A KNIFE EDGED RIDGE CASE

This gentleman wanted to be able to chew again on his right jaw. A very narrow ridge. We placed in the implants and usually in such cases, the bridge is cemented permanently within a month. The bridge was cemented. As a result, the patient was able to chew his food again. It encouraged him so much  that within six months,after a successful removal of bladder stones, he began to exercise regularly and cut down in his smoking. The last time we saw him, he was hale and hearty and telling his friends about how dental implants changed his life for the better.

ANOTHER CASE OF KNIFE EDGED RIDGE

This is a patient who already had a conventional in place from another dentist and came back from another country. We placed in a Mostdi and a mostdibud and cemented a two unit bridge over it.

Yes. We practise lipping over the mucosa liberally. It is a practice which every dentist have used successfully over the years with conventional bridges built on natural teeth. The main problem then were and are cervical caries in the abutment teeth immediately adjacent to the pontics. When used with implants, it does not happen because implants do not decay. In addition, a large sulcus in the name of a nice emergent profile is avoided with its concomitant uncleansable excess cement is avoided. In this case, all the excess cement can be removed definitively with the use of a dental floss. A cleaning groove in between the two abutments will allow a bridge cleaner to effectively remove all excess cement conclusively. Gives you great peace of mind.

WHAT IS A SAFE DISTANCE BETWEEN MINIS?

A rule of thumb would be 2mm. We can do it closer than conventionals because of its smaller diameter. The basic principle is to ensure optimal living tissue around the implant to maximize healing potential.

I think you should have a very rational way of doing things and that should keep a dentist within the limitations of any form of treatment modality. We should stop looking at minis emotionally but scientifically. I say emotionally because many criticisms are based on the suspicion that the dentist cannot do conventionals... therefore resort to enter into the game via minis. While true sometimes, what is wrong with that?..... and what do you say to a dentist who is adept at using both and yet still use minis successfully and rationally in situations where conventionals just will not do?? We should move on and just accept that dental implants come in all forms of shapes and sizes and materials etc. etc. and as professionals and scientists, use them based on principles and common sense and not just condemn blindly. This will rob the profession of a very useful treatment modality and shortchange the patient. We should see minis like we see fillings. We have different materials for fillings to be used in different situations within their known limitations.

MOSTDIS: A SOLUTION FOR BLACK TRIANGLES.... TREATMENT OF CHOICE ! ? !

In upper anterior cases where the use of conventionals usually result in black triangles due to its large size, I am increasingly convinced that minis should be the treatment of choice because their narrow diameters allow plenty of nutrients for the inter-implant tissues so much so that initial black triangles rapidly get filled up with living tissue, and aesthetically to boot.

BLACK TRIANGLES !

A month or so later, they have disappeared.

This particular patient was a total dento-phobic ++++. He had never seen a dentist for years. He called me on the phone and outlined his fears. His first visit, all I did was talk to him, took an impression and an OPG. If I were to offer to do conventionals only, I gravely doubt that I would ever see him again. With minis, I had great confidence to treat this patient with the minimal of trauma and pain and delivered his teeth fast and in a very satisfactory way. He completed a questionnaire in which he said that he was very happy with the results except for the price and I was charging him less than half what I would have charged him with conventionals with the accompanying steep prices, surgery, time  and possible complications with such a complex case.

Even though they look awfully close, they are not that close because they are minis and have plenty of living tissue surrounding them. The lower left second molar area have two minis that look as if they are touching each other. They look like that because they were placed diagonally to each other and a 2D xray gives that impression. This last 2 failed not because they were too close but because the upper molar had overerupted and bit heavily on them. 

GOAL !!!

There are many cases where minis are the treatment of choice. 

Congenitally missing upper laterals. 

Lower anteriors. 

Ectodermal Dysplasia. 

Post cancer rehab. 

Post facial trauma rehab. 

Patients who do not want bonegrafts and narrow ridges.

Recently, I gave a talk on "Minimized Implants and Their Uses". 

Later, I gave another talk entitled "A Happy Balance".

Minis are an important adjunct in implant dentistry and I really think that it is the way forward. In this talk, I outlined what "Evidenced Based Medicine" is and gave documented evidence to support minis. Thinking dentists should not be prejudiced. The first implant dentists were general practitioners and were considered quacks. Since then, the specialists have claimed implant dentistry for themselves. We should proceed with openness and humility instead. I have done on both Asians and Caucasians and minis work on both indiscriminately, always with informed consent after offering them options for conventionals and minis or both.

I will be speaking on the topic, 

"Treatment of Complex Cases: Striking a Happy Balance". 

I will show how conventionals and minis can be used in tandem to resolve cases simpler, faster, safer...... that otherwise will be very difficult. This will be in the MDA/FDI Scientific Convention and Exhibition in January Kuala Lumpur Malaysia.

Check it out here: http://www.mda.org.my/90-20130112-01.html

My blog that I am refering to is not the blog showing different clinical cases. 

It is another blog where I am writing a book entitled, 

"Minimized Dental Implants: 

The Coming Workhorse of Implant Dentistry".

http://minimized-dentalimplants.blogspot.com/2010/05/minimized-dental-implants-coming.html 

Cheers.

Dr Chow

IMPLANTATION AND EXPLANTATION ON PATIENT'S INSISTENCE

We placed in the upper anterior implants carefully and everything healed uneventfully. 

However, when the patient returned, he insisted that we remove them, the reason being that,

"He just could not accept them as part of his mouth and body!"

This was a realization that he had only after he had the implants placed.

After numerous attempts to persuade him otherwise, we finally accepted the fact that the patient for some reason beyond us, cannot accept the dental implants as part of his mouth and body. By then, the implants were fully osseointegrated and ready for harvesting and prosthodontics. 

So near, yet so far!!!!

Rest assured, we tried our level utmost to convince the patient how simple the prosthodontics were and how much he already paid and what a boon a set of fixed teeth as compared to his dentures were.

With all the preliminary exercises in persuasion and explainations done conscientiously, we got the patient to sign a carefully worded consent form indemnifying us from all the consequences of his thoroughly informed consent. With that in safely in the drawer, we proceeded to grant the patient his wishes.

We exposed the implants and tried to unscrew them first. 

One came out just by unscrewing them at about 50 ncm, my guesstimate.

One had to be trephined almost the whole length before it could be removed.

One was trephined to about 2-3mm depth and then it was elevated gently out.

We stitched it up and the wound healed uneventfully.

The patient wore back his old set of dentures, happily relieved..... I think.

We never saw the patient again because we wrote into the informed consent a clause stating that the patient will not seek any further treatment from us again.

A CASE OF OBSESSIVE-COMPULSIVE BEHAVIOUR?


MY BLOGBOOK:
http://minimized-dentalimplants.blogspot.com/2010/05/minimized-dental-implants-coming.html

IMPLANT TOGETHER WITH BONE GRAFT

This patient's lower right molar had to be removed due to severe chronic periodontitis and loss of supporting bone. After one month, after the mucosa had overgrown the socket a bit, we inserted the implant the following way:-

1. We drilled right through the mucosa in a flapless procedure until we hit paydirt.... I mean bone. Unfortunately the first drill went right into the inferior dental canal and there was a gush of blood. The bleeding was stopped with a piece of spongostan and biting on a piece of gauze.
2. After another 2 months, we went in again flapless again, this time more carefully in avoiding penetration of the inferior dental canal. After tapping the osteotomy and trying in the implant to its full depth, we removed it and made a straight incision along the direction of the alveolar crest.
3. After lifting the flap bucally and lingually, we curetted the socket thoroughly to gain a raw fresh bony surface. 
4. We then removed any loose granulation tissue attached to the flaps, screwed in the implant 4.5 by 11mm Ankylos. Bio-Oss was used to fill up the gaps 360 degrees around the implant. No membrane was used. Primary closure was achieved.

Because of some general health issues, we could not complete the case sooner. After almost one year, we screwed on the abutment, cemented on the crown and took an Xray and we had the pleasant surprise of seeing the bone graft substantially replaced by well calcified bone to the maximum level available!!!!!

MY BLOG BOOK: HTTP://MINIMIZED-DENTALIMPLANTS.BLOGSPOT.COM/

CAN I AVOID A MAXILLARY SINUS LIFT?

IN ANSWER TO THE ABOVE QUESTION IN AN OSSEONEWS DISCUSSION

http://www.osseonews.com/can-i-avoid-a-maxillary-sinus-lift/

http://smalldentalimplants.blogspot.com/2010/12/anatomical-positioning-of-minis-to.html

K. F. Chow BDS., FDSRCS May 7, 2010 at 10:43 am

Dear Dr A,

I guess you are another fictitious Doc with an alphabet. Nevertheless, it is an interesting question.

If you do not want to do a sinus lift, any reason will do though it might not be a good one. I myself once did not want to do it because I hated having to make a large opening into the sinus! And if I can avoid it, I did. So I tried crestal lifts invented by Summers. Works, but often found myself having to spend more time than if I just did a lateral window which is more sure and definitive. There are various ingenious ways nowadays, the latest seem to be the “hatch” technique with a special off centre drill.

However, if you want to avoid all these, there are several ways to avoid a sinus lift altogether:-
* Do a conventional bridge on adjacent teeth. Use the tooth in front and the tooth behind the edentulous space. Or a cantilever might work.
* Place an implant in the tuberosity where there is usually more than enough bone and join it to the natural tooth just anterior to the edentulous space.
* Or use MINIs! Do a tripod. 3 minis with the tips cut off at 5mm length, and build a crown on it.
* 2 or 3 Minis carefully threaded into the walls of the sinus on the buccal and the palatal where there is usually 3-5mm thickness of bone. These technique requires a lot of skill and experience though.
* Use short large diameter fixtures from Bicon, Endopore or some of these Korean makers that come in diameters up to 8mm!
* Or like Dr Richard Hughes suggest…. place in a subperiosteal.

Now all of the above require quite a lot of skill and experience…..maybe you might just want to learn to do a lateral window sinus lift which actually, once you get the hang of it may be actually simpler and surer in results!

Cheers.

Ken Clifford, DDS May 8, 2010 at 9:40 am

Dr Chow – Three questions. 1} Never thought of “cutting off the tips” at 5mm on a mini. How do you do that? 2.}How do you get it to “catch” the threads if the tip is cut off? 3.}I have built several crowns on tripod minis, but I haven’t seen clinical techniques discussed on how to “fix” the parallel problem. Your suggestions?

K. F. Chow BDS., FDSRCS May 8, 2010 at 12:48 pm

Hi Ken,

Since we have only 5mm bone height, we can reduce the threaded part of the mini-implant to 5mm by cutting of 5mm of a 10mm thread. Use a sterile orthodontic cutter. Grip the mini by the collar with a sterile orthodontic pliers or even a tweezer…. and then cut! With experience, you can just cut off 3mm and leave a 7mm threaded part. As you screw it in, it will do a Summers sinus lift.

Always make sure your drill hole is about 0.8 to 1.0 mm in diameter smaller than your mini diameter. If you are using a 2.5mm diameter mini, your last drill should be 1.5mm diameter or even less if your bone is soft. If the drill hole diameter is smaller than your implant diameter, then even if you have cut off the tip, the remaining threads should still bite into the side of the hole and draw in the implant as you clockwise it.

Lastly, you have rightly observed that our current prosthodontic solutions for the minis for both removable and fixed prostheses are still less than satisfactory in terms of simplicity and ease of maintenance. As such, I have developed a system called “THE BUDDY SYSTEM” to try to address the current shortcomings. I will post the sequential write-up in my smalldentalimplants.blogspot.com and will appreciate yours and others advice for any possible improvement. Hopefully, the problem of parallelism can be resolved with a moulding device and that of maintenance of fixed prostheses can be resolved with the use of “cleaning grooves” which I will describe.

Warmest regards and cheers.