentures, and fixed partial upper and lower dentures. There was an overall failure rate of 6% with significantly more implants failing in the maxilla than in the mandible; the average time to failure was 6.4 months. The authors considered that repeated forces of denture insertion and removal may have a tendency to disrupt the process of osseointegration however the overall implant survival rate was 94%. The authors commented that this rate of survival was likely due to the minimally invasive surgical approach which preserved the peri and endosteal blood supply. Flanagan (25) published a case report of three MDI implants placed in three mandibular extraction sockets and used to support a splinted fixed partial denture. The mini implants were immediately placed after extraction and allowed to heal for four months before fitting the lower partial denture. The case was followed for two years. The fixed partial lower denture was considered to be successful with no complications

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reported. There was no apparent bone loss on radiograph and no clinical signs of inflammation or mobility. Histology studies Balkin et al (26) placed one MDI implant of 1.8mm diameter in each of two patients to act as transitional supporting implants for lower dentures. The MDIs were trephined out of the bone at four and five months. Histological evaluation showed that bone was in close adaptation to the MDI implant surfaces and vascular elements were apparent in the bone. The bone around the MDIs appeared to be healing, mature and well integrated into immediate function in the four to five month post-insertion period. The authors concluded that the MDI 1.8mm implant had the potential to become osseointegrated. MAINTENANCE Minis should be cleaned daily with a toothbrush and toothpaste. An electric brush may be used. In case of bridge or splinted crown installations, a water jet or floss threaders may be employed. Periodic follow -up visits will be scheduled to monitor mini implants, the fit of the dentures and the health of the gums. The O- rings will get loose and will need to be replaced because they do wear out. The more often that the patient removes and replaces his dentures, the more frequently he will need to come in to the office and have the o-rings replaced. simplified insertion technique involving placement without raising a flap and immediate loading (35). Suggested indications for use for MDI include patients with inadequate bone width; older or medically compromised patients who would benefit from the preservation of blood flow to the implant area as a result of the flapless insertion technique; patients who wish to avoid extensive bone augmentation treatment. The relatively low cost of MDI enables the clinician to offer this treatment option to more patients (23, 30 ). The minimally invasive surgical insertion technique with the MDI brings greater postoperative comfort and decreased morbidity for the patient, allowing patients with health problems that preclude extensive surgical procedures the option of an implant (33). This ease of placement of MDI is considered to be a safety factor in its use (30), the ability to avoid flap surgery aids in healing as the periosteum is left undisturbed (36,37). Gingival healing is typically seen in 2 to 5 days (30). After placement of the MDI a patient can have an immediate temporary denture fitted. An extended healing period with MDI is usually not necessary (33). The pull-out strength of an implant has been shown to be based on its length rather than its diameter (38). The surface area of five MDI implants is considered to be equivalent to two traditional 3.75mm implants of equal length (30). In the edentulous arch multiple mini dental implants are considered to be more stable than two standard implants. The arch distribution of multiple MDIs will better offset any fulcrum or tipping problems that can occur with two conventional implants positioned at the canine area (30). The MDI mini dental implant is available with either an O-ball head for use with removable or fixed dentures, or a square head for fixed prostheses or retrofitting a poorly adapted partial denture (16). The O-ball is considered to act as a shock absorber (39). The MDI is manufactured as a standard thread 1.8mm diameter, and with a modified thread and 2.4mm diameter. It comes in four lengths 10mm, 13mm, 15mm and 18mm. The clinician should always select the longest possible MDI for the available bone to maximize stability (40). An absence of excessive micromotion at the bone-implant interface is required to enable the osseointegration process (41-43). It is thought that there is a critical threshold of micromotion above which a fibrous encapsulation process occurs rather than osseointegration (44) possibly around 100 (42).

Discussion
The MDI is a one-piece implant that does not require a separate abutment. This simplifies the restorative phase resulting in a reduced cost for the patient. The MDI implant is made of a titanium-aluminum-vanadium alloy for increased strength. The MDI was initially designed for temporary prosthetic stabilization during the healing phase of standard implants (27). The MDI is also used for orthodontic anchorage (28) and temporary fixation of transplanted teeth (29). Its success in these procedures has led to its use in long term fixed and removable dental prostheses (30-32). Conventional implant treatment requires adequate bone width and interdental space. Augmentation procedures can be used to overcome these problems (33) but these techniques are complex and can cause post-operative pain and discomfort for the patient as well as incurring additional costs. The mini dental implant can be used in many such cases to overcome these kinds of limitations (34). Although the mini dental implant has a reduced surface area compared with a conventional endosseous implant (34) histology has shown that the MDI implant undergoes osseointegration . The percentage bone to implant contact for MDI is comparable to conventional implants (35). The narrow diameter of the MDI allows a

Conclusions
Mini implants are indicated for areas where the use of narrow diameter implants (3.0 mm) are contraindicated. Until long-term longitudinal clinical data on mini dental implants are unavailable, their use should be limited to areas with potentially less occlusal load.

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About the Authors

1. Dr. Puneet Chopra

M.D.S.

Assistant professor, Department of Prosthodontics Kalka Dental College, Meerut, U.P

2. Dr. Priyanka Chopra

M.D.S.

Assistant Professor, Department of Periodontics School of Dental Sciences, Sharda University, Greater Noida, U.P

3. Dr. Harpreet Singh Grover,

MDS

Professor & Head, Department of Periodontics & Oral Implantology, SGT Dental College, Hospital & Research Institute, Gurgaon, India.

Address for Correspondence

Dr. Harpreet Singh Grover, MDS

Professor & Head, Department of Periodontics & Oral Implantology, SGT Dental College, Hospital & Research Institute, Gurgaon, India.

Email: drgrover13@yahoo.co.in

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