Resorbed Mandible Case: Best Treatment Plan?

Dr. D asks:
I have a 61 year old male patient in good health with an edentulous mandible and wearing a complete denture for 15 years. His chief complaint is that his denture has poor retention. I have attached his CBVT scan below. I would like to get some advice on the best way to restore his mandible with implants to provide increased retention for his mandibular complete denture. The alveolar ridge from mental foramen to mental foramen has significant resorption and I am wondering if I can engage the inferior cortical plate with a implant fixtures for increased stability.

CBVT Scan:

81 thoughts on “Resorbed Mandible Case: Best Treatment Plan?

  1. sb oms says:

    You have more than enough height / width for implants. you will want to lower the crest slightly to achieve a flatter / wider site. you will want at least 12 mm length to engage basal bone as the alveolar bone density looks poor.
    Your patients chief complaint is denture retention. my questions are:
    1. What is this denture opposing
    2. Is there any bone height distal to the foramen?
    some choices are:
    1. Two implants with retentive abutments
    2. Two to Four intra-foraminal implants with a retentive bar
    3. Other fixed solutions (all on 4, on 6)

    This is a relatively young and healthy patient. I think the two implant option may be under-treating as the case needs 30 years of function. I have seen many removable cases loose function from under-engineering problems.
    My recomendation with the limited info I have is 3-4 implants with a retentive bar. I would need to see the entire scan and models to give more info.
    Remember that removable cases can be very challenging. For surgery you will want a clear duplicate of the denture with holes or channels placed in the ideal implant position. You should not guess during surgery, and it will be easy to loose your orientation without some kind of guide.

  2. Carlos Boudet, DDS says:

    I prefer regular diameter implants whenever possible, but in cases like these, I would consider placing four or five minis in the intraforaminal area as an alternative option.
    You might be compromising the existing bone height to widen the ridge by flattening to obtain adequate width for regular diameter implants.
    sb oms has given you good advise in his post.
    Good luck,

  3. Dr Mac says:

    I think that you can use a narrow diameter implant eg. 3.5; and by placing 3 to 4 would have a very successful case using Zest attachments. The crestal bone can be flattened slightly but some should remain for initial stability. Also,are you aware of American Dental Implant’s 2.4 skinny with a 3.5 platform? I have used these a number of times successfully. Minis are also an option, I prefer Intra Locks as they are slightly larger diameter than Imtecs.I lay a flap with these also and “level-remove knife edges-flatten” the ridge; place the minis then suture around the minis then check heights by placing the housings on the implants and adjusting accordingly.

  4. mwjohnson DDS, MS says:

    There is plenty of bone. All you need is 5-6mm of width and 8mm of height to adequately place conventional implants. Place 5 implants between the mental foramina and make a fixed hybrid prosthesis. Not only will the patient love it, it is fixed, no clips to change, no ridge pressure but you wil too since it has minimal maintenance. You can do a fixed prosthesis with 3.5mm implants without a problem, just make sure there is as great an A-P spread as possible to keep the cantilever forces from overloading the implant components (screws). A bar retained denture is OK, but clips need changing and dentures need relining over time.

  5. Dr. Samir Nayyar says:

    Well you just need to give 3 or 4 mini (overdenture) implants and fabricate a denture over that after healing. Even 2 mini implants work good for retention purposes if you don’t get enough bone width in the mandibular anterior region.

  6. Dr Rob Dunn says:

    This is an ideal case for mini implants and I would recommend 1.8mm x 10mm implants from 3M Imtec. By using four in the intra-foraminal space you will gain excellent retention, and with the bone available some bi-cortical stabilisation which could give you immediate loading.

  7. Paresh B Patel says:

    Great case for mini dental implants. If all the patient wants is more retention then 4 mini’s (any brand -Intra Lock, IMTEC, OCO) will be sufficient. You have enough room to engage the inferior cortical plate. I would make sure to take the pilot bit almost to length to help ensure that the mini implant does not bind in the last few mm and break off the tip.

  8. jg says:

    great, straight forward case….minimum two implants( 3.7’s by 10 0r 11.5’s)in the canine area,and locator abutments….what a service your pt, will love you for it!!!!!

  9. steve c says:

    If the other CBCT slices in the area look this good you will have many treatment options, both fixed and removable. Why use mini implants when you are able to use standard diameter at an 11 to 13mm length? I would follow the suggestions put forward by sb oms or mwjohnson DDS MS.

  10. Dr. Dennis Nimchuk says:

    There is over a centimeter of bone width here so why would anyone wish to use mini implants? Also there is very good length potential. Anything is possible here, from a fixed 6 unit implant supported bridge with a removable partial to a two stud retained CLD.

  11. K. F. Chow BDS., FDSRCS says:

    “the best way to restore his mandible with implants to provide increased retention for his mandibular complete denture.”

    The best way to a retentive mandibular complete denture is mini-dental implants. It is a no-brainer!

    Specifically, 4 O-ball headed mini-implants inter-foraminally. The corresponding O-ring and housings are cold-cured into the denture and the patient can snap them in and out with a little guidance and practice, all done within 2 hours. The patient is ready to eat and enjoy his/her life anew. In some cases, not only is their confidence and quality of life sent sky-high, their lives are prolonged! As for worn-out O-rings, I provide my patients O-rings and a dedicated instrument to change them themselves.

    Minis is the treatment of choice in this case. It is faster and cheaper, stronger and safer….period. Yes, I shamelessly say…. cheaper! Often, cheap is a word used for lower quality but in this cases, it is the best option over and above conventionals. And if more of us dentists come to this realisation, will bring great improvement of life to many more people than we are doing now especially those who can only afford removable dentures.

  12. Dr. Everardo Ramirez says:

    Hi there, I would like to see more inf, about the patient but I think you have enough bone to place implants for an All on 4 and a complete fix denture

  13. MEU says:

    Hi: I think that your patient has adequate bone volume for the placement of four or five 3.5 or 4.0mm (length to be determined upon further measurement on the tomogram, but it looks as if you can easily use at least 10mm) regular implants and the subsequent fabrication of a mandibular fixed hybrid prosthesis. I am a Certified Prosthodontist and I can asuure you that a fixed mandibular prosthesis is the best way to address your patient’s concern regarding the retention problem.As someone mentioned previouly,there is hardly any maintenance problems and patients feel almost as having their own teeth back. Both the patient’s self esteem and confidence goes way high up. Iam sure that you will also feel great after providing your patient
    with this kind of service

  14. K. F. Chow BDS., FDSRCS says:

    Read his lips! Read his lips! The patient did not ask for a fixed prosthesis! He wants better retention for his loose lower full denture! The question is, “What is the best way to provide increased retention for his mandibular complete denture?”

    Of course a fixed prosthesis is better….any experienced implant dentist will tell you that. But the question is when the patient cannot afford a fixed prosthesis with the accompanying pricey number of implants. Instead, he humbly requests for better retention for his denture for a price affordable to him. What do we do then?

    With that in mind, paying due attention to the patient’s request and financial ability, and his local oral condition and what’s available……mini-implants with O-rings and housings is the best bet.

  15. MEU says:

    Well, I don’t know how Mr Chow arrived to the conclusion that the patient is ” humbling” asking for better retention for his lower denture. I understood that it was Dr D who asked what was the best way to improve this patient’s lower denture problem regardless of the finances involved. I personally never allowed the cost of treatment dictate my treatment recomendations and always recommended what I thought was best for my patients. This case, and to answer Dr D’s question, a fixed hybrid lower prosthesis is the best way to fulfill your patient’s need. Perhaps Mr Chow has not done any fixed lower hybrid prosthesis?

  16. K. F. Chow BDS., FDSRCS says:

    Elementary,my dear MEU…….elementary.

    Patient comes with loose lower full falsies and pleads for help. Dr. D ….help!

    “Your best bet is to fix a new set of porcelain falsies on to dem new-fangled implants! Sir,” offered DD confidently. Turning pale at the whispered price, he wondered whether he could still try dose dem new-fangled implants without the high cost.

    Gently, the good Dr. replied that the falsies cannot be fixed then, but can be made more retentive so…..anyway….I will ask the rest of my wonderfully helpful colleagues from all over the world how to do it! You are one lucky patient……you.

    And so Mr Chow, obviously oriental and deficient in the goode olde Englishe totally went off the mappe and even spelt intra-foraminal as inter-foraminal! Yeah probably one of them denturists who have never heard of hybrids..what?!? Hybrids? Here in tropical Asia? Of course I have heard of hybrids….they are orchids…see orchids!

    Price no problemo. The best …the best sometimes is not the most pricey eh…what?

    Cheers and regards.

  17. Dr.A.T says:

    i have on several occasions place 4 interforamina ankylos implants and given my patients immediate function with Syncone abutments 4deg taper.
    The patients are happy to walk out of the office with a fixed removable option.

  18. Dr.Vaziri says:

    First we have to look at the question .Dr D. ask for some retention for mandibular denture.
    I agree with Dr. Chow, mini implant with O-rings and housings is the best.
    patient has complet denture on maxilla,however, placing any fixed lower hybrid prosthesis makes flashy mucosa on maxilla,so absolutely no!
    Dr.vaziri from Iran-Tehran

  19. Dr. josh keren says:

    Dear doctor
    I’d consider one of 2 options: 1}Dentatus implants for a better stability of any lower full Denture
    2}Move on to a fixed bridge usuing the PROTOCOL of AO4

  20. John Carroll, DMD says:

    There is a lot of good advice but whatever you do, do not place mini implants. You will find that they have high fracture and failure rates. Unless the patient understands that he/she will pay for a new mini every time one fails or fractures. You have plenty of bone for standard implants. Look at what the leading implant practitioners are advocating (minus Gordon Christensen). Good Luck

  21. Dr J says:

    I think Dr.Chow and others advocating placing mini in this case instead of the regular diameter implants have something to gain besides the patient’s best interest.

  22. Dr SenGupta says:

    This a slam dunk case .
    low risk highest success rate in the site
    All options offered would work no question
    offer patient the options present well and pt will decide what they value the most.
    Dr Carol your stats on minis are wrong …if they have been breaking when you are using them you are using incorrect protocol.
    There are a number of reasons implants can fail Minis included .
    If you have only done limited cases and you had failure then I would suggest inexperience…if you have never done them I dont understand why you would make a statement as you did .
    Mini Implants will break if they are over-torqued…for sure!

    Mini Implants will also break due t poor prosthetic protocol…if your over denture is SUPPORTED rather than RETAINED on the implants …of course the minis will break…they were never designed to be support for a full arch of teeth …they are designed to hold down the denture like tent pegs …this is the classical mistake and misunderstanding the “nay sayers” of mini implants have.
    Millions of them have been placed and they are working well when the protocol is followed.

  23. John Carroll, DMD says:

    Dr SenGupta,

    I think if you look at some of the literature on mini implants the numbers are on my side. You could also argue that an MODBL, cusp replacement, pin retained filling can last a lifetime as long as there isn’t an opposing tooth. I get at least 1 patient every two weeks that has had major issues with their mini implants. We have transitioned these patients to standard implants with virtually no problems and extremely high success rate. The bottom line s that there are no patients that can have mini’s placed that can’t have standard implants placed. If the patient is very medically compromised and wants some relatively inexpensive way to add retention to their lower denture then I would place a mini. The patient has to understand that if an implant does not integrate or fractures they would have to pay for a new one. on the other hand I can guarantee standard implants for life because they don’t have problems. I know that a lot of practitioners love mini’s because they are very easy to place in compromised sites and you don’t have to be a great surgeon to place them. I would never have a mini placed in my mouth because of the issues that have been mentioned, so why would I place them on one of my patients. I am sure some of you will be very upset at this post but the facts are on my side, you can try to spin it and justify it any way you want but you guys know the truth about this controversial topic. Just look at the facts guys!!!!

  24. K. F. Chow BDS., FDSRCS says:

    Dear John Carroll,

    Will appreciate if you will kindly quote the references to the literature on mini implants that you have been reading that lend credence to your stand that the numbers are on your side.

    Apart from Shatkins’s 5000 case study that indicate a success rate comparable to that of regular implants, I cite 2 other studies.

    1.Measurement of the Fatigue Life of Mini Dental Implants by Dennis Flanagan in 2008, Journal of Oral Implantology.
    2.A Comparison of Resistance to Fracture and Deformation between One and Two-piece Small Diameter Dental Implants by James Owen Jacobs, a master’s thesis presented in Ohio State University in 2009

    My readings so far and experience is that mini dental implants may be stronger and less likely to fracture than regular 2piece implants.

    I am glad that you do concede that minis have a place in certain cases like people who are medically compromised …..and also some who are financially compromised. I would like to add that they are also very useful in people who are also osseo-compromised….i.e. insufficient bone….and in many cases, after considering all the factors involved may be the treatment of choice!

    I am one of those who love minis and is very adept at putting in regulars too and use both in my treatment planning. I place minis not so much because they are easy to place and don’t have to be a great surgeon to place them…being a fellow of the royal college of surgeons. I place them often because I am beginning to be more and more convinced that in many cases, it may be the treatment of choice, all things considering.

    Anyway… if you can do something just as good if not better in a simpler, cheaper way…why not. It is a fallacy to think that cheaper is not better. Very often …cheaper may prove to be better.

    In the Journal of Dental Research, 2003…. a number of researchers came to the conclusion that one-piece implants should be utilized more often to minimize potential soft tissue inflammation and bone loss. The study is “Persistent Acute Inflammation at the Implant-Abutment Interface”. The authors include Schenk and D. Buser. Sincerely.

  25. John Carroll, DMD says:

    Dr. Chow,
    Hmmmmm… let’s not count Shatkin’s “case study” since it may be slightly biased. The JOI article showed how most of the minis broke after 1 million cycles, and the master’s thesis you quote only shows that a one piece is stronger than a two piece implant comparing the Astra, Nobel and Biohorizon implants. Thanks for quoting such profound proof that mini implants are the modality of choice. I think that you should write a retrospective study on your cases. You are obviously doing something most mini implant users are not achieving. BTW, today I removed three broken mini implants and 2 failed ones. Wonder why? Must of been the prosthesis. Hey, if you’re getting such remarkable results then more power to you. I guess it’s the rest of us that are having less than 95% success rates with minis. One last thing, what is stronger a 2.1mm wide screw or a 4mm wide one? Just curious

  26. Dr. Ares says:

    Dear Dr D,
    The images show that there is sufficient bone for either regular or mini implants.
    If you flatten the alveolar crest, you will be able to place 3.5 mm wide implants (2 or 4 implants in the interforaminal area) and then a Hader bar or ball and o-ring retained overdenture.
    I would use conventional implants. I have nothing against mini implants and have used them on several patients, including my own father (following protocols), and noticed, in my experience, that they work well for about 5 years. Many times they become loose, and can be unscrewed easily by hand, or wear and break at the ball attachment. In the end, I have had to use conventional implants with a better outcome. In my country, the price is not too different between mini implants and conventional implants, so for me, that is not an issue. I would still use mini implants though, on patients that have a very resorbed mandible, or patients that do not wish to go through bone grafts or bone augmentation procedures.
    Hope this helps

  27. Dr. Ares says:

    Oh, and by the way, my thesis for becoming an oral surgeon, was about immediately loaded mini implants on the edentulous mandibular ridge!

  28. Dr SenGupta says:

    Thanks for your post Dr Carroll ,you seem to be the “go to” guy for the mini implant failed cases.:)
    i place both routinely now for many years
    I cannot disagree with a standard implant being stronger but it depends how it is used..
    I like your analogy about the large amalgam that lasts for ever probably would, if it opposed a full upper denture… .
    To extend the example would you therefore change all your plastic 1 and 2 surface restorations with cast or indirect inlays /on lays..?
    After all, the indirect restorations are “stronger”
    As stated before if minis are used correctly in proper clinical circumstances they work very well..there is no spin on this I assure you.
    It is sound clinical judgement and skill based on experience and understanding biomechanics.
    When used correctly mini implants act as “tent pegs” holding down a denture RETAINING the denture never SUPPORTING it
    If designed correctly it is impossible for the over denture to break the mini implant even if you wanted to …if you do a poor retrofit of the denture to 4 toothpick size mini implants and create a twelve unit fixed bridge supported on 4 implants ..well of coarse that will have problems…
    I think the Minis have been too often touted as “easy” ..they are not that easy ..I would say they are more “accessible” for general practitioners who don’t necessarily want to get into big surgery but still want to serve their patient base.
    You say that all cases can be treated with standard implants..BUT not if the patient cannot afford it .
    i serve a spectrum of patients in my office ..not everybody can afford the Cadillac..and thats ok
    It is by no means a shortcut on clinical expertise and dental knowledge

    An over denture on standard implants is certainly not more retentive than minis ….your standard implant over denture will be more forgiving to poor clinical accuracy (not suggesting that of you at all BTW) simply because if you err on to the side of causing the denture to be supported on the implants you will likly get away with it as the standard ones are stronger
    i do both standard and Mini procedures selectively and regularly ..the minis OD is 1/3 the price of the standard OD and delivered the same day.
    I have served many many patients with this excellent adjunct to my range of treatments offered in my office
    many elderly folks in their 70s+and I have no regrets whatsoever
    There are a wide spectrum of people and conditions needing a variety of dental procedures that will benefit from a broader more holistic approach than a “one size fits all”…I am quite bewildered as to why this is “spin” or fooling myself ?

  29. K. F. Chow BDS., FDSRCS says:

    Dear John Carroll,

    Hmmmm….. “Most of the 2mm diameter implants fractured after more than a million cycles”, when considered in a cursory manner seems to be dire but when considered in context means that when used intelligently will last as long as regular implants if not longer.

    Let me explain. This is a scientific study to measure the fatigue life of a dental implant. The mini dental implant fixed to a rigid base is subjected to a horizontal force of 200 to 300 Newtons(the average biting force of an adult) 6 times a second. And it takes a million cycles before it fractures and this translates to about 9 years of constantly biting 300 times a day laterally on it. In the actual mouth, most of the forces are a range of between 50 to 200 Newtons acting axially mostly and sometimes angularly….never laterally. Also the implant in the mouth is not fixed in a rigid base but an elastic one! In this perspective, we can see that the test implants were subjected to extreme conditions over and above that in the mouth and yet it needed a million cycles before they fracture.

    Let me spell it out:- The probability that the implant will last a lifetime when used in its usual environment in the mouth and not subject to unusual forces is very high. This tests are on one piece solid implants. Two piece regular implants joined by a 1mm to 1.5mm diameter screw will give a poorer result….but will still last a lifetime in normal conditions.

    Profound proof may be stretching it a bit too far, profound implications are more like it. The profound implication of the last study I cited by 9 research scientists in the Journal of Dental Research 2003 is even more incriminating against all us implant dentists……uh I mean it should cause us to pause and seriously consider one piece implants to reduce soft tissue inflammation and bone loss.

    Power lies not in declarations but in strategic and intelligent deployment of the armaments at our disposal. Still awaiting the references of the literature that will put the numbers on your side.

    I have seen broken minis and also broken regulars. They are few and far between and usually caused by poor biomechanics that can be solved once the source of the abnormal forces and the reasons for them are identified.

    Finally, want to hear why a one piece 2.1 to 2.5mm diameter mini implant is stronger than a 4mm two piece implant?…… with a hole in the center that results in a rim of only 1mm thickness……and a screw that……’nuff said. Sincerely.

  30. DrSS says:

    Dr Carroll
    A solid screw is stronger than a hollow one of the same diameter..we all agree..
    There will not be much in it between a solid 2.1mm and a standard hollow 3.5mm.with internal joins and screws..?
    Dr Chow raises excellent points on well researched data then further explains in detail the mechanics .
    You dismiss well established data, claim you have better data and tell us ,(we who have been doing this for years) that we are to “look at facts” and imply that we are fooling ourselves or indeed being dishonest of our success and ,you do so with sarcasm.

    It has further been clearly indicated that skill and in-appropriate use has been the commonality in Mini implant failure (nothing new in Dentistry)
    We get it.. you don’t do and most likely have never done are yet to state evidence for your unfounded claims
    It is indeed possible to restore mouths in more than one way and consider that there is a different patient at the other end of your blade each and every time .

  31. R. Hughes, DDS, FAAID,FAAIP, DABOI/ID says:

    I nwould use 4, 3.75 mm wide implants and do not perf the inferior cortical plate, due to the high probability of mandibular fracture. I know it sounds slick but in reality the patient and you do not need the grief. You could make a sub if you are trained and have enough surgical and prosthetic knowledge and skill.

  32. John Carroll, DMD says:

    The impact of loads on standard diameter, small diameter and mini implants: a comparative laboratory study.
    Allum SR, Tomlinson RA, Joshi R.
    CONCLUSIONS: The diameters of the commercially available implants tested demonstrated a major impact on their ability to withstand load, with those below 3 mm diameter yielding results significantly below a value representing a risk of fracture in clinical practice. The results therefore advocate caution when considering the applicability of implants

  33. DrSenGupta says:

    Thank you Dr Carrol
    The forces on implants are Compressive ,Tensile and Shear .
    A correctly placed mini implant under an over-denture does not undergo these forces IF correctly placed and the prosthetics are properly executed.
    Subsequently hi compressive load is not a factor that is a concern for minis under a denture… which is why when done properly they work so well
    You certainly have a case with using minis for fixed crown and bridge ,however clinical knowledge and biomechanical design again come into play.
    Each case has to be carefully assessed for the options and limitations.

    If I were to use minis for a fixed bridge in the lower posterior quadrant ..I would like to see
    Crown root ratio of maximum 1:1
    Bone density of minimum type 2
    Splint all implants together
    Minimal cuspal inclines
    iPremolarise all the teeth (ie small occlusal tables)
    I would look to obtain canine or incisal guidance
    I would not use minis on a patient with serious parafunctional habits
    i would carefully consider the condition of the opposing arch
    Consider tripodisation (internal and external) of the implants if ridge is wide enough

    Then of coarse proper protocol is followed for the placement (there are many little nuances to this ,as many as with standard implants)

    If all these guidelines are judiciously considered i can promise the patient longevity reasonable aesthetics and treatment of about one third of the price of standard implants.
    There are clearly some cases where minis cannot be done…Ok.. thats why we have options

  34. DrSenGupta says:

    correction to my last post above …i mean that the Minis when correctly placed do not undergo these forces “to an extent that their diameter is a limitation .”…in the case of over dentures

  35. K. F. Chow BDS., FDSRCS says:

    Dear John Carroll,

    Thank you for your one reference to support your claim that the numbers and facts are on your side. The full conclusion of the study you quoted is…..

    “The results therefore support caution when considering the applicability of implants

  36. K. F. Chow BDS., FDSRCS says:

    My regrets for all the repeats cos somehow only the first few lines came out. This is the last time trying, failing which look into my blog.

    Dear John Carroll,

    Thank you for posting one reference to support your claim on having the numbers and facts on your side. Let me quote the full conclusion that was given in the study that you quoted……

    “The results therefore support caution when considering the applicability of implants less or equal to 3mm diameter for single tooth and FPD restorations. Standardized fatigue testing reports for commercially available implants is recommended.”

    The keyword is “caution”. The study does not proscribe or condemn outright the use of minis. Instead, it advocates caution because it realizes that its conclusion is deficient and inconclusive because of the following:-

    • Insufficient data. Only 9 samples from Straumann 3.3mm NN, NobelDirect 3.0 and Hi-Tec TRI-N-13 were tested as prescribed.
    • It is a simple overload test and not a cyclic loading test. A simple overload test is one in which you just keep pressing on to the test object until it breaks or bend. A cyclic loading test presses onto the test object intermittently at forces equivalent to those common in the average mouth until it breaks or bend.
    • The introduction to the study itself confesses to its deficiency, “ Cyclic loading tests mimicking years of functional use should ideally be used to test implant designs [Bragger 1999]……ISO 14801; 2003.” Thus a simple overload test is deficient and not conclusive.

    Before taking a position, we need much more evidence than from one study that has clear shortcomings. The literature to support the increasing use of minis is quite a lot. I will quote just a few:-

    • The effect of maximum bite force on marginal bone loss of mini-implants supporting a mandibular overdenture: a randomized control trial. Clinical Oral Implants Res. 2010 Feb.
    • Immediate obturator stabilization using a mini dental implants. J Prosthodont. 2008 Aug.
    • Mini-implants to reconstruct missing teeth in severe ridge deficiency and small interdental space: a 5-year series. Implant Dent. 2004 Dec.
    • Clinical evaluation of single-tooth mini-implant restorations: a five-year retrospective study. J Prosthet Dent. 2000 Jul.
    • Mini dental implants: An adjunct for retention, stability, and comfort for the edentulous patient. Oral Surg/Med/Pathol/Radiol/Endod 2005
    • Immediate loading of narrow-diameter implants with overdentures in severely atrophic mandibles. Sang-Choon Cho, Stuart Froum, Chih-Han Tai, Young Sung Cho, Nicholas Elian, Dennis P. Tarnow.

    The gold standard is a double blind randomized control trial. Until that comes, we have to depend on case studies and reviews on minis which is currently quite substantial. We should use both regulars and minis judiciously as both has their pros and cons.


  37. king of implants says:

    According to some of the doctors on this post I guess we should only be placing mini implants. Interesting…

  38. king of implants says:

    Unless of course I need an implant, then we can use a traditional implant…but for my patients I will place the minis 😉

  39. K. F. Chow BDS., FDSRCS says:

    Dear king of implants,

    Alas we are meeting the ruler of all implants. Your majesty, forgive my presumption, but as a fair and just ruler, I am sure that you agree that we should use both regulars and minis judiciously as both have their pros and cons, depending on the particular case.

    I have one case in which I treatment planned both into the equation. Check it out on my blog by clicking my name. If the patient was me, I would want my dentist to do exactly the same thing for me.

    Thank you for your kind indulgence.

  40. king of implants says:

    Dr Chow,
    I have read all your comments on this thread and I hereby bestow you the title of king of mini implants… You make a great argument for the minis. Knowing what I know and taking into consideration all your very useful contributions on this thread, I would still prefer not to have minis placed in my mouth. They have their place, but not in my mouth.
    THe King

  41. king of implants says:

    Dr Chow,
    As far as your cases go, we definitely have a very different perspective on restorative options for our patients. I wouldn’t do a lot of what you present on your blog. Doesn’t make it wrong obviously, just different philosophies.
    PS-Not sure about the “bone climbing up the mini implant”, if that’s the case you should no doubt publish so we can all switch over to minis. Before you do that, check the angulation on your x-rays, there is an obvious difference in both. Making such an outrageous claim really diminishes your credibility on the subject, which you eloquently show on some of your posts.

  42. K. F. Chow BDS., FDSRCS says:

    Dear king of implants,

    I beg to decline your most generous bestowal of the title “king of mini implants”. I am just the pretender because it is the Chercheve Brothers of France who rightfully deserve that illustrious title.

    I am most grateful for your kind declaration that minis have their place……though not in your royal stoma…..though others who are lesser may. Please bear with my insolence to suggest that your reluctance to have it in your mouth may have been a religious decision and not a scientific one.

    However, if you would condescend to look at my blog and observe this case of ectodermal dysplasia… Are MINIS THE BEST BET to complete this case…. considering the various constraints pointed out ?

    At your service.

  43. King of Implants says:

    Dr. Chow,
    How can mini implants be a permanent solution when you can just unscrew them whenever you want. Try doing that with a conventional implant. OK so you want to stabilize a denture with minis, I get it. But to place crowns over the minis is a whole different thing. Do you tell your patients that those crowns, over the mini implants, can last a lifetime if they do their oral hygiene and come in for their bi-annual check ups? I am truly curious. Or do you tell them that MAYBE they will last more than 5 years? We had issues with the IMZ press fits lasting more than 7 years, or was it the prosthetics/occlusion that made all those IMZ’s fail?

  44. sergio says:

    wow… there are dentists who give pateints life time guarantee on something? anything?
    On what scientific back ground? Sure ther are many 5 year longevity studies on implants but has anyone actually done a longitudinal studies on patients over 50 years? Oh wait, implants haven’t been around that long. Let’s throw away all this technicality bulls**t and do what works in our hands. And king of implant? what a name….

  45. K. F. Chow BDS., FDSRCS says:

    Dear king of implants,

    Bear with me and let me explain……actually even conventional implants can be unscrewed…at least some of them…..just like minis. Some minis can be unscrewed and some will break during the attempt….just like conventionals.

    The reason why conventionals seem more difficult to unscrew is that when you try to do it, you have to fix back the driver inside in order to apply a strong reversing force. This is difficult to do, thus giving the impression that conventionals are difficult to unscrew. I actually have unscrewed conventionals out before. The minis are much easier to unscrew because they are solid one piece and therefore its easy to apply a reversing force on it.

    Forgive me m’lord for repeating myself …. we should treatment plan with both types in mind, taking into consideration the general medical and local oral conditions, the expectations and budget of the patient and the materials and expertise available.

    In this particular ectodermal dysplasia case, I would use minis with fixed prostheses. On such patients who are below 18, I will use the minis as denture anchorages until they reach skeletal maturity, and then switch the minis to carry fixed prosthese. I expect them to last a long time, and if they fail, I will replace them. But if they last a lifetime, I will not be surprised. Being able to unscrew them may be an advantage…but I digress.

    The goal is cheaper, easier, faster, safer…..stronger…uh just as strong…. slip of the tongue, your eminence.

  46. K. F. Chow BDS., FDSRCS says:

    As for the subject of “bone climbing up the mini implant”. You are right m’lord, it really is a truly outrageous claim and it definitely diminishes my credibility on the subject, despite my eloquent words.

    But I canna help it. Just incorrigible, I suppose…. and I think I have to throw out me old fashioned xray machine…..(maybe get a digital one so that I can edit outrageous stuff out), causes it isss making me see thingssss!!!! Its getting too eloquent for me…my preess…cioussssss.

    Anyways check out me pics and tell me if I am sane or not…probably not. Clicksy me and seeee.:#

  47. mike ainsworrth says:

    We do many types of procedure but i still think syncone is the most satisfying thing i do as a dentist. life changing, simple, solid, predictable, nice. don’t really feel comfortable with fixed hybrids. I wouldn’t like plastic stuck in my mouth and I have not heard of chewable sterident yet. I personally think that if you go fixed you need ceramic, but syncone is ridiculously retentive, so you have the best of both worlds.

  48. John Carroll, DMD says:

    Chow Baby,
    Do you think that maybe standard implants are “harder” to unwcrew because of surface area? Or is that an outrageous claim? Minis can be taken out with SIMPLE FINGER PRESSURE… What does that tell you? If nothing, more power to you. No need to keep arguing then.
    I think I will concede to you, because if you still think that there is no difference in the angulations of your x-rays, thus making them seem like bone has grown around a mini, then I see where the problem is.
    Good Luck Chow baby! keep growing that bone one mini at a time. BAHAHAHAHAHAHAHA!!!!!!!!!!!!!!

  49. King of Implants says:

    Well said John. A bit sarcastic, but well said. I’m tapping out at this point before it gets more ridiculous.

    The King

  50. Dr TMG says:

    You can unscrew a 4 mm implant with your hands, if you do not have good sound bone around it. (some call that osseointegration). You cannot unscrew a 2mm implants if it is bonded to the bone, or it would break. The opposite is also true.
    Nothing to do with the implant diameter….

  51. Ken Clifford says:

    I have two 2.5mm x 15mm mini implants placed in my own mouth in non-parallel positions in good bone for replacement of tooth #4 over two years ago. The latest CBCT and PA shows no bone loss at this time. The “crown” is a simple resin buildup done directly in the mouth. It is in occlusion and has nice proximal contacts. I am just pointing out to the sarcastic dentists that some of us are willing to put our money where our mouth is. Is this scientific evidence? No. Will it still be in perfect condition in 30 years? Ask me again when I’m 93 years old. Also note that sarcasm and insult is the last outpost for a lost argument. Most of us are not advocating for mini implants only. I tell my patients that conventional implants are a sound solution and are well tested and proven, but most of my patients have already rejected the conventional implant solution because of cost. Should I therefore leave them edentulous? Your choice, Doctor.

  52. sergio says:

    Wow, ken.
    You read my mind. Exactly what I wanted to say.
    I ve seen some dentists who placed about 20-30 implants and act like they are expert in the field. try 1000 or over. And you still run into situations make you scratch your head. Our goal is to continue to learn. There is a reason why we ” practice”.

  53. Richard Hughes, DDS, FAAID, FAAIP, DABOI says:

    The resorbed mandible can be managed quite well with a subperiosteal implant or a famus frame implant. Of course one has to have advanced surgical and prosthetic skills than that to manage a root form case. Also, remember if one tries to place too many root forms in the symphysis that you can actually fracture the mandible. You will probably have to perform a vestibuloplasty with said case.

  54. K. F. Chow BDS., FDSRCS says:

    Dear John Carroll,

    Glad to have you back….. dad? Its very encouraging.

    Dr TMG makes sense. It is not the diameter of the implant, it is the amount of osseointegration that determines how difficult it is to unscrew an implant.
    A large diameter implant which has deficient osseointegration will be easy to unscrew while a narrow diameter implant with 70% surface osseointegration will be more difficult to unscrew.

    I do concede that there is some difference in angulation of my consecutive xrays portraying “bone climbing up a dental implant”, but the difference in angulation is insufficient to explain the great difference of the bone levels portrayed in my xrays.

    Actually, I am quite anxious to be rebutted successfully so that I can go back to placing conventional dental implants and making a fortune faster, but as it is…..I am a captive to what I know and the need of the many who needs dental implants cheaper, easier, faster, safer….

    Hope the King will be more magnanimous and not abandon his hapless subjects. Help! Queen is calling..have to go.

  55. Dr. M says:

    Implants are implants, don’t get caught up on the label, ie, “mini”. Every case is different, choose your implants based on the case you are treating. Personally, I generally use 1.8 and 2.4 mm implants for transitional situations. If, after reviewing options, the plan is to stabilize the lower denture, consider Milo 3.0 mm one piece implants. Very strong, and one has the option of placing crown abutments, straight and angled, or use the ball and housing attachments. They are compatible with Imtec. I actually like this a lot because I often use the angled abutments from Milo on the smaller diameter implants (Imtec) for transitional appliances. I think the bottom line is, treat each case depending on it’s particular presentation. Think about the possibility of losing one implant, where does that leave you/patient?

    As for mini implants breaking, it sounds like some basic principals are being ignored. One has to fit the denture as if there are no implants involved. Remember, if the goal is to retain the denture, it’s got to fit as well as it can first, then the implants will help hold it in position. If the implant are holding up the denture, one basically now has a fixed appliance on small diameter implants. Of course they will break, but it’s more of a practitioner problem vs. an implant problem.

  56. King of Implants says:

    BIC mean anything to anyone? if it doesn’t, no worries. Haven’t encountered a mini that I can’t unscrew with finger pressure. They may be out there, I just haven”t seen any I guess. I have a heck of a time taking out a conventional implant. In fact, much harder to remove a conventional implant than a tooth. Dr. Chow, I’m worried you still claim growth of bone around a mini. You make a great argument for minis, but that statement is completely ridiculous (respectfully).
    Good luck

  57. King of Implants says:

    DO you use a floss threader to clean between the two mini’s used to replace #4? WHy two mini’s rather than one conventional? Are you a dentist? Just curious…

  58. Dr Mac says:

    Dear King, I have had a number of years experience with minis…both Imtec and Intralock..ranging from 1.8mm diameter to 3.0. I have never had the experience of “unscrewing” one with finger pressure in the mandibular arch. I have placed them in patients as old as 95. I do not do them in the maxillary arch, there they are unpredictable. They can be a great service for denture patients and are more affordable + they can be used immediately to secure a well fitting denture.

  59. Shirley A . Colby says:

    Dear Dr. Clifford,

    What an innovative way to address the issue of ratio and proportion! You have not only made your implants AND restoration MORE secure against fracture, you have found a way to SIMPLIFY implant placement without having to sacrifice STREGTH AND STABILITY.

    I agree, not all patients can afford the convetional
    implants. Finding alternatives to solve their predicaments is the DISTINCTION that separates a
    BETTER DENTIST from a good one. It is my hope that
    COMPASSION and CREATIVITY are still very much part of our profession.

    It is a pleasure to read your thoughts, Doctor!

    Warmest Regards,

  60. Ken Clifford says:

    King – Yes I am a dentist, since 1980. Since the two mini implants are angled to the buccal and palatal (just like a normal bicuspid) I cannot floss between them. I chose mini implants instead of conventional because I wanted to see how it felt and functioned in my own mouth. There is no apparent bleeding or inflammation when I floss and brush the interproximal areas. Current I-Cat scan shows no bone loss. Never any pain or discomfort after placement. When you place multiple conventional implants for a fixed prosthesis, are your patients able to floss between all implants – and do they actually do it? When you see them at recall is there ever any bone loss? Just curious…..

  61. King of Implants says:

    What you have in your mouth is nothing new. Linkow used to do these procedures before Branemark came out with his profession changing research. The profession has evolved. Not that it’s not a good option but, what are the benefits?
    When performing a procedure like the one you have in your own mouth, would you charge less than a conventional implant?
    YES, all adjacent implants I place give patients the option to floss between them on a fixed prosthesis. I would say most of my implant patients do floss due to the emphasis we place on it at every hygiene visit. The flossing is directly proportional to the amount of investment made on their implants.
    As far as bone loss, I see less bone loss around implants than their natural dentition. I use mostly Astra and Ankylos, so bone loss is not an issue at all. Even better than Albrekson’s criteria.
    Again, minis have their place but in limited cases. There are way too many patients being given minis as their only option. I just can’t get over how easily they are removed. The only ones that require a little extra effort are the long ones.

  62. Ken Clifford says:

    Of course I charge less. The implants cost me way less than conventional implants. Placement time is under 10 minutes in most cases. No custom abutment cost. Immediate loading in many cases so less office visits needed. In my area conventional implant plus abutment plus crown costs around $3500. My fee is less than half that cost. Almost all of my patients would have no treatment at all with conventional implants simply because they can’t afford them. Sometimes our perspective of financial reality in the real world is skewed by the incomes of many of our colleagues in dentistry.
    As to ease of removal, think about it. Of course each mini has less surface area,than a conventional, but I use multiples. A small screw in wood is easier to remove than a large one, likely because more torque is applied to the surface of the screw because of the smaller radius. That’s why screwdrivers come in many sizes. Are you suggesting that osteoblasts can tell the difference between large and small diameters and bone refuses to integrate around the small ones?

  63. King of Implants says:

    “Are you suggesting that osteoblasts can tell the difference between large and small diameters and bone refuses to integrate around the small ones?”

    Yes I am, they tell me this at night before I go to bed.

    “Sometimes our perspective of financial reality in the real world is skewed by the incomes of many of our colleagues in dentistry.”

    I guess… If I only offered implants as a solution to missing teeth. Minis have their place but patients need to be thoroughly explained the difference between a mini and a standard. Majority of mini placers are exclusively mini placers and do not let a patient walk out the door to get a standard. Not any of you, of course.

  64. K. F. Chow BDS., FDSRCS says:

    “We should use both regulars and minis judiciously as both have their pros and cons, depending on the particular case”. I stand by this statement and believe that we should not be using only minis or only using conventionals but should keep both in mind in order to provide our patients with a suitable treatment plan based on their expectations and budget, their oral and general condition and lastly our expertise and materials available.

    M’lord, I am deeply gratified that you recognize that minis do have their place and that the patients [who are really the true lords over us, since we live to serve them], should be duly informed of the differences between the conventionals and the minis, so that they can exercise their rights to have informed choices.

    Cheaper, faster, safer, stronger is the goal. And I wish to highlight one reason why I think minis are safer.

    Ken Clifford has replaced his upper premolar with 2 anatomically correctly positioned minis, mimicking the natural tooth, one on the buccal and one on the palatal, with a crown on top. He can floss it mesially and distally all the way to the surface of the implant proper, but not in between. If he had used a conventional with a nice large emergence profile, he would only be able to floss the contact areas but not into the “sulcus” or more accurately the periodontal pocket that is around every dental implant ever placed. We have also been advised not to probe into this pocket unnecessarily else it may cause an infection.

    Yes. Minis are safer because they have a smaller pocket and can be flossed whereas conventionals have a large pocket and cannot be reached with a floss. In Ken’s case, there is a way to floss even between the two minis if he has incorporated a cleaning groove in between. I actually have a similar case… not on me… my patient. But if I am my patient, I will do exactly the same!

  65. sergio says:

    King of implant,
    they tell you at night before you go to bed?
    Who? Your gut feeling? Textbook? oh wait, there is no textbook ever specified on this subject. Even carl Mish seems to have a lot of guess talk on this topic. ‘I wouldn’t do that’ is not a valid reason to convince other clinicians. First time I used Astra impant, at the neck of abutment, it fractured after loading it. Does it somehow mean that astra implant’s flatform switch is a bad idea and no one should place one of these? NO.
    I know many other docs who have good result with astra impants.
    I understand this is a debate and many people speak from their personal experience but when you say ‘they tell you at night… ‘ B.S., I really know why those pioneers 40 years ago on implants got criticized so much. Keep that kind of not so scientific statement to yourself. Pretty annoying when some one with no research background tries to state a breakthrough fact when it’s not a fact.

  66. Shirley A . Colby says:

    Simmer down, Sergio…

    The King may act like a Monarch but he does have a sense of humor to balance it. You’re taking him far too seriously!

    I find this real amusing…

    that each design comes with its own. Let’s just leave it at that.

    Warmest regards,

  67. King of Implants says:

    LOL! Thank you for having a good sense of humor. I was asked a ridiculous question, so I gave a ridiculous answer.

    ” If he had used a conventional with a nice large emergence profile, he would only be able to floss the contact areas but not into the “sulcus” or more accurately the periodontal pocket that is around every dental implant ever placed.”

    Disagree… Don’t have that problem with implants like Astra, Ankylos, etc.

    “We have also been advised not to probe into this pocket unnecessarily else it may cause an infection.”

    Disagree… That was the advise in the 1990’s, not anymore. You want to probe to establish a baseline and determine if there is a periodontal pocket forming.

  68. K. F. Chow BDS., FDSRCS says:

    M’lord. Bear with me as I impose upon your magnanimous patience a little bit longer.

    The common universal weakness of every dental implant ever placed is the transmucosal passage through which it emerges through the mucosa into the mouth. In spite of all the claims of different manufacturers about hemidesmosomes and the like, even if true is a far cry from the real thing which is the sophisticated, superbly designed periodontal apparatus that forms a tight self renewing cuff around the neck of the tooth.

    Every dental implant ever placed has a periodontal pocket around it…… yeah… you heard it right…. a pathology….. a disease around it! Until we have perfected a tooth germ implant, we will have to live with it and manage it. Thankfully, they give far less problems than it could have…… maybe because the oral tissues have enhanced defenses, more than other parts of the body. Almost all these dental implants show a certain degree of perimucositis onwards to peri-implantitis, though most are symptomless and under control by the immune system.

    The solution to the problem is thus to probe and scale it only when necessary, i.e. when signs and symptoms of inflammation/peri-implantitis become clinical rather than sub-clinical. We should not routinely probe and scale the pockets around implants else we introduce infection to a vulnerable subclinically diseased area.

    Periodontal pockets are different from perioimplant pockets. Periodontal pockets should be eliminated if possible and regularly scaled if not. Perioimplant pockets should be left alone until clinical signs and symptoms present.

    What a mouthful! My gratefulness for your forbearance in this subject’s attempt to break new ground, your graciousness.

  69. K. F. Chow BDS., FDSRCS says:

    Dearly beloved leader… I mean, king,

    “You want to probe to establish a baseline and determine if there is a periodontal pocket forming.”

    I beg to disagree. There is already a periodontal pocket around every dental implant ever placed. I repeat, “Every dental implant ever placed has an existing periodontal pocket…. a pathology….. a disease!” The depth of the pocket is dependent on how hard you probe because there is nothing there to resist it except a few miserable hemidesmosomes. Thus the baseline is subject to the sharpness of your probe and the the power of the thrust.

    The way forward in order to reduce the incidence of peri-implantitis is to reduce the pocket and protect it. To eliminate it completely is not possible yet.

  70. John Carroll, dmd, ms says:

    “I beg to disagree. There is already a periodontal pocket around every dental implant ever placed. I repeat, “Every dental implant ever placed has an existing periodontal pocket…. a pathology….. a disease!” The depth of the pocket is dependent on how hard you probe because there is nothing there to resist it except a few miserable hemidesmosomes. Thus the baseline is subject to the sharpness of your probe and the the power of the thrust.”

    “The solution to the problem is thus to probe and scale it only when necessary, i.e. when signs and symptoms of inflammation/peri-implantitis become clinical rather than sub-clinical.”

    Call the “POCKET” what you will. The American Academy of Periodontology disagrees with you. They do recommend probing and establishing a baseline.
    As far as pocketing, I rarely find any “pockets” greater than 3mm on Astra, and Ankylos. I ask my hygienests to treat these implants like any other tooth… plaque free. I wouldn’t scale a tooth that didn’t need it, so I wouldn’t scale an implant that didn’t need it. Don’t get caught up on insignificant semantics on this exchange. Yes Chow you know what you’re talking about about when it comes to implant periopockets, great! Let’s move on to the real issue.

    I’m surprised nobody chimed in on my comment that “Majority of mini placers are exclusively mini placers and do not let a patient walk out the door to get a standard.”… Interesting.

  71. King of Implants says:

    “I’m surprised nobody chimed in on my comment that “Majority of mini placers are exclusively mini placers and do not let a patient walk out the door to get a standard.”… Interesting.”

    I appreciate you backing me up but you’re taking credit for my statements…

    “I’m surprised nobody chimed in on my comment that “Majority of mini placers are exclusively mini placers and do not let a patient walk out the door to get a standard.”… Interesting.”

    Regardless, you are correct about the AAP recommendations. Now that I also exclusively place implants like Astra and Ankylos and others similar, I do not see the pockets I used to get when I placed Branemark clones. I would probably agree with Chow and be more selective in my probing when using a Branemark clone and encounter a 5-6mm “pocket”. I don’t find that to be the case any longer with these other systems. I see more and more practitioners switching over to systems like these… but that’s another thread. I would still want to establish a baseline regardless of the type of implant they have in their mouth.

  72. King of Implants says:

    The King forgives you…

    In residency we conducted a study on external hex 3i implants with screw retained crowns. We would probe the implant pocket, remove the crowns and measure from the base of the pocket around the coronal portion of the implant to an adjacent tooth landmark. We would also probe and leave it in place and xray the area to determine we had reached the base of the pocket. What we found was that we were consistently able to probe to the base of the pocket. The probes were not dull or bulky, so Chow is partially correct on the sharpness of your probe would affect your readings. I still disagree with him in regards to not probing around implants. I think that if he probed his minis he would find that in fact bone wasn’t creeping up the mini, as he has stated.

  73. K. F. Chow BDS., FDSRCS says:


    “Every dental implant ever placed has a perioimplant pocket around it…… yeah… you heard it right…. a pathology….. a disease around it!”

    May I humbly request your kind indulgence to proclaim me as the first implant dentist to blow the whistle on the most well kept secret in implant dentistry.

    I have no quarrels with the American Academy of Periodontology if they are merely advocating a very gentle initial probing to establish and record a baseline for future comparison to confirm whether it is getting deeper than before….. as long as it is not supposed to be done regularly, but only initially and then subsequently when peri-implantitis is suspected.

    However, I still question the usefulness of it because the probing is very subjective to the instrument, pressure used, the current edema present, and the individual dentist. My take is still to leave it alone and probe only when clinical signs dictate. This is the stand of the Academy of Perioimplantology.

    Minis, midis, maxis are all dental implants and all of them work within sensible parameters. Minis will have a smaller perioimplant/disease pocket and theoretically then will be safer. If you can scratch your nose with a finger directly, why stretch your arm around your head to do so? Oh, those clever osteoblasts have confirmed that they do not exactly climb, they actually crawl cause they ‘ave those fancy shape-changing tentacles.

    Pardon the mischievousness y’ighness.


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