DENTAL TECHNIQUE

Clinical guidelines and procedures for provision of mandibular

overdentures on 4 mini-dental implants
Manabu Kanazawa, DDS, PhD,a Jocelyne Feine, DDS, MS, HDR, FITI, FCAHS,b and
Shahrokh Esfandiari, BSc, MSc, DMD, FITI, PhDc

Mandibular 2-implant over- ABSTRACT

dentures (IODs) are recog-
This article describes the apless placement of mini-dental implants (MDI) to retain mandibular
nized as the rst choice of overdentures. Clinical inclusion/exclusion criteria and clinical protocols for the apless placement of
treatment for patients with MDIs and for retrotting the overdenture are presented. A minimum bone height of 13 mm and a
edentulism,1,2 in that 2-IODs minimal ap are recommended. After drilling, the 4 implants are placed with a self-tapping process.
have been shown to improve A minimum of 15 Ncm of resistance upon nal insertion indicates that immediate loading can be
oral health-related quality of performed. The metal housings with O-rings are incorporated into the prosthesis using autopoly-
life,3 mastication,4 and com- merizing resin. The technique and protocol for immediately loaded 4-mini-implant mandibular
fort.5 Furthermore, this treat- overdentures is minimally invasive and cost effective. (J Prosthet Dent 2016;-:---)
ment is more cost effective
over a lifetime than conventional dentures6 and pre- morbidity and patient discomfort.16 Older patients tend
7
serves some of the residual bony ridge. to refuse IODs because they fear greater pain and asso-
Mini-dental implants (MDIs) offer alternatives to ciated complications, even when cost is not an issue.17
mandibular 2-IODs with standard-width implants. A To overcome these problems, the immediate loading of
healing period of 3 to 6 months before functional loading 4 mini-implants placed with apless surgery has been
of standard-width implants has been recommended for suggested.18 The cost of mini-implants is considerably less
8
proper osseointegration. This healing period before than that of standard implants. IODs with 4 MDIs are more
prosthesis delivery may be esthetically, functionally, cost effective than 2 conventional implants with bar or ball-
psychologically, or socially intolerable for patients.9 One and-socket attachments.18 The use of MDIs for over-
complication of 2-IODs is the potential for anterior- dentures in the edentulous mandible is well documented
posterior rotation. Denture rotation may cause food (5th ITI Consensus Conference).19 For patients with narrow
particles to lodge under the dentures and result in dif- alveolar ridges seeking dental implants, reduced diameter
cult mastication, particularly when food is masticated implants may be accommodated by an atrophic alveolar
with the anterior teeth.10 The initial cost of 2-IODs is 2.4 ridge, thereby negating the need for additional surgical
times that of treatment with conventional complete procedures.20 Four implants with stud attachments may
11,12
dentures. In a standard implant placement protocol, also reduce the denture rotation commonly associated with
a ap is raised during implant placement surgery, leading 2 implants and ball attachments.21 When 4 implants are
13,14
to swelling and pain. If patients have a narrow ridge, used, the cantilever length to the anterior-posterior spread
bone augmentation procedures, such as grafting, may be is the most important element for stress distribution.22
15
needed. This may be expensive and present high Furthermore, the survival rates of immediate loading

Supported by 3M ESPE.
a
Visiting Professor, Faculty of Dentistry, McGill University, Montreal, Quebec, Canada; and Assistant Professor, Tokyo Medical and Dental University, Tokyo, Japan.
b
Professor, Faculty of Dentistry, and Associate Member, Department of Epidemiology and Biostatistics, Department of Oncology, Faculty of Medicine, McGill University,
Montreal, Quebec, Canada.
c
Associate Professor, Faculty of Dentistry, McGill University, Montreal, Quebec, Canada.

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protocols are reported to be similar to the early and con-
ventional loading of standard implants.23 In fact, the loss of
an MDI is easier and less expensive to replace than the loss
of standard-width implants. Oral health-related quality of
life and satisfaction after immediate loading have been rated
by patients as signicantly better than when implants are
loaded using a delayed protocol.24 The survival rates of
implants placed using apless techniques have been re-
ported to range from 94% to 100% over 4 years.14 Moreover,
patients were highly satised with apless surgical ap-
proaches,25 perhaps because pain and swelling are reduced.
Some reports are available on mini-implants sup-
porting mandibular overdentures. Bidra and Almas20
conducted a meta-analysis on the survival rate of mini-
implants for denitive prosthodontic treatment. Evi-
dence for the short-term survival of mini-implants when
used exclusively for denitive prosthodontic treatment is
encouraging, with a 94.7% rst-year interval survival
rate.20 Unfortunately, the survival rate of mini-implants
less than 3 mm in diameter is documented only for the
edentulous jaw and single-tooth, non-load-bearing re-
gions. Long-term data and success rates for the latter are
unavailable.26 However, there are a few reports on the
survival of mini-implants with mandibular overdentures.
Griftts et al18 assessed the acceptability of mandibular
overdentures supported by 4 MDIs in 30 patients. They
reported a 97.4% implant survival rate at 13 months.
Jofr et al27 reported a 100% survival rate at 3 years of
2-mini-IODs on ball and bar attachments in 45 partici-
pants. Elsyad et al28 assessed 4-mini-IODs in 28 partic-
ipants, reporting a 96.4% cumulative survival rate after 3
years. Scepanovic et al29 reported a 95.9% success rate
after 1 year of 4 immediately loaded mini-implants
supporting mandibular overdentures in 30 participants.
Although the short-term success/survival of mini-
IODs has been reported, to date, little published
information is available on the appropriate diagnosis,
planning, and treatment procedures for mini-implants.
The purpose of this article is to provide criteria that can
be used to determine the feasibility of and treatment
planning for the apless placement of 4 mini-implants
and the immediate loading of mandibular overdentures.
TECHNIQUE
Patient selection
1. Examine the panoramic radiograph for any
anatomic abnormalities that may hinder implant
placement.
2. Screen the height of the anterior mandibular region
with dental calipers from the tip of the edentulous
ridge to the outer lower part of the chin as illustrated
in Figure 1. An approximate minimum height of
27 mm is needed for the placement of a 10-mm
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Figure 1. Measure height of anterior mandibular region with dental
calipers from tip of edentulous ridge to outer lower part of chin.
implant. The 27-mm requirement accounts for the
total height of the mandibular anterior bone, soft
tissue, and keratinized mucosa. Using 10-mm
implants, the remaining 17 mm is an over-
estimation to ensure adequate height for thick
mucosal conditions. Thereafter, any necessary vari-
ations in the length of the implant can be calculated
on the basis of this minimum required height.
Surgical procedure
1. Mark the juxtaposed distal point of the canines and
the mandibular midline on the inside of the
mandibular denture with an indelible marker
(Pyoktanin Blue Solution; Hayashi Pure Chemical
Ind Ltd). Mark 2 equidistant points on each side of
the midline and canine line.
2. Dry the edentulous ridge and insert the marked
denture in the mouth. Marks will be subsequently
transferred to the patients tissue. Three lines and 4
points each representing the future implant place-
ment location should be visible. Repeat this step
until all points are visibly recognizable (Fig. 2).
3. Anesthetize the buccal anterior mandibular region.
Administer topical anesthetic, followed by buccal
mucosa inltrations. Block anesthetics are not needed.
4. Using a 15C scalpel (Bard-Parker; Aspen Surgical),
perforate the summit of the mandibular ridge
corresponding to each point. This is not ap
elevation. This procedure simply reveals the width
of the ridge, which cannot be examined from a
panoramic radiograph (Fig. 3).
5. Place the pilot drill (1.1-mm Pilot Drill; 3M ESPE)
lightly on the entry point and using very little
pressure, move it up and down until the cortical
plate is penetrated (Fig. 4). Make sure that the
drilling site is irrigated with sterile saline solution
to avoid overheating the bone (1200 to 1500 rpm is
Kanazawa et al
- 2016
Figure 2. Three lines indicate midline and distal point of canine. Four
points indicate future implant placement location.
Figure 4. Use pilot drill placed on entry point until cortical plate is penetrated.
recommended). You may penetrate one-third to
one-half the height of the implant.
6. Place the implant (MDI implant collared
O-Ball,f1.8 mm; 3M ESPE) into the hole. The
driver (Winged Thumb Wrench; 3M ESPE) is
attached to the head of the implant. After inserting
the implant into the prepared site, rotate it clock-
wise while exerting downward pressure until the
wrench becomes difcult to turn (Fig. 5). This
procedure is the self-tapping process and is used
until noticeable bony resistance is encountered.
7. Place the implants as parallel to each other as
possible. Parallelism is partly achieved by placing the
implants individually. The rst implant is screwed in
only half way before the second hole is drilled. In this
fashion, the rst halfway inserted implant acts as a
placement guide. The same procedure should be
repeated with the third and fourth implants.
8. Carefully turn the torque wrench (Adjustable
Torque Wrench; 3M ESPE) toward the denitive
placement position of the implant.
Kanazawa et al
3
Figure 3. Perforate summit of mandibular ridge with scalpel.
Figure 5. Place implant in hole with self-tapping.
9. Place the implant so that it allows the abutment
head to protrude from the gingival soft tissue at its
full length and with no neck or thread portions
visible (Fig. 6).
10. Do not over tighten. A minimum of 15 Ncm of
resistance upon nal insertion is sufcient for
the immediate loading. Excessive tightening
(>45 Ncm) may fracture the body of these narrow
diameter implants.
Prosthetic procedure
1. Trim 2 to 2.5 mm of the green rubber tube (Blockout
Shim; 3M ESPE) and place on each implant to block
out undercuts (Fig. 7).
2. Place the metal housings with O-rings (metal
housings; 3M ESPE) on each implant (Fig. 8).
3. Place the mandibular denture in the mouth to view
the location of the implants in relation to the
denture.
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Figure 6. Place implant as abutment head protrudes from gingival soft
tissue.
Figure 8. Place metal housings with O-rings on each implant.
4. Trim the intaglio of the denture with a round acrylic
bur (TC Cutter-cut 70; EDENTA) Do not overextend
trimming beyond the premolar regions. Posterior
soft tissue support is needed to make sure that the
patient occludes in an appropriate and comfortable
position (Fig. 9).
5. Replace the denture in the patients mouth and
conrm that there is a passive t over implants and
housings. Ensure that the posterior region is in
contact with the soft tissue.
6. Apply a thin layer of adhesive to the relief area of
the denture. The autopolymerizing resin (Secure
Hard Pick-Up material; 3M ESPE) is extruded
directly onto the metal housings and into the relief
area of the denture.
7. Slowly and carefully place the denture in the pa-
tients mouth. Ask the patient to close and apply
normal occlusal pressure to conrm centric occlu-
sion. This step should take 5 to 8 minutes for the
acrylic resin to polymerize.
8. Remove the excess resin and trim the denture (Fig. 10).
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Figure 7. Green rubber tubes are placed on each implant to block out
undercuts.
Figure 9. Denture base is trimmed for metal housing.
9. Instruct the patient to keep the denture in place for
the rst 48 hours after placement to prevent tissue
overgrowth and to eat a soft diet for 2 weeks.
Chlorhexidine 0.12% for mouth rinses is recom-
mended and ibuprofen 600 mg may be suggested to
control any pain or discomfort after implant place-
ment. There is no need for antibiotics.
DISCUSSION
A thorough examination, augmented by information
from the panoramic radiograph and palpation of the
bony ridge, determines the denture tooth position. The
most posterior implant is placed at least 7 mm anteriorly
to the mental foramen, as shown on the panoramic
radiograph, to avoid any possible risk to the anterior
loop, if present. In a apless approach as described
herein, there is risk that the sharp and thin drills required
might perforate the cortical plate of the mandible or
damage other anatomic structures. These procedures
should be performed by or under the supervision of
Kanazawa et al
- 2016
Figure 10. Intaglio of denitive prosthesis.
experienced surgeons. Ideally, a pretreatment assessment
should include cone-beam computed tomography scans.
However, the clinical aspects of this report were based on
our aim to test the feasibility of a minimally invasive
approach to implant rehabilitation for patients with
edentulism. Thus, reduced cost and exposure to radiation
were integral. A panoramic radiograph, combined with a
careful intraoral evaluation, should sufce to determine
the suitability of patients for treatment with MDIs.
Verifying the available bone height is essential in
determining the appropriate length of a mini-implant.
However, it is sometimes difcult to estimate bone
height without making a specialized radiograph. Thus,
using a caliper as a guide to screen bone height is rec-
ommended; it is safe, time-saving, and easy to accom-
plish. When the caliper indicates that a patient has less
than 27 mm of bone, there is likely not enough bone to
place 13-mm implants. Patients with more than 27 mm of
available bone can be managed using a panoramic
radiograph. In addition, the use of single axis solid im-
plants like mini-implants, especially in an atrophic
mandible, would allow signicant freedom to angulate
implants in desired positions. This technique is a apless
approach; only a small incision is made on the summit of
the mandibular ridge with a scalpel, and a ap is not
elevated.
For the prosthetic procedure, when the metal hous-
ings with O-rings are captured, the mucosal surface of
the molar region should be retained to secure the posi-
tion of the denture in the mouth. If the entire mucosal
surface is removed or relined, the position of the denture
tends to be lost. The denture should be seated with
gentle occlusal pressure guided by posterior mandibular
soft tissue support in the molar region.
This less invasive protocol is favorable for most older
patients with edentulism who have resorbed narrow
ridges. Although some evidence of the usefulness of this
method exists, additional studies are required to further
assess the efcacy and effectiveness of MDIs.
Kanazawa et al
5
SUMMARY
A technique and protocol for immediately loaded 4-mini-
implant mandibular overdentures has been described.
This technique is less invasive, suitable for narrow ridges,
and cost effective. This protocol causes minimal swelling
and pain. Additional evidence is required to determine
the efcacy and effectiveness of MDIs in the longer term.
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827-34. Copyright 2016 by the Editorial Council for The Journal of Prosthetic Dentistry.

THE JOURNAL OF PROSTHETIC DENTISTRY Kanazawa et al