Narrow anterior mandible: Recommendations?

Dear Friend, Narrow anterior ridge is quite a common problem which limits the insertion of wider diameter implants. According to me the diameter you have selected (3.5 mm) is proper and reasonable... Try to reflect flap as much as possible so that you can see most of the part of anterior ridge and feel the bone on buccal & lingual side with your fingers while drilling. your fear of perforation is also correct but you can overcome this problem very well by expanding the ridge before you place Implant. After using first 1 or 2 drills use ridge expander (Osteotome like device comes in various diameters & has markings on it to decide the desired length). Just put the drill expander in Osteotomy site and tap it and progress mm by mm, as you reach the desired diameter & length place your implant. You can avoid bone block & other advanced surgeries. Best of Luck

Hello, I have a few comments/suggestions. You could place four smaller diameter implants. American Dental Implant Corp, and no I do not work for them, makes a 2 stage 2.4mm implant. You could place two where you planned, and after flattening the ridge you could place two there. With the quality of bone there, a large grafting project isn't very appealing.

Hallo! I would extract all the remaining teeth and after waiting three months I`put three implants intraforaminal into the body of the bone.Then a prothesis with locators.

Firstly, its important to know what the eventual treatment plan is. If you are planning on placing just two implants with an implant supported denture or placing more implants at a later stage. Presuming that its only these two implants that you are placing, I would personally recommend that you place maybe a narrower diameter implant to be safe. Imtec has diameter 2.8mm available with them, but these are one piece implants for over dentures. The option of making a bar prosthesis would not be available.

A typical prosthetic problem in such cases is a big difference in bone level between central and molar areas, which can lead to a lever-moment mastication loading.

Definately use a CT guided surgiguide you have very high muscle attachments on the lingual you can see on the ct scan. STAY OUT OF the floof of the mouth!! If you are not comfortable evacuating a floor of the mouth hematoma of trying off lingual bleeders use a guide. There is no reason to elevate the lingual tisses you have enough bone. Good luck

Consider using 4 mini-implants laying a flap first buccal-lingually to make certain of your angulation; recontour the crestal bone as necesary for harmony in the vertical placement. I have used Imtec minis many times and have not had any problems in an edentulous mandible. Good Luck!

This may be a good indication for the miniimplants. I have used them several times and they have reasonable success. Use four of them, evenly spaced between the foramina.

Minis don't last, how old is your patient?

You have plenty of bone if you extract the remaining teeth and place 2 3.5mm implants in #22-23 and 26-27 area. you will run into periimplantitis (due to height discrepancy from implant head to adjacent teeth creating a food/plaque trap)) if you place them at where you are proposing and also making your job lot harder.

This is an ideal situation to place 1.8 or 2.0 mm implants. I don't understand the reluctance to use them when they are indicated. I have placed 53 and lost 3 over a ten year period. All of the overdentures place on 4 or 3 are doing fine. They work very well long term IF ONE FOLLOWS THE PROTOCOL. Studies show that patients are equally satisfied with mini or conventional implants when used to retain ODs.

Why not use the study that you have proposed on the implant edit. The purpose of having a scan, in my opinion, is to allow you to predictably choose your implant and position, before you "cut" the patient. In my hands, assuming the patient refuses to save any teeth; I would perform the extraction/alveoloplasty(s) and place the implants in the same setting. Please don't put mini implants in this patient. Call me and I'll send you standard implants. This case could be treated with 4.1 or 4.3 mm fixtures. B Vinci

My firt choice of implant would be 4 mini implants. The could be done with a flapless procedure and no grafting. The denture could be fabricated before implant placement and retro fit to the implants. In this case the implants could be 15mm or more in length and then take immediate load, but it would be better to allow 2 - 3 months for healing before loading. I have been using mini implants for mandibular overdentures with O rings since 1999 and have lost a few individual implants but have not had a single case failure. Considerations are oppossing teeth as well as quality and quanity of bone. Mini implants can be used to support a bar but if you want to try this use as many as you can fit into the space. The problem is metal fracture of the implant body with lateral load. If the narrow implants are used only to resist displacement of the mandibular overdenture they will work very well and are not subject to forces that will fracture them. Place at least 4 and at least 2mm diameter and as parallel as you can, if one fails you still have a functional case. When a mini implant fails there is usually very little bone loss and most times another mini implant can be placed into the same site within a month or two. As with the larger diameter implants allow a few months healing time. Failures are much higher with immediate load. Just hollow out the denture right arround the implant so that it is not loaded. The mini implants will with some time integrate as do the larger diameter implants. Used for this purpose the mini implants have FDA approval. Check out the intra-lock.com site. Other companies have great products also but this site has a lot of info.

Dr. Bob, you give us several reasons as to why you need to place more fixtures, secondary to the high fracture rate of these systems, so why would we use them. This patient's mouth is in poor repair, so the suggestion of placing as many as you can, makes no sense. The patient has to clean them! The FDA approval means that they are safe to put in a patients mouth and that is all it means. This type of therapy needs scientific endorsement, so in my part of the country, I could not find one omfs in several meetings, that will even consider placing mini implants, with the exception of temporization and orthodontic anchorage. I have remove over 50 mini implants and not a single one has shown any form of integration. My experience is limited, I will grant you that, but unfortunately, it will always be, most likely. I have yet to see a single indication, in 20 years, where a standard implant could not be used. B Vinci

Dear colleagues, thanks for all the advices, always interessting to the different treatment protocols. I have already done the surgery. I exctracted all the teeth, did mucoperiosteal flap facially/lingually and osteotomi reducing the alveolary crest until sufficient wideness and then I placed 2 3,5 implants regio 22-27 with very god primary stability. As expected, fenestration happen regio 21, although marginal bone was presevered. The defect was augmented with granulated autogenous bone from the alveoplasty/osteotomi and covered with collagenous membrane. Nice primary wound closure was reached and healing uneventful. I will wait at least 3 months before conducting 2. stage surgery. I decided to insert implant in the extractions alveole of canine (27), I could have placed both implants more distally regio 21 and 28, leaving space for additional 2 implants anteriorly, in case of different prosthetic solution in the future would be requested by the patient. But I am confident and of course I have informed the patient preoperatively, that 2 implants with locator-system will be satisfactory. I have uploaded the panoramic x-ray, please note that her mandible deviate to the left resulting in that implant regio 27 optically looks like is closer to the midline. Thanks!

You are aware that your measurement( bucco-linqually) is at the soft alveolar bone. If the appropriate alveoloplasty is performed, you will have 7-8 mm of width. Just stay above the genial tubercles and you could place 5x12 mm fixtures. I can promise you that you will get a significantly better product. It is Ill-advised to place the implants in the soft alveolar bone and have them situated 5-7 mm above the mandibular body region. You should have a level ridge, in my opinion. B Vinci. Vinci oral and Facial surgery. Baton Rouge, La.

Baker, You gave this doc good advice as per ramping down the ridge and having a more stable site and more bone width wise for implant placement. The newer docs should observe some of these cases to see how they are done, learn how and when to use various instruments.

Thanks, Richard ! Bv

There is NOT enough bone to implant contact with mini implants. Yes pins etc were used in the past, but not singly. They were used in a tripodal manner. That said, minis have a place as a provisional implant. Not a definitive implant! One, if serious, has to learn when to augment and how to augment the bone and not hinge their treatment on minis or on one modality. Minis were first developed to use as a provisional implant. Yes, minis are approved by the FDA, but the FDA has been hood winked or dropped the ball in the past, eg. , Thiladmide, bisphosphonates and various devices. Baker, I get your drift but vetinary medicine does perform at a high level. That said, I have seen one mini fives case that was in function for over 8 years. More long term studies have to be performed.