Ara Nazarian DDS, DICOI
As the baby boomer population increases in number and size, so does the number of edentulous patients since tooth loss and age are totally related. As a result, these denture patients are presenting to the dental office with concerns of ill-fitting or loose dentures, inability to eat or function as well as continued bone loss. For one reason or another, the denture patient has caused many frustrations for the providing dentist, especially in regards to these issues. Conventional dentures for patients with severely atrophic maxillary and mandibular ridges often times presents additional problems of sores, infection and pain due to instability.
Endosseous implants have been successfully used to restore edentulous ridges with implant supported fixed bridges, hybrid prosthetic dentures, and removable overdenture prostheses. However, atrophy of edentulous ridges may limit implant placement. Anatomic limitations and resorbed alveolar ridges may compromise implant number, length, and inclination. The use of traditional implants sometimes requires extensive surgery, ridge augmentation, or bone grafting.
Small-diameter implants placed with flapless surgery to support pre-existing conventional dentures present an alternative method of restoring patients with atrophic jaws. Small-diameter implants are an excellent example of this trend. They dramatically broaden the spectrum of overdenture patients who can be successfully treated. These small-diameter implants 1.8 to 3 mm differ from their full-sized counterparts in a number of significant ways. The configuration of the implant permits a more conservative placement protocol. No tissue flaps or tapping procedures are required, which results in fewer traumas to both gingival tissue and bone. Their smaller size also permits placement in ridges that might not otherwise be suitable for full sized implants.
The implants are firmly seated in place in intimate contact with bone. Once they have been fixed in place, they can be immediately loaded. There is no need for a long waiting period or second stage surgery. The simplified protocols, conservative procedures, and elimination of gingival surgery make this implant ideal for medically, anatomically, and financially compromised patients.

CASE HISTORY
A man in his early 60s presented to our office frustrated with his upper complete denture that opposed a natural lower dentition from teeth Nos. 19 to 31. He complained that his upper denture was nonretentive and nonfunctional always falling out during speech or during eating. In fact, he mentioned when he did use moderate amounts of adhesive to keep the prosthesis in, it would still cause him to gag severely.

Palpation and radiographic examination revealed a moderately narrowed maxillary ridge (Figure 1). Crestal bone and ridge height were sufficient to receive a 3 mm x 12 mm I-Mini Dental Implant (OCO Biomedical) in the premaxilla region. These small-diameter implants were selected for this particular case because of the active aggressive thread design. In the maxillary arch, I have personally found these implants and others like it (I6B [AB Dental USA]), HM [Hiossen], MILO [Intra-Lock International], Midi [Basic Dental Implants], and Intermezzo [Mega'Gen]) to be very successful compared to small-diameter implants with more conservative threads because of the porous nature of bone in the maxillary arch. In addition, the patent pending bull-nose auger tip of the I-Mini Dental Implant also locks the apex of the implant by pulling bone up and around the threads. The thread pattern and pitch of the implant are purposely designed to immediately maximize bone to thread contact. In summary, it is important to select an implant that allows for immediate loading with deeper threads by resisting lateral occlusal forces especially when softer bone is present.
All risks, benefits, and alternatives were reviewed with the patient before initiating treatment. The patient was draped and a clean operating environment established. Local infiltration of anesthetic was administered. Markings were placed to designate landmarks and areas of insertion.
Keeping correct alignment, a 1.8 mm pilot drill was placed into the sites and advanced to a depth of 14 mm measuring from the tissue surface using a surgical motor (AEU-7000E-70V [Aseptico]) with generous amounts of sterile water. This additional 2 mm was the same depth of the tissue height to bone. In other words, 12 mm for the osteotomy in bone and 2 mm for tissue thickness was created to place a 12 mm long implant. Paralleling pins (Salvin Dental) were placed in the sites of the osteotomies and an x-ray taken to check the angulations to ensure proper orientation amongst the implant sites (Figure 2). Using a rotary tissue punch, provided in the OCO Biomedical Surgical Kit, a 3 mm outline was created over the initial osteotomies and the tissue plugs removed with a serrated curette (Dental USA). Since there was a thin band of attached gingiva, a countersink drill was used to countersink the implant collar sites. The final drill in the OCO Biomedical Surgical Drill is side cutting only and used to form the final osteotomy since the depth was set by the pilot drill. Once the osteotomies were completed, six 3 mm x 12 mm I-Mini Dental Implants were placed in the osteotomies using an implant finger driver until increased torque was necessary. The ratchet wrench was then connected to the adapter and the implants torqued to final depth reaching a torque level of 55 Ncm (Figures 3 and 4). A postoperative radiograph was made of the implants before initiating the prosthetic phase of treatment (Figure 5).
At that point, the location of each implant was transferred to the denture using bite registration material (Take 1 Advance Bite Registration [Kerr]). These areas were relieved to a diameter of 5 mm and the denture was reseated, confirming adequate relief had been established.
A small piece of rubber dam was placed over each implant, allowing only the o-ball of the implant to be exposed. This step prevented problems of the reline material locking around the implants. A female o-ring keeper cap was then fitted over each implant. Retentive fit and mobility were then again verified. Each o-ring would create a retentiveness of approximately six pounds. Since there were 6 implants with corresponding housings, the total amount of force needed to remove the prosthesis would be 36 pounds.
The cleaned and dried recesses in the denture were filled with cold cure acrylic (GC Reline [GC America]) seated onto the implants and allowed to polymerize (Figure 6). Upon setting, the denture was relieved of flash and the posterior palatal seal area relieved (Figure 7). The patient was so excited and pleased that his denture was now very retentive and did not cause him to gag (Figure 8). The patient was then instructed in denture placement, removal, and oral hygiene.
A small-diameter implant service provides clinical and economic benefits to your practice and restores function and confidence to your patients. Denture retention and function are dramatically improved, and the results are immediate. The advent of the small-diameter implant has given general dentists an easy, less costly and rapid way of solving many of the difficult problems that arise in dental practice with complete dentures. It is estimated that more than 36 million patients in the United States have lost their teeth, however, only one half of one percent have received implant therapy. This striking disparity signifies a huge untapped market for implants and dentures.
Dental practitioners interested in implants should consider postgraduate teaching institutions like the Misch Institute (misch.com), and organizations like the International Congress of Oral Implantologists (icoi.org) for more information and training.

Basic Dental Implants

MIDI series implants bridge the gap be-tween mini and conventional implants. Two 1-piece configurations are available: o-ring attachment for denture stabilization and angled abutment fornonremovable prosthodontics. With lengths of 11, 13, and 15 mm and diameters of 3, 3.8, and 4.3 mm, these implants economically accommodate most cases where strength and bone volume are a concern. For more information, call (888) 888-1468.

Implant Direct

This broad line of narrow-diameter implants combines the prosthetic versatility of 2-piece implants with the simplicity of application-specific, one-piece implants. Each 3-mm implant is approved by the FDA for permanent clinical use because of its surface area and strength. They are self-tapping for ease of insertion and have mini-threads to minimize bone loss. All-in-one packaging includes abutments, transfers, and, where required, healing collars and cover screws. For more information, call (888) 649-6425 or visit implantdirect.com.

3M ESPE

The MDI mini dental implant system features a minimally invasive 90-minute patented protocol that almost always stabilizes loose dentures immediately. MDIs are designed for stability in soft and dense bone, with several attachment designs available for custom retention. In addition, 3M ESPE offers affordable, one-day MDI certification seminars, led by some of the most experienced small-diameter implant clinicians in the world. For more information, call (800) 634-2249 or visit the Web site 3mespe.com/implants.