Dr. S. asks:
I have a female young adult patient who avulsed her lower right central incisor (#24) 5 months ago. We have bonded a Maryland bridge temporarily for aesthetics. The mesiodistal space is a mere 3.5mm. Buccolingually, she has 4mm if we flatten her crestal bone about 2mm relative to the crestal bone of her adjacent teeth. I have treatment planned her for the insertion of a narrow platform implant. I would then place another temporary crown and later a porcelain fused to metal crown. Will this work? Should I attempt to bone graft at the time of implant placement?
Mesiodistal Space a Mere 3.5mm: Will My Plan Work?
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The space is too narrow for a implant. I would recommend a permanent Maryland bridge or orthodontics to open up the mesio-distal width to at least 5mm before considering a dental implant in the area.
Always remember that the patient has consulted you for the replacement of lost tooth, not for an implant to be placed.
So its your duty to offer the best treatment plan and you know this case situation does’nt allow you to place a fixture there, hence go in for a maryland bridge and sleep well without thinking about any thing else.
This sounds like a perfect spot for a 2.0mm diameter, 18mm length MDL implant. Get a CBCT, confirm my guess on the length, be sure there are no nasty undercuts on the lingual, and happily place the implant. Immediately load with a temp, send your lab an analog and a straight cementable abutment, and do a “normal” PFM – I would use porcelain to gold. Sleep well.
An interesting story about this situation – two years ago when I was really getting started with minis, I mentioned it to my dermatologist as he was zapping my face. He eagerly told me that he had a mini implant crown on a lower central incisor. Turns out he had it placed in 1996 in Baltimore while he was in medical school. His dentist told him it was an “experimental procedure” and he opted for it anyway. It is perfect today and he has had zero problems with it. His local dentist here in Chico has a recent x-ray showing no bone loss and full integration. I KNOW one case and 13 years is not acceptable proof, but it sure is interesting.
yes you can use mdi mini implants i myself has used this and found it an interesting one
“This sounds like a perfect spot for a 2.0mm diameter”
Dear Dr Clifford, this is not exactly sensible advice for someone who’s posting on an open website and one might therefore suspect is not hugely experienced.
Let’s just start with the absolute perfect placement – 0.00mm margin of error. He will then have 0.75mm of space between the roots and the implant on either side.
Forget Tarnow’s figures and let’s instead just live in reality – nobody is perfect. Let’s just say that over that 18mm of length that you state you want he’s a fraction off – just a tad, a smidge, a tiny bit off dead centre………
Can this case be done using MDIs? Of course, anything can be done in implant dentistry.
Is this site “a perfect spot for a 2.0mm diameter”? No and let’s keep this guy’s feet in reality.
Dr S – Consider conventional dental treatment – adhesive bridges or conventional bridges. Consider orthodontics – with or without implants. Even possibly consider additional lower incisor extractions, if their long-term prognosis is poor, to enable you to place conventional implants. Finally, when these options have been explored and rejected, then try and squeeze a mini dental implant into this too-small space.
Kind Regards,
Bill Schaeffer
I use MDIs, conventional implants, short implants and zygomatic implants. I have no financial interest in any dental product.
Ih ave done both. A LAVA all ceramic Mayland brige looks beautiful! I find that the mandibular anterior is sensative to compression necrosis when adjacent teeth are present. With the right adapters you can use a torque wrench to keep it within 35-50 ncm. 1.8mm will work if you are carefull (x-ray with 1-1.5 mm drill in place.
Bill – You’re probably right, this is not a good case for a beginner. I wouldn’t consider this for a mini without a “3D Scan” – I use that term because my patients seem to get it quicker than “cone beam” or other dental terminology. I wish you had a website link so I could get a better feel for your practice. I have found that many patients on this site do click on the name and find us. One really good patient from Sacramento actually found me in Chico from OsseoNews, so I do recommended using that feature.
I completely agree with Dr.Bill and Dr.Narang.As professionals, it is our job to first ensure we rovide care that is best for our patients and not to inflate our own egos with heroic procedures that sometimes succeed.A permanent Maryland if the occlusion and the neighboring teeth permit seems to me the least invasive treatment option
I completely agree to the comments which Suggest placement of 1.8 mm dia. MDI implants. They do work fantastically without any complications .Only thing to keep in mind is path of drilling for parallelism . it will not leave any space for errors..Dr sameer Bhandari
Some of the comments on this thread are terrifying!
Bill, suggesting to have another incisor extracted for the sake of placing conventional implant is terrifying to me and probably to majority of patients as well. You mentioned above ‘let’s keep this guy’s feet in reality’.
That doesn’t sound like all that practical solution, maybe realistic.Ok, actually not all too realistic either.( I ve suggested that option to how many patients before? and how many looked at me like I was some nut? ) I ,too, place minis and conventional implants. To me, unless you are dealing with a patient who’s willing to spend thousands of dollars for ortho and conventional implant, better way to go will be either bridge or mini as long as things get explained to patient about mini’s background, pros,cons…
We all want to do it right. Sometimes, other factors force us to do no tx at all or take alternatives.\
remember that.
Sergio,
In a “young female patient”, with 3.5mm between her adjacent teeth, the following two are terrifying comments;
“This sounds like a perfect spot for a 2.0mm diameter”
“I completely agree to the comments which suggest placement of 1.8 mm dia. MDI implants. They do work fantastically without any complications.”
If you read mine, after advising consideration of an adhesive bridge or ortho, I stated “Even possibly consider additional lower incisor extractions, if their long-term prognosis is poor, to enable you to place conventional implants.”
Why is this terrifying? I am not suggesting taking out healthy teeth. I am suggesting assessing the other incisors. If they are of poor prognosis, why not change an unpredictable implant treatment plan, (i.e. squeezing a mini implant into 3.5mm mesiodistal space) into a highly predictable one (for example, a 4-unit lower incisor bridge on two lateral incisor implants – IF the condition of the other incisors warrants this).
What’s the fall-back plan if you place a MDI and an adjacent incisor tooth fails? Another MDI? And another…..
Kind Regards,
Bill
Dear Dr. S.
The options are:-
1. Do a Maryland.
2. Do a conventional tooth supported cantilever bridge using the left central as an abutment.
3. Maybe close it up orthodontically which is a long shot.
4. Place in the smallest conventional 3mm diameter together with a bone graft with a membrane stabilised with pins to ensure success.
5. Put in a mini 2.0mm diameter or less and finish with a PFM crown.
If you flatten the crestal bone to achieve a 4mm platform to put in a conventional which will be at least 3mm diameter [with great skill and luck], you will have a 1/2mm margin of bone buccally and 1/2mm margin of bone lingually, which can break down quite easily due to compromising its bone supply by the raising of a full thickness periosteal flap. On top of this complication, you may have to deal with the aesthetic problem resultin from the lowering of the crestal bone by 2mm in relation to the adjacent alveolar bone.
Take your pick. The best bet in my opinion is the 5th option, which is to put in a suitably sized narrow diameter or mini implant to the optimal depth available , and finish off with a PFM crown.
Cheers.
Bill,
your reasoning sometimes doesn’t resonate as reasonable solution when it’s transferred to patient.
‘ depending on prognosis, extract another incisor .’
Try to explain to patient and convince them to go with that single implant. Their reasoning will be ” why do I do that? sounds like I might lose wholtta other teeth soon or later..” Again, trying to present with realistic option that’ll make win patient’s agreement sometimes differ from short term, practical, not so realistic, whatever options.
And fall banc after mini falls out? then think about doing convention implant, partial( if conditions of other teeth are that bad,. ) or bridge. It’s not mini implant that will bring the end of other treatment options. You place conventional and if it fails, then a lot of times, you have to do bone graft( ususally not enough buccal bone on the lower anterior area to expect preditable result ) Worse yet, if bucal bone is lost from orginal implant, then chnace gets worse or worst even with graft. That’s why I would start from less invasive treatment option first. Or better yet find out what the patient’s expectation is, and if it’s something not that realistic, don’t do anything at all.. Just a thought.
I think better way is diliver maryland all porcelain bridge. First, it is minim invasive. SEcondly you still have the option for implant in the future.
best regard
PLs read the actual indications in the mini’s package.
You are treading heavy to do this procedue unless you read them first and inform the patient that long term does not mean permenant.
I would opt for the Maryland Bridge. This is a low stress area and it should work. Generally one would allow 2mm space between the implant and the adjacent tooth(Tarnow)to maintain a healthy bone level. With only 3.5mm space, a 1.8 mm mini would only leave 1.7 space, or 0.85mm to either side of the implant. If it was to succeed, great, you’d be a hero. If this failed then a potential argument on inadequate spacing would be VERY easy to use against you. Just my 2 cents worth.
Bill,
You’re making this seem harder than it is. The 1.8 imtec mini’s are self-threading. That means you only have to perforate the cortical bone…not drill the full depth of the osteotomy. It’s a simple case, really. Perforate the cortical plate and insert the mini…advance a few mm and take a digital x-ray…advance a few more and take another x-ray, etc, etc, if the angulation gets off back it out a few turns and advance at the proper angulation..and take another x-ray.
Many OMS don’t have direct digital and only take pre-ops and post-ops….that would make this case much more difficult. With self-threading implants and direct digital radiography, this case is very straightforward.
Dear Paul,
Thank you for the info which may be useful for dentists unfamiliar with MDIs.
I use Imtec MDIs (I’ve also used other makes of MDI) and I know how they work. I also have digital intra-oral, pano and CBCT equipment all on-site.
Can a mini implant be used here? Absolutely.
Is it “easy” as has been suggested? Absolutely not.
Would I have one put in my brother’s/sister’s mouth in this situation? I don’t know – I don’t enough information about the case – but I very much doubt this is the way I’d go.
Kind Regards,
Bill Schaeffer
This is an obvious case for an MDI 1.8mm
I see no down side
Predictable area ..anterior mandible
Leaves sufficient bone interdentally
Take x ray after decortication ..see protocol etc
I cant think why a mini should not be used