What do you do when its Friday afternoon and this walks in with a crying patient attached to it?

Well I looked in the tool box and thankfully I had a stash.  No not anything illegal but a stash of Intra Lock Mini Dental Implants from Shatkin FIRST Labs.  Jay Moore (the well respected and highly knowledgeable sales manager) had just sent me 24 mini implants in the 'Cash for Clunkers' trade in program.

The patient stated that the bridge was 'slightly decayed' for a while and that she had noticed some movement over the past few months.  Well from where I was sitting I don't know where the 'slightly decayed' came from.....it looked more like a stroll down the street in Anbar Province Iraq. 

I was able to tack mush to mush and took a pre op pan xray

Of course I was drooling over the thoughts of Mini Implants everywhere for this patient!  But I had to slow down and go over all the options from

1. Do nothing...not really an option....but I have heard that patients can get creative with Super Glue!

2.  Extract and recommend a denture or partial.

3.  Extract and implants for an over-denture or implants and a fixed bridge.

4.  Extract and mini dental implants for a fixed bridge or mini implant retained full denture.

To my surprise the patient had done her homework and had come to see us specifically for mini dental implants and a mini implant bridge.

I told her lets's slow it down a bit.  How about we make it the first goal to take out the broken root tips and preserve as much bone as possible with some peritomes(dental instruments to extract teeth with less trauma to the facial bone).  Then see about placing some mini dental implants and for certain figure out how to make her a temporary bridge to wear while some healing occurred.

Minis all went in as planned.  She will return in a few weeks for a tissue check and I will update the photos. 

 iCAT CT scan of mini dental implants in place for a fixed bridge

Post operative pan xray of mini dental implant in upper jaw for fixed bridge

Ok...so more than 6 weeks have passed since the blog about the mini dental implants and do they hurt.  But the patient has finally come back and we took the impression for her crowns.  If you need to scroll down to the original post you can see the teeth that were extracted and the mini dental implants that were placed.

I really wanted to do some Porcelain crowns over the mini implants but $$$were scarce in this case so a decision was made to use lab fabricated resin crowns.  I took a standard Poly Vinyl impression and sent the case to Shatkin FIRST Lab.

Nothing new required for me as the dentist.  From there FIRST Labs places the mini dental implant analog into the impression and makes a replica of what is in the mouth.

 The following set of pictures are the resin crowns on the lab mini dental implant model.  I will take clinical photos of the mini dental implant crowns cemented in place in 2 weeks.

One of the most prevalent dental conditions is missing upper laterals (about 10% of the population is missing these teeth from birth). 

Some of the time, even with orthodontics, there is not enough space to restore the missing teeth with traditional implants (implants with a diameter greater than 3.0 mm).

Most of the patients I have seen either have some sort of removable appliance or a orthodontic retainer with the two missing teeth on it.  The issue is that these teens don't really care to wear their retainer. 

Another solution, the bonded bridge, seems to fail.  While the bonded bridge works well on missing lowers, the clinical data shows that bonded bridges to replace missing upper laterals fail quite often because the central and canine tooth both move to different degrees under chewing function. 

One solution that works well in my hands is a technique that Dr. Todd Shatkin taught me....use mini dental implants.  The Intra Lock or IMTEC Mini Dental Implant can be threaded in between the canine and central.  This mini implant can then hold a crown in place that the patient does not remove.  

This photograph shows a Intra Lock 2.5 x 18mm mini dental implant to replace missing laterals.

www.dentalminiimplant.com

At the last Annual meeting for Mini Implant Dentists a friend of mine, Dr. Steve Brown, showed several of his cases where he used one mini dental implant for each root on a missing tooth.  Of course I thought, huh?  Not a bad idea, but is there really space? 

To confirm I spoke with Valdi at Sam Shatkin's FIRST Labs.  Valdi is the master lab tech at the Lab and he said, 'No problem, Dr. Brown has been doing that for years.'  So with that information in hand I had to give it a try.

So, having the sink or swim kind of attitude, I enlisted the help of a friend and long time patient of mine.  He had a missing upper molar that he desperately wanted back, not to mention he had been bugging me to death about it.

So with the big day here and multiple sizes of Intra Lock mini dental implants in stock, we got John numb with 1/2 a carpule of Lidocaine...not a lot really.  Just enough to get the gum tissue numb.

We made one pilot hole and placed a 2.0 x 11mm mini....and then another pilot hole was made carefully.  One more mini was tightened into place.....was there space for one more?  I looked over at the assistant, she nodded her head in approval.   The patient was just sitting there just like the guy in the cartoon....'A bit wider Mr. Sprinkle, I need to see if this tennis ball, I mean this last mini implant can be fit in' I said. 

So there it was, 3 mini dental implants all snug in place ready to support a molar crown!

An Itero impression was taken and its off to Shatkin FIRST Lab for a PFM Mini Implant Crown. 

 

Ok..after a few weeks of procrastination I have finally got the pictures off the digital camera and am ready to share the initial results of the Ken Clifford Fixed Mini Implant Bridge.

To read Part I scroll down in the main blog to the Ken Clifford Bridge Post.

To clarify, the acrylic bridge is totally mini implant supported; it is not tissue supported.  Every effort has been made to keep the bridge at least 1mm off the tissue to allow my patient to use a water pick to flush out any food that gets under the pink acrylic. 

Mini Implant Bridge Lingual view Mini Implant Bridge Space under Acrylic Ken Clifford Bridge
Underside of Acrylic Fixed Hybrid Clifford Bridge


The acrylic bridge cemented in place. 2 week post op picture.  The patient has been keeping the acrylic mini implant bridge clean with a water pick and a electric toothbrush.  I will continue to take clinical photos at the 6 month recare appointments and will share how the bridge functions, looks, gum health, and implant stability. 

2 weeks post insertion

Mini Dental Implants for Single Crown

Our patient today, as it seems like most these days...seem to know WAY more about implant placement than I would have ever thought.

Charlotte had braces years ago and was going to get an implant to replace her missing lower premolar tooth.   As we all know, life has a way of throwing the unexpected at you and she never got the implant and crown.  Over that period of time the molar tipped forward a bit into the space. 

More importantly the width of the missing tooth area collapsed (cheek to tongue distance).  Charlotte had already did her research on bone splitting and bone block grafting as an option to place a traditional implant.  She decided to consider getting a mini implant as an alternative to those procedures and have a PFM crown placed as the final restoration. 

We talked about her options and she elected to have the mini implant placed.  Mini Dental Implant placed in thin ridge

 
 With Charlotte's permission guiding planes were made on the two adjacent teeth.  This also helped to upright the tipped molar for a better contact area for the PFM mini implant crown. 

Intra Lock MDI 2.0 x 10mm in place and above the Inferior Alveolar Nerve Canal

I will continue the post with pictures of the Mini Implant Crown in place.

I had a hard time figuring out how to start this case blog.  Its an interesting story.  A patient of mine, who was one of the first multiple crowns over the top of mini implants that I did, referred to me a friend of his.  The patient of mine was a boxer and was missing teeth on each opposing side. 

I knew I was in for a challenge, but to my surprise the case turned out well.  Lots of help from Jon at First Impression Dental Lab and getting his bite as correct as possible made the difference in this case.  I do not envy anyone who has to get someones bite established that has no frame of reference and has teeth on the opposite sides! 

Although we did not do as many crowns and mini implants as planned, the case worked out well for the patient.   Most important to him is that he no longer has to wear partial dentures. 

The case has been in function over just over a year (9-25-09) and hopefully I can track the case for several years.  One year post op pan is shown.  I told him if he did not return for the follow up exams every year...I would find him and knock out the rest of his teeth!  Somehow I don't think I would win that boxing match, but he seems like a nice enough guy and will return without threat of bodily harm. 

The Main Event

Now to the real case.  Our new patient, intrigued with implants to replace his missing back upper teeth, saw a prominent and well qualified dentist in his home town of Asheville NC. 

A CT scan (3D - xray) was taken and a very impressive treatment plan was created for our patient.  Bi lateral sinus lifts, bone grafting, PRP(Platelet Rich Plasma), implants, custom zirconium abutments, and zirconium crowns.  The treatment plan could not have been any better.  The one thing that stopped this case dead in its tracks was that it was not affordable to the patient.  As I tell my patients there is only one treatment plan in the end that is right....its the one the patient understands the pros and cons of and can afford.  Apparently he noticed my boxer buddy's new teeth and they got to talking about mini implants...one thing led to another and he ended up coming to my office for a alternative treatment plan. 

Why minis?  Both mini implants and conventional implants are constructed from medical grade titanium alloy.  Mini implants have been researched and used widely now for over 10 years all over the world. Conventional dental implants now have more than 30 years of data, and many dentists will only use these larger implants. I believe that now is the time for a paradigm shift as I have been working with this alternative.   I have no quarrel with others who are uncomfortable with mini implants, but I am ready for a change in thinking and treatment planning for patients that otherwise could not have implant supported teeth. 

After studying his CT scan I told Tim that I though he had enough bone on the palatal slope of his upper jaw to place mini implants and skirt around the sinus pneumatization (dropping down of the sinus balloon to where the bone used to be). The mini implants could support a set of fixed crowns.  Tim was not ready to get rid of the existing bridgework he had on his remaining upper teeth just yet.  We did discuss that when that time comes we ccould extract the remaining upper teeth, place additional mini implants and fabricate a full arch bridge.  This wwould also give us the benefit of cross arch stabilization.   Another challenge to the case was the hyper eruption of the last molar on the lower right side.  The space between the arches had gotten so small I cautioned Tim that we may not be able to get porcelain on the top of the last tooth.

The mini implants were placed, impression made and on this case I tried a modified ridge lap design where there will be a 1mm space from the lingual so Tim can use a electric toothbrush to keep the implants clean.  I know that most dentists who place crowns over mini implants like having the ridge lap design tight to the tissue on both the cheek side as well as the roof of the mouth or tongue side.  I think with having a 1mm space I know the implants can be kept clean.  Minis in place 1mm gap being show from lingual  Occlusion being established...the bridge will be sent back to the lab to final polish the metal. 

 Pan x-ray with crowns in place.  I will have the patient come back in 1 month, 3 months and then 1 year to see how the soft tissue reacts to the 1mm space and how he is keeping thing clean.  The post will get updated with new pictures at those times. 

I get asked this question quite often.  Of course there is going to be some discomfort you would think having a titanium screw inserted into the jaw bone.....but believe it or not most if not all of my patients claim it was less painful than having an extraction.

Not ever having an implant placed or a tooth removed from my own mouth I always think when I see the condition of most of the mouths that need implants...how is this not hurting to begin with?

But as with most things in life the older I get the more I figure out I don't understand. 

So without further adieu...our patient in her early 60's is now ready to introduce her broken down teeth to Dr. Good (as in good by to the broken and unrestorable roots she has left).  They have been in this sort of condition for the last decade or so. 

The teeth are atraumatically extracted (how an extraction is autraumatic I am not quite certain).  But we try and preserve as much bone as possible I guess is the point. 

The sockets are packed with our freezed dried mixture of mineralized and de-mineralized bone and closed up tight so we hopefully will have some bone to place our mini implants in a few months.

Tick tock...tick tock...tick tock...

Wow...its now been 4 months all in the space of a few lines. 

The patient has mini implants placed in the healed areas and we will splint the minis together with some composite while the integrate into the bone. 

On the patients left side the mini ended up having to be placed a bit closer to her natural tooth as there lack of good bone where I wanted to place the mini implant. 

She is coming back to see us in 6 weeks and I will continue the post at that time.  To keep costs down for her she has elected to have resin crowns made to fit over the mini dental implants. 

News flash of the week...we had our first 'drive by'.  No not a drive by shooting but a patient that said, he saw our sign on his morning drive to work each day.  Intrigued by what a mini implant was he did, 'a bit of searching on the inter-web.'  Pleased with what he learned he decided to make a visit to our office.

So Danny's now in the chair and as he is talking to me he has a curious habit of flipping his one tooth partial round and round in his mouth.  He tells me its been years since he lost his front tooth, thought about getting a 'real implant' but he did not see the value in around $1500 for the implant, $500 for the screw that goes into the screw, and $1500 for the cap (all his words). 

I assured him that I was not going to put a 'fake' implant in his mouth...it would be made of a similar titanium alloy and should integrate into his upper jaw just like those 'real' implants. 

We decided to place a Intra-Lock MILO 3.0 x 15mm mini implant to support a single front tooth crown. No flap, no stitches, two small drill holes and then the implant was seated in the bone.  The entire process to place the mini implant was a surprise to Danny in terms of time and lack of discomfort. 

I was able to take one of my acrylic burs and make a hole in the back of his partial.  He was able to use that to cover the mini implant until the lab fabricated crown come back to the office. 

The post will be updated with his final crown photo in a few weeks.

   He did ask if I could cut off the front tooth on his partial when he gets his crown.  Why, I asked puzzled?  He said, ' so I can flip that darn thing round and round.'