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Two-Stage Mini Dental Implants: Is It Time to Join the Party?

Chances are, you have contemplated learning how to place dental implants. During the past several years, you’ve been inundated with offers of continuums that promise to make you implant ready as long as you can spare the few full weekends it will take to get you there (not to mention the cost of the education and the multitude of airplane rides and hotel stays). You may have also rationalized that you don’t really like the sight of blood, and your flap management and suturing techniques are maybe a bit rusty. Still, there may exist a gnawing feeling that you have become “dentally dated” by not being able to look in the mirror and tell yourself, “Hey! I just placed a dental implant! I’ve put something where there was nothing. Never thought I could do it! ”

MINIS FOR STARTERS
If this sounds like you, then you owe it to yourself to take a second look. Many things have changed in the implant world. You may have noticed that mini implants (also called small-diameter implants [SDIs]) have been gaining considerable popularity. Bolstered by the refinement of implant systems and many ambitious clinical studies that have validated their use, mini implants provide an excellent segue for you to dip your toe into the virtual implant ocean. The courses are brief (in comparison to the multiple weekend extravaganzas alluded to above), inexpensive, and capable of making you “mini-ready” in short order. Typically, after you’ve taken a beginner and an advanced course, you’ve heard all that you need to hear. The rest of your “mini-education” happens on your patients, notably the ones with copious amounts of bone but no teeth; the patients whom you like and make you comfortable when treating them—they complete your residency program. In doing so, you gain the one key skill/ability that prepares you for the next level of involvement. That new ability is learning how to drill through gum and bone (flapless) when creating a mini-osteotomy. Just as when you learned to cut enamel and dentin, it becomes necessary to gain knowledge of the tactile sensations experienced when penetrating the cortical plate with an osteotomy drill. One also gains knowledge of the difference in feel between soft bone (the maxilla) and hard bone (the mandible). Key point: The flapless approach coupled with the diminutive osteotomy affords the new user a certain amount of comfort. With properly chosen cases, there remains plenty of wiggle room for less-than-perfect placements of mini dental implants, particularly when stabilizing floppy dentures, as they are best used. The SDI arena is a perfect training ground for the next level of involvement: the venerable 2-stage, nonimmediate load implant.

TWO-STAGE GRADUATION
Have you noticed that the post-op implant films that your specialists are sending you lately no longer feature “foot-long” metallic substructures but rather diminutive, slender, root form implants? They are often shorter than the natural teeth that they have been placed next to, thus keeping them well away from vital structures. As you encounter these images of single-tooth replacements, notably the lower first molars or maxillary first or second bicuspids, it might have occurred to you that it doesn’t look that difficult. Actually, it’s not, and today’s implant manufacturers are trying very hard to simplify and streamline the placing of implants in a strong effort to attract general practitioners to the process. One company, OCO Biomedical (founded by a dentist, Dr. David Dalise), serves as an excellent example of how dental implant placement has been reduced to fewer steps with built-in checkpoints that, in some respects, conjure up endodontic therapy. And yes, it also retains similarities to placement of mini dental implants, notably a flapless approach using a shallow osteotomy, for starters.

Figure 1. OCO Biomedical’s complete implant placement kit enables the dentist to place any one of the company’s families of 7 implant types. Figure 2. No. 8 high-speed round bur (all needed burs are included in the kit) is used to create access and purchase point for pilot drill osteotomy.
Figure 3. Osteotomy drill with drill stop in place, thus limiting drill depth. Figure 4. A 1.8 pilot drill is advanced until drill stop engages soft tissue.
Figure 5. Paralleling pin in place to determine desirability of initial osteotomy. Figure 6. Tissue punch is now employed to create clear access to osteotomy site.
Figure 7. A No. 8 round bur is used to remove tissue button from osteotomy site. Figure 8. Pilot drill goes to full depth.
Figure 9. Final osteotomy former goes to depth (set by pilot drill) and no further. Figure 10. Engage implant carried to newly created osteotomy site.

The typical procedure for placing a bone-level, 2-stage implant (Engage [OCO Biomedical]), enabled by their all-inclusive implant placement kit (Figure 1) goes as follows:
1. Locate where you wish to place your implant by creating a small divot with a No. 8 high-speed round bur (all burs required are included in the kit) that penetrates the gingiva and creates a shallow purchase point in the cortical plate in which to seat your 1.8 mm osteotomy drill (Figure 2).

2. After having placed a drill stop (designed to control the depth of the original entry) on your osteotomy drill, you then seat the tip of the osteotomy drill and align the drill shaft as you would envision the desired angle of the implant, using adjacent teeth and radiographs to guide your “3-D vision.” Take your time on this step, and if possible, do it on a study model in advance of treatment to familiarize yourself with the landmarks available to you. When you think drill stop, think endo stop—a system safeguard that limits instrument travel. However, the drill stop differs from an endo stop since an endo stop can move and the OCO drill stop cannot; it is physically impossible to drill deeper than intended. Using a water-cooled surgical handpiece at 1,200 to 1,500 rpm, one then drills until the drill stop reaches the gingival crest (Figures 3 and 4).

3. The equivalent of taking your “working length film” is next. A paralleling pin that resembles an abutment is dropped into the initial osteotomy to check one’s angulation, and a radiograph is taken (Figure 5). If you don’t like what you see, re-drill at the angle that suits you and re-evaluate.

4. When ready to proceed, a matched tissue punch with a center guide pin is used to drill down to bone (Figure 6). This step allows removal of a tissue button matched to the diameter of the implant that you will be placing. The button can either be curetted out or spun out with the same high-speed round bur used to initiate the site (Figure 7). You are left with a perfect view of the bone and osteotomy site.

5. Now replace the same osteotomy drill into the initial channel and continue drilling until the drill stop encounters the crest of bone (Figure 8). You’ve now defined the final depth of the osteotomy.

6. The final drill, designed to cut no deeper than the pilot drill is then used to create the final shape of the osteotomy. An o-ring on the final drill is set in conjunction with the implant length and tissue thickness. (In the case of a 12-mm implant, 2 mm for tissue plus 12 mm for implant length, for a ring setting of 14 mm.) The final drill will go to depth fairly passively. It will follow the path that you created and stop when it can go no further (Figure 9).

7. The Engage implant is then removed from its color-coded packaging and carried to the implant site with its amber-colored delivery cap (Figure 10). The cap is used to initially thread the implant into the osteotomy until resistance is met.

8. At this point, one removes the amber cap and uses either the thumb or ratchet wrenches with the Engage driver to seat the implant (Figure 11). You can use the torque wrench to determine the torque reading upon final seating (Figure 12).

9. In a flapless technique, as described here, the healing screw and extension cuff are removed from the amber cap that does double duty as a container for these important attachments. The healing cap is threaded in place with the accompanying 0.050 Hex Driver and Thumb Knob (Figures 13 and 14). You are finished!

10. See the patient in one week to check for favorable tissue response and then set your alarm clock to remind you when 4 months have gone by. Hopefully, you’ve purchased the EPK2 accessory kit (OCO Biomedical) when you purchased the implant. It has the restorative parts you will need to complete the restoration (more on this ahead).

Figure 11. Ratchet wrench used to tighten down Engage (OCO Biomedical) bone-level implant. Figure 12. Torque wrench is used to assess how tightly the implant is engaged in bone.
Figure 13. Engage implant, as it appears after flapless placement. Figure 14. Tissue/healing cap screwed in Engage implant to guide healing of the soft tissue in a flapless approach.
Figure 15. Closeup of OCO instrumentation system. Notice the color-coded serial
progression of the instrument presentation.
Figure 16. Color-coded osteotomy formers are easily identifiable.
Figure 17. Close-up of the Engage implant and abutment. Figure 18. Stainless steel ball bearing and Kodak’s Digital Imaging suite measuring tool can was used to assess bone height on a periapical radiograph.
Figure 19. The 3D Diagnostics (3ddx.com) 3-D rendering of implant placement treatment plan. (Note: Start with a case that is not so complex!) Figure 20. Surgical guide from 3D Diagnostics designed and constructed cone beam tomograms study and a study model of case.

DISCUSSION
The above method description is included only as an attempt to demystify the placement of root form, 2-stage implants in well-chosen sites. Certainly, an introductory course or 2 from the manufacturer is advisable. Such courses, typically with hands-on components, highlight potential pitfalls and allow familiarity with the component parts in a nonclinical setting. When taking such courses, you will notice that contemporary kits are both color-coded and procedure-flow oriented such that corresponding parts are grouped in sequence, and by implant size and type. The process becomes formulaic; very reminiscent of endodontic therapy but with fewer components (Figures 15 and 16).

Another interesting benefit has surfaced and, again, is well illustrated by the OCO system. When purchasing OCO Biomedical implants, there is all-inclusive packaging at no extra cost. The EPK1 package includes an analog, impression coping, cover screw/gingivaformer, and implant. The EPK2 package adds a stock straight abutment to the EPK1 package for just a few dollars more—one-stop shopping, if you will. Of course a full selection of specialty abutments are available. For simple straightforward cases, where alignment is not an issue, the stock abutment will do nicely using either direct or indirect placement techniques enabled by the kit contents.

As an aside, the OCO Biomedical system, and in particular, the Engage implant, are nicely engineered (Figure 17). The Engage implant is self-tapping for an enhanced mechanical lock in the bone. The Bull Nose Auger tip will not proceed any deeper than the initial pilot drill and will lock into the base of the osteotomy for excellent stability. Engage implants also have a proprietary surface treatment designed to increase the surface area of the implant for optimal bone in-growth and stability. The titanium alloy Ti 6AL-4V ELI lends the Engage implant the best possible strength that is critical for smaller diameters. It also features the universal internal hex connection that most of us are familiar with on the restorative side.

On a personal level, having placed a sizable number of mini implants during the past 5 years, I found the placement of an Engage implant very much in keeping with what I had become used to and in some respects, enjoy the “2-stage” aspect of the process, not feeling the pressure of needing immediate load torque on placement, as is often the case with mini dental implants. As for physical placement of the Engage, it couldn’t be any smoother or precise. It’s worth pointing out that OCO Biomedical also offers an SDI that is placed in much the same fashion as all other SDIs, using simply a pilot drill. The OCO Biomedical Complete Implant Surgical System contains all of the instrumentation needed to place any one of their 7 implant families.

TECHNOLOGICAL SUPPORT
To date, my cases have relied upon a digital panoramic or periapical radiograph used with a software-based calibration tool (Kodak Digital Imaging) that uses a 5-mm diameter ball bearing placed somewhere in the proximity of where the implant is planned (Figure 18). This allows for length and angle planning but, of course, lacks the third dimension. In these cases, dental intuition has been relied upon (mostly by creating study models for measuring width and locating a desirable position) to place the implant fixtures. The power of digital palpation, and how it is interpreted in the mind’s eye, is also heavily relied upon when planning is limited to 2-D radiographs. For simple cases that feature abundant bone and adjacent teeth, this approach can work with regularity.

Let’s say that what’s holding you back is the fear of creating an off-angle osteotomy or the possibility of encroaching on the inferior alveolar nerve, maxillary sinus, or exiting the mandible altogether. Amazingly, you can have access to serious technological support without purchasing your own cone beam (CB). Companies such as 3D Diagnostics (3ddx.com) will interpret independently taken CB tomograms and create remarkable 3-D imagery (Figure 19). Then, using your chosen implant system, they offer treatment planning recommendations concerning implant selection and placement as it relates to adequacy of bone and proximity to vital structures. CB exams can take place from specialists who have them, needing only to provide you the DICOM data in a transferable format to be forwarded to 3ddx.com, typically on DVD. 3D Diagnostics also partnered with a variety of companies, such as Northstar On-Site (in Connecticut), who provide minivan-based CB units that will travel to your office, your patient’s home, or place of work, to obtain the necessary CB examination.

When provided with accurate models, 3D Diagnostics can also provide surgical guides that can go so far as to determine drill placement with the very system you might be using; as long as there are teeth in the arch to fixate the surgical guide for a guided flapless approach (Figure 20). Surgical guides are available at several levels of complexity; from simple pilot hole location to guides that dictate absolute location, angle, and depth of drilling.

To be sure, this level of sophistication requires a briefing on how to participate. Know that the companies involved will take the time to acquaint you with the process. Keep one thing in mind when considering the implementation of this technology—it will add considerably to the total cost of the case. Total costs (scan, diagnosis, treatment plan, and surgical guide) can approximate $750 to $1,000. Still, given the built-in safety net and the feeling of having maxed out your planning stage, the value is there, and it’s likely that your patient will appreciate the thorough analysis if it is properly presented.

SO, IS IT TIME TO JOIN THE PARTY?
Maybe it’s time to inject a little excitement into your routine. If this makes sense to you, I would encourage you to scout out a system intro course (such as those offered by OCO Biomedical) to get a grasp on the basics. Then, begin looking for that first ideal patient case, whether it be a mini implant denture stabilization or an easy 2-stage Engage implant to replace Tooth No. 30. Remember: begin with plenty of bone (wide and deep) and a trusted patient who understands you are just entering the arena. It is best to work with patients who like you and who relax you when treating them. It might also help to offer the first case (or 2) at a bare-bones cost to further enhance the patient’s willingness to proceed. You may also wish to have a surgeon there to look over your shoulder the first time; I did this and found it both helpful and reassuring.

You may discover that the placing of implants is just what you needed to reignite your professional fires. Over and out!

Acknowledgment
Thanks to Drs. Scot Mardis and Ara Nazarian for their encouragement to get involved with placing user-friendly implants.


Dr. Goldstein is a Fellow of the International Academy of Dento-Facial Esthetics as well as the AGD and practices general dentistry in Wolcott, Conn. Recognized as one of the Leaders in Continuing Education by Dentistry Today since 2002 and for his expertise in the field of dental digital photography, he lectures and writes extensively concerning cosmetics and the integration of digital photography into the general practice. He has authored numerous articles for multiple dental periodicals internationally. He can be reached via e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it.. His current speaking schedule can be found by visiting the Web site drgoldsteinspeaks.com.

Disclosure: Dr. Goldstein reports no disclosures.



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