Introduction

Due to the characteristics mentioned above, placing the implants and immediately loading them in patients with reduced horizontal bone availability is possible. The treatment is minimally invasive, decreasing patient discomfort and shortening recovery time. These characteristics are especially convenient for patients systematically compromised.

With the Straumann® Mini Implant System (Ø 2.4mm), we are able to provide edentulous patients quality of life, in which we can offer our patients cost-effective solutions, stable removable prothesis, less invasive treatment plans, and increase patient acceptance for implant treatment by eliminating bone augmentation.

Patient Nº1 Initial situation

A 58-year-old female patient visited our dental office seeking a solution for her lower teeth. The anamnesis revealed medical conditions such as chronic obstructive pulmonary disease (COPD) and emphysema. In addition, she communicated that she has been wearing a pulmonary valve since 2017, surgery was performed in 2019, and she is not allergic to any drugs. Given her systemic condition, the patient was classified as ASA III.

The patient's expectations included having an aesthetic, stable, new lower prosthesis at an affordable price because of her current financial condition. She considered her prosthesis loose and unaesthetic and referred it was affecting her general quality of life.

The intraoral examination revealed the absence of all upper teeth. In the lower jaw, the patient was periodontally unstable. All teeth exhibited grade III mobility, decays, and presented a full arch tooth-supported cemented prosthesis with loss of seal (Fig. 1.1).

The panoramic radiograph assessment revealed generalized moderate bone resorption in the mandible and reduced vertical dimension in the posterior area—however, adequate bone availability for the implantation of Straumann® Mini Implants for a full arch rehabilitation. (Fig. 1.2)

Treatment planning

Given the patient's systemic condition, she was referred to the respective medical specialist before the beginning of the treatment. The specialist provided consent for the treatment with dental implants and suggested applying a less invasive technique that involves the less time intervention possible.

The overall prognosis of the teeth in the lower jaw was unfavorable due to the periodontal and restorative conditions. Therefore, it was decided that all the remaining lower teeth had to be extracted, except for tooth #48, which was only visible radiographically and did not cause any discomfort to the patient.

Different options, including the flapless technique, were presented to the patient with their advantages and disadvantages. However, the financial condition was a decisive factor for the patient. Since she didn't mind having a removable prosthesis if it was stable enough, the shared decision was to have a removable implant-supported restoration with the Straumann® Mini Implant system.

Furthermore, the patient expressed concern about her appearance and did not want to remain toothless during treatment. Thus, an immediate four implant-supported overdenture with a flapless approach option was chosen.

Surgical procedure

The patient was instructed to rinse her mouth with 0.12% chlorhexidine gluconate on the day of surgery. The surgical procedure was done under local anesthesia with 2% lidocaine and 1:100,000 epinephrine.

The remaining and hopeless teeth were extracted in an atraumatic way using a periosteotome (Fig. 1.3). The sockets were probed and examined before being rinsed with saline. To maintain a safe distance to the mental foramen, the implants' length was determined preoperatively on the patient's radiograph.

Flapless surgery was carried out, and the implant sites were drilled according to the Straumann® Mini Implant system protocol.

Four Straumann® Mini Implants 42-32: 12 mm GH 2.8 / 35-45: 10 mm GH 2.8 were placed through the mucosal tissues, hand free with the plastic holder in a prosthetically driven position.

The final vertical placement was done with the torque wrench without exceeding 60 Ncm. When the torque reached 60 Ncm before the implant was in the correct position, the implant was unscrewed for some few millimeters and then re-screwed. Like this, the bone was progressively expanded together with the implant without affecting its stability (Figs. 1.4-1.5).

Prosthetic procedure

A removable temporary prothesis was immediately stabilized on the four implants using four matrix housings with white retention insert. (Figs. 1.6-1.7).

Treatment outcomes

After two months, the four implants were osseointegrated, and a final prosthesis was delivered (Figs. 1.8-1.9).

Patient Nº2
Initial situation

A 65-year-old female patient with a good general health condition came to the dental office with a chief complaint of masticatory difficulty. She claimed that all her removable prostheses were loose, painful, and had short durability. During anamnesis, the patient reported that she was looking forward to having a new prosthesis and did not mind that these were removable. Her only request and expectation were to have a restoration that remains stable in her mouth during function.

The intraoral examination revealed bimaxillary edentulism with an aesthetically acceptable but poorly adapted prosthesis. (Fig. 2.1 & 2.2)

The tomographic assessment revealed moderate bone resorption in the mandible, but adequate bone availability for the implantation (Fig. 2.3)

Treatment planning

After a careful diagnosis, clinical data collection, and patient expectations, it was decided to suggest a treatment plan involving a maxillary and a mandibular overdenture attached to six mini-implants in the upper jaw and four in the lower jaw. The use of the Straumann® mini-implants system (Ø 2.4mm) was offered considering her needs, expectations, limited bone availability, financial situation, and desire for a less invasive but stable solution. After explaining every step of the treatment workflow in detail, the patient agreed with this option.

Surgical procedure

The patient was instructed to rinse her mouth with 0.12% chlorhexidine prior to the surgery. The surgery was done under subperiosteal infiltrative anesthesia using local anesthesia (2% lidocaine with 1:100,000 epinephrine). Open flap surgery was made to place the implants under direct vision. The same drilling protocol as in the patient one was used. Straumann®12 mm GH2.8 were placed (Figs. 2.4-2.5).

Interrupted sutures were used to close the flaps on both arches (Fig. 2.6).

Prosthetic procedure

Implants and soft tissue support overdentures. Therefore, a chairside intraoral modification of the current removable prostheses was made so that the seating of the attachments could accommodate any micromovement of the soft tissue, which is challenging to do in a hard dental cast. The modification of the removable prostheses was immediately stabilized on the ten implants using ten matrix housings with white retention insert (Figs. 2.7-2.8).

The overall result was meticulously checked, and the adaptation was made until the patient felt comfortable and satisfied with the function.

Treatment outcomes

Because of the covid pandemic, the final prostheses were performed seven months after surgery. The follow-up with a new X-ray and photos was made two years after surgery. Again, the stability was good, and there was no need to change the retention inserts. The patient was delighted with the results, fulfilling her expectations (Figs. 2.9-2.15).

Patient Nº3
Initial situation

A 71-year-old retired woman, active smoker (5 cigarettes/day) and with a history of platelet anti-aggregating therapy, presented to our clinic. The intraoral examination revealed maxillary edentulism and a full-arch prosthesis in the lower jaw supported by three implants (Fig. 3.1).

She reported that four implants initially supported her prosthesis until one implant was lost; thus, the prosthesis was unstable.

The radiographic assessment revealed deep and wide bone defects around implants. In addition, one implant was entirely out of the bone, and one abutment was fractured. (Fig. 3.2)

Treatment planning

The surgeon who performed the initial surgery was retired. His successor suggested removing all implants, placing bone grafts, and a temporary prosthesis during the healing period to later place four implants and finally a screw-retained overdenture. The patient was afraid of the suggested treatment plan, concerned about the price, and at the same time, didn't feel confident about the treatment being predictable. Therefore, she decided to ask for a second opinion.

Following a detailed medical and dental history; and a deep understanding of the needs and concerns of the patient, we proposed a customized treatment approach for her. This consisted in removing the hopeless implants, cleaning the infected bone, and placing four mini-implants with an immediate removable prosthesis. By placing the mini-implants, we could avoid the bone augmentation procedures and, consequently, reduce the treatment time, costs, and morbidity. The advantages and disadvantages of the treatment were explained in detail to the patient.

Surgical procedure

A local anesthetic with 2% lidocaine and 1:100,000 epinephrine was administered after intraoral and extraoral antisepsis. The three dental implants and the prosthesis were removed with elevators and forceps. The implants' threads oppose no resistance due to little residual bone-implant contact, and not even rotating movements were required for the explantation (Fig. 3.3). One implant was left in region #44, and it was later removed during the surgery (Fig. 3.4).

A crestal incision along the maxillary ridge was used to raise mucoperiosteal flaps. The same drilling protocol as cases one and two were used. Four mini-implants (Straumann® Mini Implant Ø 2.4 mm - SLA® 10 mmm GH 2.8 mm Optiloc® - Roxolid®) were placed in positions #43, #41, #31 and #33. The insertion of the implants was performed manually (Figs. 3.5- 3.8).

The area was finally sutured with Nylon 4/0 (Fig. 3.9). A new removable temporary prothesis was immediately stabilized on the four implants using four matrix housings with white retention inserts (Fig. 3.10 & 3.11).

Prosthetic procedure

Following one year, the patient returned to our practice for the preparation of the final prostheses. The clinical assessment revealed healthy tissues, and the patient reported an uneventful healing period (Fig. 3-12 & 3.13).

The initial step was to attach white processing collars to each Optiloc® to block out the space around them. After that, each Optiloc® abutment was colocated with a matrix housing with a retention insert, leaving the collar beneath it (Fig. 3.14). Using a resin bur, the denture base was altered in the areas of the Optiloc®, leaving a minimum of 1mm around the housings to provide for sufficient resin thickness. Before applying self-curing PMMA resin to the matrix housings of the denture, the denture was prepared and then placed on the patient mouth.

The Optiloc® impression copings were installed for the final prosthesis (Fig. 3.15).

This information was sent to the lab with the bite registration for the final prosthesis fabrication.

Treatment outcomes

Due to a heart issue, the patient could not continue the treatment for three months. After this period, the patient presented to our practice, and the clinical assessment showed poor oral hygiene. Therefore, reinforcement of oral hygiene habits was performed. We explained to the patient the importance of oral hygiene and its role in the predictability of the treatment. Afterward, the final prostheses were installed, and their esthetic and functionality fulfilled the patient's wishes (Fig. 3.16-17).

In the one-year follow-up, new X-rays and photos were taken. The patient was delighted, and her oral hygiene had remarkably improved. In addition, the stability of the overdenture was optimal, so there was no need to change the retention inserts (Fig. 3.18-19).

Author's testimonial

A cost-effective solution to improve easily and efficiency the quality of life and the dental wellness of the edentulous patients.