Inclusive - Glidewell Dental Labs

Inclusive®
Restorative Driven Implant Solutions Vol. 2, Issue 1
A Multimedia Publication of Glidewell Laboratories • www.inclusivemagazine.com
Q&A with
Dr. Gordon
Christensen
Inclusive ® Mini Implants recently
received FDA clearance and will
be available March 2011
An Exclusive Interview
About Mini Implants
Page 11
The Truth About
Small-Diameter
Implants
Dr. Gordon Christensen and
Dr. Paul Child Jr.
Page 6
Predicting Implant
Performance with
Finite Element Analysis
Grant Bullis and Vaheh Golestanian
Page 24
Clinical Tip: Taking
Accurate Full-Arch
Implant Impressions
Page 36
Billing Dental Procedures
to Patient Medical Plans
Dr. Olya Zahrebelny
Page 53

On the Web
Log on to www.inclusivemagazine.com
for bonus content and in-depth coverage.
ONLINE Video Presentations
Watch Drs. Alexandre-Amir Aalam and Mamaly
Reshad present a systematic approach to advanced
implant treatment planning in a Lecture-on-Demand
from gIDE. Also, see how Dr. Timothy Kosinski uses
digital treatment planning and guided surgery in
combination with narrow-body implants for mandibular
overdenture stabilization.
ONLINE Photo Essays
Gain further insight into Dr. Bradley Bockhorst’s
technique for obtaining accurate full-arch implant impressions
by viewing the photo slide show that accompanies
his article. Plus, check out clinical photos
from Dr. Raymond Choi’s presentation on surgically
placing mini implants to support and retain a denture
in an edentulous mandible.
ONLINE CE credit
Earn free CE credit for the material you’ve seen in
this issue. You will earn two hours for each test you
complete and pass. Take the CE tests on our website,
www.inclusivemagazine.com.
PLUS...
New this issue, read Inclusive magazine on the go
using your smartphone. You can now enjoy exclusive
Web content anywhere you go, including video presentations,
photo slide shows and featured articles.
Check us out online to see what the implant
industry is buzzing about.
When you see these icons, it means we have even more information on
that topic available at www.inclusivemagazine.com.
– www.inclusivemagazine.com –

Contents
Features
6 The Truth About Small-Diameter
Implants
24 Predicting the Performance of
Mini Implant-Retained Prostheses
Using Finite Element Analysis
36 Clinical Tip: A Technique for
Obtaining Accurate Full-Arch
Implant Impressions
11
18
30
43
53
Mini Implants: An Interview with
Dr. Gordon Christensen
Leading proponent of mini dental implants Dr. Gordon Christensen
shares his experience on the subject in an exclusive Q&A interview
with Inclusive magazine. Learn about Dr. Christensen’s placement
approach, and find out what he considers to be the primary benefits
of small-diameter implants and how to utilize them successfully.
Mini Dental Implants for Every Dentist
Dr. Raymond Choi delves into the world of mini dental implants
with a discussion of their benefits and limitations, as well as their
indications and contraindications. He also details a case in which
“minis” are surgically placed to support and retain a denture in an
edentulous mandible.
Mandibular Denture Retention:
The Mini Implant Solution
According to Drs. Stephen Wagner and A. Burton Melton, edentulous
patients in need of complete dentures were, until the standardization
of dental implants, destined to wear prostheses that provided
them with low levels of overall satisfaction. Today, mini implants
are proving to be a viable alternative to standard-diameter implants
for a variety of permanent applications, due to factors such as their
lower cost and less-invasive surgical protocol.
Utilizing Digital Treatment Planning and Guided
Surgery in Conjunction with Narrow-Body Implants
Dr. Timothy Kosinski presents a case study, utilizing CT diagnosis,
digital treatment planning and guided surgery, for the immediate
stabilization of a mandibular implant-retained overdenture. Included
is a flapless surgical technique, immediate implant placement
and resulting improved stability of the patient’s existing mandibular
denture prior to delivery of the final prosthesis.
Billing Patient Medical Plans:
There’s Nothing Illegal About It!
Seeking to dispel the misconception held among some dentists
that they can only access benefits from dental plans, Dr. Olya
Zahrebelny argues that numerous routine procedures performed in
general and specialty dental practices are covered by patient medical
benefit plans. Before clinicians bill procedures to these medical
plans, however, she advises that they adhere to some basic rules.
– Contents – 1

Letter from the Editor
We saw many changes in implantology in 2010, including rapid growth in monolithic restorations
such as BruxZir ® and IPS e.max ® , as well as the use of CAD/CAM technology in
the design and fabrication of custom abutments, crowns, overdenture bars and frameworks.
Digital treatment planning and guided surgery continued to grow with expanded access to
CBCT scanners. Local reaction to the expansion of national chains brought about renewed
interest in screw-retained dentures. And these were just a few of the changes.
This issue focuses on small-diameter implants (SDIs). While controversial, mini implants are
gaining popularity, so we asked several clinicians who have significant experience using SDIs
to share their observations with us. Included is a featured reprint by Drs. Gordon Christensen
and Paul Child, followed by an exclusive interview with Dr. Christensen, one of the most
outspoken proponents of SDIs. Reading these articles should help you decide if minis have a
place in your implant practice.
Another subject garnering discussion is insurance coverage of implant cases. While we are
all familiar with the ins and outs of dental insurance, Dr. Olya Zahrebelny discusses how you
may also be able to access patient medical benefits by following some basic rules.
The featured Clinical Tip outlines what we have found to be a highly predictable procedure
for obtaining accurate full-arch implant impressions. Although the accuracy of CAD/CAM
designed and fabricated titanium frameworks has greatly improved and simplified restoring
full-arch cases, marking an end to the days of cutting and soldering conventional cast
frameworks to achieve a passive fit, an extremely accurate impression and master cast are
still critical requirements.
Our goal with Inclusive in 2011 is to keep you up to date on the latest products, procedures
and dental materials in implantology. We will also demonstrate our commitment to continuing
education with the opening of our 2,800-square-foot training and education facility.
(Watch for updates on upcoming courses and programs.) For expanded magazine content,
please visit www.inclusivemagazine.com.
Thank you for your continued support. We wish you and your practice a prosperous new year!
Regards,
Dr. Bradley C. Bockhorst
Editor-in-Chief, Clinical Editor
inclusivemagazine@glidewelldental.com
– Letter from the Editor – 3

Publisher
Jim Glidewell, CDT
Editor-in-Chief
Bradley C. Bockhorst, DMD
Managing Editors
Jim Shuck; Mike Cash, CDT
Creative Director
Rachel Pacillas
Clinical Editor
Bradley C. Bockhorst, DMD
Contributing editors
Dzevad Ceranic, CDT; Greg Minzenmayer
senior Copy Editor
Jennifer Holstein
copy editors
Melissa Manna, Eldon Thompson
Graphic Designers/Web Designers
Jamie Austin, Deb Evans, Joel Guerra, Lindsey Lauria,
Phil Nguyen, Kelley Pelton, Ty Tran
Photographers/Clinical Videographers
Sharon Dowd, James Kwasniewski, Sterling Wright
Illustrators
Phil Nguyen
coordinatorS/AD Representatives
Teri Arthur, Vivian Tsang
If you have questions, comments or suggestions, e-mail us at
inclusivemagazine@glidewelldental.com. Your comments may be
featured in an upcoming issue or on our website.
© 2011 Glidewell Laboratories
Neither Inclusive magazine nor any employees involved in its publication
(“publisher”) makes any warranty, express or implied, or assumes
any liability or responsibility for the accuracy, completeness, or usefulness
of any information, apparatus, product, or process disclosed, or
represents that its use would not infringe proprietary rights. Reference
herein to any specific commercial products, process, or services by
trade name, trademark, manufacturer or otherwise does not necessarily
constitute or imply its endorsement, recommendation, or favoring
by the publisher. The views and opinions of authors expressed
herein do not necessarily state or reflect those of the publisher and
shall not be used for advertising or product endorsement purposes.
CAUTION: When viewing the techniques, procedures, theories and materials
that are presented, you must make your own decisions about
specific treatment for patients and exercise personal professional judgment
regarding the need for further clinical testing or education and
your own clinical expertise before trying to implement new procedures.
Inclusive is a registered trademark of Glidewell Laboratories.
Contributors
■ Bradley C. Bockhorst, DMD
After receiving his dental degree from
Washington University School of Dental
Medicine, Dr. Bradley Bockhorst served
as a Navy Dental Officer. Dr. Bockhorst is
Director of Clinical Technologies at Glidewell
Laboratories, where he oversees Inclusive
® Digital Implant Treatment Planning
Services and is editor-in-chief and clinical editor of Inclusive
magazine. A member of the CDA, ADA, AO, ICOI and
AAID, Dr. Bockhorst lectures internationally on an array
of dental implant topics. He maintains a private practice
focused on implant prosthetics in Mission Viejo, Calif. Contact
Dr. Bockhorst at 800-521-0576 or inclusivemagazine@
glidewelldental.com.
■ GRANT BULLIS
Grant Bullis, director of implant R&D and
digital manufacturing at Glidewell Laboratories,
began his career in the dental
industry at Steri-Oss in 1997. After Nobel
Biocare acquired Steri-Oss, Grant worked
in the R&D department. Since joining the
lab in March 2007, Grant has been integral
in obtaining FDA 510(k) clearances for the company’s
Inclusive Implant Abutments. In 2010, he was promoted to
director and now oversees all aspects of CAD/CAM, implant
product development and manufacturing at Glidewell.
Grant has a degree in mechanical CAD/CAM from Irvine
Valley College in Orange County, Calif., and an MBA from
Keller Graduate School of Management. Contact him at
inclusivemagazine@glidewelldental.com.
■ VAHEH GOLESTANIAN
Vaheh Golestanian received a master’s
degree in biomedical engineering at Iran
University of Science and Technology in
Tehran. In 2008, he joined Glidewell Laboratories’
Implant R&D and Digital Manufacturing
department as a manufacturing
engineer. Vaheh has eight years’ experience
as a mechanical engineer focused on finite element
analysis and CNC programming. A member of the Society
of Manufacturing Engineers, he recently co-authored a
technical paper on using finite element methods to design
zirconia abutments. Contact him at inclusivemagazine@
glidewelldental.com.
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■ Paul L. Child Jr., DMD, CDT
Dr. Paul Child graduated from Case Western
Reserve University School of Dental
Medicine, completed a prosthodontic residency
at Louisiana State University School
of Dentistry and is a CDT. He also maintains
a private practice at the CR Dental
Health Clinic in Provo, Utah. As CEO of
CR Foundation ® , Dr. Child conducts extensive research
in all areas of dentistry and directs the publication of the
Gordon J. Christensen CLINICIANS REPORT ® and other
publications. He lectures nationally and is a member of
many professional associations and academies. Contact
him at 801-226-2121 or toni@cliniciansreport.org.
■ Raymond Choi, DDS
Dr. Raymond Choi graduated from USC
School of Dentistry, where he was an assistant
clinical professor in the TMJ and
Facial Pain Clinic for 10 years, and completed
a TMJ/Facial Pain Preceptorship at
UCLA. He is also a graduate of the Misch
International Implant Institute, Fellow of
the ICOI and Associate Fellow of the AAID. Dr. Choi was one
of the first dentists on the West Coast to start using IMTEC
Sendax Mini Dental Implants for lower denture stabilization.
Founder and president of the Global Mini Implant
Institute (GMI), Dr. Choi maintains a general private practice
in Tustin, Calif. He has been conducting mini implant
seminars and surgical workshops for dentists since 2002
and lectures extensively in the U.S. and internationally.
Contact him at www.miniimplanteducation.com.
■ Gordon J. Christensen, DDS, MSD, Ph.D
Dr. Gordon Christensen is a practicing
prosthodontist in Provo, Utah. His degrees
include DDS, University of Southern
California; MSD, University of Washington;
and Ph.D, University of Denver. He
is a Diplomate of the American Board of
Prosthodontics; Fellow and Diplomate
of the ICOI; Fellow of the AO, ACD, ICD, ACP and Royal
College of Surgeons of England; Honorary Fellow of the
AGD; and Associate Fellow of the AAID. Drs. Gordon and
Rella Christensen are cofounders of the nonprofit Gordon
J. Christensen CLINICIANS REPORT. Contact him at
801-226-6569 or info@pccdental.com.
■ TIMOTHY F. KOSINSKI, DDS, MAGD
Dr. Timothy Kosinski graduated from University
of Detroit Mercy School of Dentistry
and received a master’s degree in biochemistry
from Wayne State University School of
Medicine. An adjunct assistant professor
at Mercy School of Dentistry, he serves on
the editorial boards of numerous dental
journals and is a Diplomate of the ABOI/ID, ICOI and AO;
Fellow of the AAID; and Master of the AGD. Contact him at
248-646-8651, drkosin@aol.com or www.smilecreator.net.
■ A. Burton Melton, DDS
Dr. Burton Melton received his undergraduate
degree from BYU, his DDS from
Baylor College of Dentistry and his Diploma
in Prosthodontics from the University
of Missouri School of Dentistry. He has
practiced prosthodontics in Albuquerque
and Santa Fe, N.M., since 1972. Dr. Melton
has presented programs to audiences in the U.S., Japan,
Korea, Mexico, Taiwan and England, and has appeared
as a guest lecturer at dental schools across the U.S. Contact
him at 505-883-7744 or abmeltonnm@aol.com.
■ Stephen A. Wagner, DDS
Dr. Stephen Wagner is in his 32nd year of
private practice in Albuquerque, N.M. He
received his dental degree from USC School
of Dentistry and his prosthodontic training
from MD Anderson Cancer Center in
Houston, Texas. Dr. Wagner serves on the
review board of the International Journal
of Oral and Maxillofacial Implants and is a Diplomate
of the American Board of Prosthodontics. Contact him at
bigjawbone@mac.com.
■ Olya Zahrebelny, DDS
Dr. Olya Zahrebelny graduated from the
University of Toronto Faculty of Dentistry
and completed a general practice residency.
She has practiced in hospital and private-practice
settings. A former insurance
plan consultant, she has taught at three
dental schools and was an attending physician
at the University of Illinois Medical Center. Repeatedly
named a leader in continuing education and dental
consulting by Dentistry Today, she has lectured nationally
and internationally. Contact her at drz@thezgroupllc.com.
– Contributors – 5

The Truth About
Small-Diameter Implants
Go online for
in-depth content
by Gordon J. Christensen, DDS, MSD, Ph.D and Paul L. Child Jr., DMD, CDT
If we listened to and believed some of the comments about small-diameter implants
(SDIs or “mini” implants) that we hear coming from some areas of surgical dentistry,
we would be led to think that these devices simply do not work. However, the truth is diametrically
opposed to what some are saying, and it has been our observation that some of the most severely negative
comments come from dentists who have never placed SDIs.
This article includes: the definition of mini implants or SDIs; a discussion of the evolution of SDIs, including
their clearance by the U.S. Food and Drug Administration (FDA) and research support; reasons for SDI
use instead of conventional-diameter implants; the indications for SDI use; and suggestions on how to use
them successfully.
THE EVOLUTION OF THE
SMALL-DIAMETER IMPLANT CONCEPT
There is no question among dentists that root-form implants,
3.0 mm in diameter and more, are one of the most
successful and important additions to clinical dentistry
in the entire history of dentistry. The FDA cleared these
conventional-diameter root-form implants for clinical
use in 1976. Millions of conventional-diameter implants
have been placed for more than four decades, and their
cumulative success rate of around 95 percent is impressive.
In many situations, it has been our experience that
the conventional prosthodontic portion of implant treatment
fails faster than the properly integrated root-form
implants themselves.
In the early 1990s, some innovative practitioners started
using SDIs (up to 2.9 mm in diameter) for long-term use in
situations with insufficient bone. At that time, SDIs were
considered to be for transitional use only. Also, orthodontists
began using SDIs, also known as temporary anchorage
devices, for anchorage for difficult tooth movement
situations. It soon became obvious to those practitioners
that properly placed SDIs were working adequately.
As a result of their obvious clinical success, SDIs were
cleared by the FDA for “long-term intrabony applications,”
with the help of IMTEC (a 3M ESPE company), in 1997.
Subsequently, numerous other SDI brands have received
similar FDA clearance. Thousands of these SDIs are now
in successful restorative use, with a reported 91 percent
to 97 percent survival rate. Numerous surveys, testimonials,
research projects, and satisfied dentists and patients
attest to that fact. 1–6 Many more positive references are
available in the restorative, prosthodontic and orthodontic
literature.
WHY USE SMALL-DIAMETER
IMPLANTS IF CONVENTIONAL-DIAMETER
IMPLANTS ARE SO SUCCESSFUL?
The authors of this article are prosthodontists who place
conventional- and small-diameter root-form implants. The
following are their observations on the desirability of SDI
use compared to conventional-diameter implant use.
Inadequate Bone Quantity
Conventional-diameter implants, averaging about 3.5 mm
in diameter, require minimally about 6 mm of bone in
a facial-lingual dimension, and about 10 mm of bone in
a crestal-apical dimension, for uncomplicated placement
without grafting. Some patients accept the overall implant
concept, but they have inadequate bone quantity and do
not want to undergo significant bone grafting.
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If SDIs were used only for patients with edentulous
mandibles, roughly 35 to 40 million edentulous patients
in the U.S. alone would have better fitting and retained
complete dentures.
SDIs can be placed in as little as 3 mm of
bone in a facial-lingual dimension and 10 mm
of bone in a crestal-apical dimension. In fact,
often bone 3 mm or 4 mm in a facial-lingual
dimension is ideal, because the cortical bone
plate on the facial has nearly approximated the
lingual cortical plate, and this dense bone holds
the SDI securely. Some experienced implant
surgeons may question this, until they consider
the fact that the SDI is usually a “screw,”
expanding bone instead of cutting it away.
Inadequate Financial Resources
Some patients have inadequate bone, accept
the implant concept, accept the need for extensive
bone grafting, and they are ready to
accept the treatment with the following exceptions:
the cost of the grafting is too high, the
expense of the restorative treatment is high
and conventional-diameter implant treatment
is denied. SDIs frequently solve this challenge,
as stated in the previous point.
Compromised Physical Condition
Many physically debilitated patients do not
have the ability to tolerate conventional-diameter
implant placement, but they can tolerate
Table 1: Use of SDIs in Approximate Order
of Decreasing Frequency of Use
Edentulous mandible
Removable partial denture
Edentulous maxilla (this use has a higher
failure rate than edentulous mandibles)
Augmentation of fixed prosthesis
Sole support of fixed prosthesis
the simple, few-minute placement of SDIs
without a flap. Recent research has shown
that flapless implant placement may accelerate
osseointegration and produce quicker
healing. Debilitated persons can benefit
from these simple procedures.
MAJOR USES OF
SMALL-DIAMETER IMPLANTS
SDIs are listed in Table 1 in approximate
order of decreasing frequency of use, as
noted in the previously referenced articles,
our own use patterns and our observation
of other practitioners.
If SDIs were used only for patients with
edentulous mandibles, roughly 35 to 40
million edentulous patients in the U.S.
alone would have better fitting and retained
complete dentures. These implants
are so easy to use in most edentulous
mandibles that it is upsetting to us they
are not used more in the profession for
the indications.
WHY DO SOME DENTISTS
STATE THAT SMALL-DIAMETER
IMPLANTS ARE NOT
SUCCESSFUL?
Many of the same surgical dentists now
condemning SDIs stated 40 years ago that
conventional root-form implants would not
work. It appears that their opinion is that
anything new is automatically bad! SDIs
are new, but they are proving themselves.
This section is probably the most important
part of this article. Some SDIs fail. We
have experienced a few failures ourselves
over the past nine years of use. These failures
were almost always related to one or
more of the following errors:
Salvage of previously made prosthesis
– The Truth About Small-Diameter Implants – 7

a
b
Figures 1a, 1b: A typical conventional-diameter implant has a blunt end necessitating
cutting a hole in the bone for placement. A typical SDI has a screw
configuration that expands minimal bone on placement. This difference is one
that allows SDIs to be placed in bone as thin as 3 mm to 4 mm in the faciallingual
dimension.
Figure 2: SDIs placed in a mandible model. Small spheres on the implants and
rubber washers in housings in the denture support and retain the denture.
■ Too much thickness of the soft tissue. If the ratio of
the coronal portion of the SDI to the portion placed in
the bone is excessive, a long lever arm is present. This
situation stresses the SDI and may lead to failure of
the implant. If the soft tissue, through which the SDI
is to be placed, is thicker than about 2 mm, it should
be reduced by removing a wedge of tissue from the
coronal portion of the ridge. This can be done before
the implants are placed, allowing for adequate healing,
or at the time of implant placement. This surgery may
be done with a scalpel, or some lasers may be used
around implants to accomplish this task without causing
damage to the implant osseointegration potential.
■ Improper parallelism of implants. SDIs should be as
parallel as possible. If these implants are much more
than 15 degrees from parallelism, technical difficulty at
placement of the prosthesis and subsequent potential
clinical failure can be anticipated.
■ Inadequate preoperative radiographs. Poor bone
is commonly present in some areas of edentulous patients.
We discourage using only two-dimensional conventional
panoramic radiographs because you cannot
determine the quality or quantity of the bone in a facial-lingual
dimension. Coarsely trabeculated bone is
not appropriate for SDIs. The more dense the bone,
the better. To determine the density of the bone, faciallingual
oriented radiographs are strongly suggested.
These include tomograph or cone-beam radiographs.
Most communities now have accessibility to some form
of the suggested facial-lingual orientation radiographs
at moderate cost.
■ Poor bone density in the posterior maxillary
tuberosity areas. Usually, the dense Type I bone
of the resorbed anterior mandible is excellent for
SDIs. The worst bone, contraindicated for SDI
placement by most experienced practitioners, is
the posterior maxillary tuberosity, with its porous
type IV bone. A careful analysis of the density of
the bone in any other part of the oral cavity is
suggested, as they too may have poor bone density
contraindicating SDIs.
To determine the density
of the bone, facial-lingual
oriented radiographs are
strongly suggested. These
include tomograph or
cone-beam radiographs.
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Figure 3: Atlas ® (Dentatus) implants placed in a mandible model. Small spheres
on the implants and soft denture reline material in the denture support and
retain the dentures.
Figure 4: Zimmer (Sterngold) implants placed in a mandible model with ERA ®
attachments on the implants. Reciprocal ERAs in the denture base support and
retain the denture.
■ Too few SDIs are often placed. It has been suggested
in both empirical and research reports that the minimal
number of SDIs for edentulous mandibles is four, evenly
spaced from the left canine area to the right canine
area. This is double the minimal number of implants
suggested for conventional-diameter implants. The ratio
appears to be two SDIs where one conventional-diameter
implant would usually be used. Some companies
are suggesting six SDIs instead of four for edentulous
maxillas, evenly spaced from the canine area to the opposite
canine areas. However, the more dense the bone,
the fewer SDIs that are needed.
■ SDIs are too short. The most popular average length
for SDIs is 13 mm. It appears from clinical observation
and research that this is a predictable and successful
length. The implants must be used in adequate bone,
according to the literature of reported successful use of
thousands of SDIs and to the discussions with manufacturers
about clinician reports to them.
■ Poorly adjusted occlusion, or loading the implants
too soon. Most SDIs are loaded immediately
on placement. Occlusion needs to be adjusted
perfectly on placement of the prosthesis. Allowing
heavy occlusion to traumatize these small implants
is asking for early failure. If questionable bone quality
or quantity is present, soft denture reline material
may be placed in the denture around the area of the
implants for several weeks to ensure that they have optimum
time for initiation of osseointegration.
SUMMARY AND CONCLUSION
SDIs that are treatment planned correctly, placed and
loaded properly, and are within a well-adjusted occlusion,
are working in an excellent manner for the patients described
in this article. It is time for those practitioners
unfamiliar with SDIs and their uses to discontinue their
discouragement of this technique. SDIs are easily placed,
minimally invasive and a true service to those patients
described. They do not replace conventional-diameter
implants; however, they are a significant and important
augmentation to the original root-form implant concept.
There is obvious evidence of the growing acceptance
of small-diameter implants by both general practitioners
and specialists.
References
1. Bulard RA, Vance JB. Multi-clinic evaluation using mini-dental implants for
long-term denture stabilization: a preliminary biometric evaluation. Compend
Contin Educ Dent. 2005;26:892–97.
2. Clinical Research Associates. Small-diameter “mini” implants — user status
report. CRA Newsletter. 2007;31:1–2.
3. Griffitts TM, Collins CP, Collins PC. Mini dental implants: an adjunct for retention,
stability and comfort for the edentulous patient. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 2005;100:e81–e84.
4. Morneburg TR, Pröschel PA. Success rates of micro-implants in edentulous
patients with residual ridge resorption. Int J Oral Maxillofac Implants. 2008;
23:270–76.
5. Shatkin TE, Shatkin S, Oppenheimer BD, et al. Mini dental implants for longterm
fixed and removable prosthetics: a retrospective analysis of 2,514 implants
placed over a five-year period. Compend Contin Educ Dent. 2007;28:92–99.
6. Vigolo P, Givani A. Clinical evaluation of single-tooth mini-implant restorations:
a five-year retrospective study. J Prosthet Dent. 2000;84:50–54.
Disclosure: Dr. Christensen and Dr. Choi report no conflicts of interest.
Reprinted by permission of Dentistry Today, ©2010 Dentistry Today.
– The Truth About Small-Diameter Implants – 9

Mini Implants:
An Interview with
Dr. Gordon Christensen
Interview of Gordon J. Christensen, DDS, MSD, Ph.D
by Bradley C. Bockhorst, DMD
Dr. Gordon Christensen is a leading proponent of mini implants. For
this issue of Inclusive magazine, he was kind enough to discuss his
views on the subject in an exclusive phone interview.
Dr. Bradley Bockhorst: I enjoyed your presentation at the American Academy of Implant
Dentistry’s 2010 Annual Meeting in Boston, Mass., last October. You are one of the most outspoken
proponents on mini implants and, as such, I appreciate you sharing your experience with us.
Dr. Gordon Christensen: Thank you. By the way, I’m very pleased to take part in this interview.
There are so many questions regarding small-diameter implants, and I’m happy to answer any
questions related to them.
BB: To start things off, how many years have you been placing small-diameter implants? And how
many have you placed to date?
GC: Probably the best answer to that question is going back to our CRA ® Newsletter report (now
the Gordon J. Christensen CLINICIANS REPORT ® ), which was published in November 2007. At that
time, I had been placing mini implants since 1997 — only about three or four years. We had 200
people in that report who stated what they had observed during their use of mini implants. I had
done only a few hundred at that particular point. The 200 respondents were all CRA Newsletter
subscribers. The respondents were from five to 65 years out of dental school, with a mean of 27.
They were in 34 states, Canada and elsewhere. Ninety-five percent were general practitioners,
4 percent were prosthodontists and 1 percent were periodontists. They had been in implant dentistry
an average of 13 years. Approximately 74 percent of them did surgery and prosthodontics.
The rest performed either surgery or prosthodontics. As for in-house education, depending on the
brand, most of them had taken a short course on mini implants. So that group represented basically
thousands of mini implants among the 200 people who responded.
– Mini Implants: An Interview with Dr. Gordon Christensen – 11

BB: And within your practice, what percentage of implants placed
would you say are small-diameter or mini implants?
GC: I’ve been doing surgery and placing implants for 25 years.
Each indication, of course, would have different percentages. Right
now, in edentulous mandibles, I would say at least 50 percent
of what I’m doing is small-diameter implants versus conventionaldiameter
implants.
The primary benefit
of mini implants is
for the person who
is too debilitated
to undergo the
surgery necessary
for conventional
implant placement;
the person who does
not have the money
for a complex case;
or the person who
will not accept, or
cannot have for
health reasons, a
major bone graft.
BB: For the sake of some of our readers who may not be as aware
of mini implants as others, what would you say are the primary
benefits for this type of implant?
GC: The primary benefit of mini implants is for the person who is
too debilitated to undergo the surgery necessary for conventional
implant placement; the person who does not have the money for
a complex case, which very often might be better; or the person
who will not accept, or cannot have for health reasons, a major
bone graft.
BB: What would you say are the primary benefits, from the clinician’s
standpoint?
GC: Simplicity. Going back to that November 2007 CRA Newsletter
report, when asked about difficulty of implant placement, respondents
reported placement without a flap as “simple” and placement
with a flap as “slightly more difficult.” That’s about what we saw
for the major advantage to the clinician. I delivered a program at
the World Congress of Minimally Invasive Dentistry, and it was on
about 20 different minimally invasive techniques. And this was one
of the major benefits for smaller-diameter implants.
Another significant advantage is that they can be immediately loaded
in bone that is adequate. With Type I bone, there’s no question;
I’ve loaded hundreds of them immediately.
BB: Initially, mini implants were primarily marketed as temporary
or provisional implants. What would you say has changed to make
them a viable long-term option?
GC: Initially, I was using them as transitional implants when I had
placed conventional implants and just wanted something to hold
the denture or the fixed bridge in place while the conventionaldiameter
implants integrated. I found, after three or four months
of waiting for the conventional-diameter implants to integrate, that
I seldom could take the mini implants out easily. In fact, I had a
couple that I practically had to cut out. That was my turning event.
When the initial transitional implants were introduced, they were
pure titanium. They were so weak that you could bend them with
your finger. They were not adequate. However, Dr. Victor Sendax
(a periodontist based in New York) got together with the IMTEC
Corporation and alloyed them, and they became stronger. The combination
of strength and ease of placement, and the fact that they
could be loaded immediately, made me change my mind about
using transitional implants.
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BB: As with conventional-diameter implants, have manufacturers
added different types of surfaces to increase bone-to-implant contact?
GC: Yes, they have. There are numerous companies now involved
with making small-diameter implants. By far the most well known
is IMTEC. Intra-Lock is making some major introductions as well.
We’re seeing about 10 companies that are involved with smalldiameter
implants at this point, and at least three of them are
major companies.
BB: One of the challenges in gaining widespread acceptance of
smaller diameters is the perception of a lack of long-term published
studies. I know you just referred us to the CRA study. Are there any
other studies out there for people to reference for relieving that fear?
GC: These are from various years, but Shatkin 1 was one of the major
ones, from Evolution Lab out of Amherst, N.Y., that found 94.2 percent
retention. Other studies found 91 percent retention, 97.4 percent
retention, 94.2 percent retention and 95.5 percent retention. 2–5 So
there are some good studies out there and surely more to come.
BB: As far as implant diameters, IMTEC started out with the 1.8
and has added larger diameters. Other companies, such as OCO
Biomedical, started with the 3.0 and are adding narrower diameters.
So several companies now have this range. What diameter do
you typically prefer?
GC: It depends on the bone. For Type I bone, I still very strongly
prefer the 1.8 mm diameter. As you know, a small-diameter implant
would go, in the current marketplace, from 1.8 mm to 2.9 mm. That
directly relates to the FDA clearance of these types of implants back
in 1997 — 14 years ago. Standard-diameter implants — 3 mm and
larger — were cleared by the FDA a long time ago, in 1976. So the
differentiation of small diameter versus conventional diameter would
be at the 3.0 mm diameter level. The sizes of mini-diameter implants
typically start at 1.8 mm and go to 2.4 mm, 2.5 mm, 2.9 mm.
The combination of
strength and ease
of placement, and
the fact that they
could be loaded
immediately, made
me change my
mind about using
transitional implants.
In good Type III bone, which is obviously softer but usually more
homogeneous, I would use a 2.4 mm diameter. And in the lower
anterior, I tend to prefer the 1.8 mm because, when going to a
larger diameter, I have broken them from the torque required to
insert them. I’ve only broken one screwing it in, but I have broken
one. And I had one break, as I mentioned at the AAID meeting in
October, in service in Type I bone. So it varies with the bone density.
The more dense the bone, the smaller the diameter. The more
porous the bone, the larger the diameter.
BB: Along that same line, most of the clinicians who are placing
implants are putting them in with a winged driver, not with a torque
wrench. Is there a maximum torque where you say, OK, stop, let’s
run the drill down the osteotomy again?
GC: Yes, you need about 30 Ncm to feel like you’re at an appropriate
level of primary stability. If at 30 Ncm you’re not making
any progress, then that makes me quite nervous. So I would screw
– Mini Implants: An Interview with Dr. Gordon Christensen – 13

I strongly suggest a facial-lingual radiograph for any
treatment plan — either a tomograph or a CBCT scan.
the thing out and make a little deeper cut or use a widerdiameter
implant. As a dentist becomes more familiar with
these, they will soon sense when threading it into place
whether the torque is approaching 30 Ncm. Let me put it
this way: Dentists need to have a torque wrench.
BB: One of the other presentations at the AAID meeting
was by Dr. Sendax. His takeaway message was bicortical
stabilization. That’s doable in the symphysis region. How
do you handle that in other regions, such as the posterior
mandible? Are you a proponent of bicortical stabilization,
or do you have a different approach as far as placement?
GC: Type II bone typically found in the posterior
mandible is not a particularly good indication for smalldiameter
implants, in my opinion, because the bone density
of the cortical plate may be 1000 on the Hounsfield
unit (HU) scale. However, the cancellous bone may be as
low as 40 or 50 HU. The bottom line is, I’m usually reaching
for a large-diameter implant, like a 6 mm, to better
engage the cortical bone. With the exception of the small
triangle of bone that’s usually directly distal to the mental
foramen, I’m wary of small-diameter implants in Type II
bone in the posterior mandible.
BB: What’s your approach in the maxilla?
GC: About the same. As you approach the sinus, which
would be the first and second premolar, that Type III
bone is going to be relatively dense. Anything distal to
that — wow! — is not for mini implants, in my opinion.
BB: That’s great feedback. Besides the quality of the bone,
what are other caveats when considering mini implants?
GC: There are many reasons for mini-implant failure.
Over the 10 years I’ve done this, I have lost only 10. Now
that sounds like a pretty egotistical statement, but when
they have failed, and when I’ve seen them fail as they’ve
come into our lab — and we do not solicit people sending
their cases to our lab — is when we see these things:
Improper radiography and lack of thorough treatment
planning. I strongly suggest a facial-lingual radiograph for
any treatment plan — either a tomograph or a CBCT scan.
The quality and quantity of bone, as well as the ideal location
of the implant, can be evaluated pre-surgically.
Too much soft-tissue thickness on the ridge is another
issue. If the thickness of the soft tissue is over 2 mm,
the clinician should take a V-wedge out and allow the
soft tissue to heal before he or she even considers making
any kind of an impression. About 2 mm should
be the maximum on the crest. I’ve seen clinicians stick
the implant through 4 mm or 5 mm of soft tissue. That’s
like sticking a 6-foot beanpole in a foot of mud — just
absolute stupidity.
Too few implants placed can also be a major problem.
For Type I bone, four mini implants in the anterior region
of an edentulous mandible is more than enough. I
usually say two small-diameter implants would equal one
conventional-diameter implant. Having done hundreds
of cases with conventional-diameter implants in the
two canine areas, we’re now putting four in the anterior
edentulous mandible, spread either equally across from
what was canine to what was canine, or emphasizing the
canine areas with two in that area spread 4 mm or 5 mm
apart, and the same in the other canine area. And then
on the upper, IMTEC and others say six implants. I have,
in relatively dense Type III bone, gotten along with four
implants very nicely on the maxillary arch, although it’s
safer to place six. I’ve seen clinicians try to put two minis
in an edentulous case. You need four to six in an edentulous
case — four in the mandible, six in the maxilla.
Besides diameter, the length of the implant must be
considered. Ten mm is very borderline. If you’re going
through 2 mm of soft tissue, you really don’t have enough
bone-to-implant contact. Thirteen is the standard length
used by the profession.
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Regarding lining up the implants — and this is totally
empirical — I do not like anything greater than 15 degrees
from parallel. Usually, the housings will compensate for
that quite nicely. If the divergence is too great, the O-rings
will wear more quickly. It has also been reported in the
literature that the metal ball of the implant may wear if
the housing is sliding off and on at too odd an angle.
And poorly adjusted occlusion is a total killer. If clinicians
attempt to put minis in the mouth of a bruxer, they’re kidding
themselves. I don’t even like conventional-diameter
implants in that situation. So, poorly adjusted occlusion
or not respecting the fact that he or she is dealing with
aggressive occlusion is problematic.
BB: As far as four or six implants in an edentulous maxilla,
do you typically go with the palate, or is a palate-less
overdenture an option?
GC: That’s a question that comes up routinely. I try to
keep a person with a palate if I possibly can. Usually
they’ve had a palate before and, with the exception of the
few people who would complain about the palate and
opt not to have it, I try to get them into a palate because
then we have some hard bone for support, and the lever
going distal from the implant is reduced. I prefer to have
a palate present.
But if I don’t have a palate present, the minis have to be
placed more distally. And you know the problem there. In
the maxillary arch, you might get one mini distal to where
the canine was, and you’ve still got a Class I lever going
distally. I would strongly prefer to have the palate, even if
six implants are planned.
BB: What is the minimum vertical space needed to make
sure there is enough room for the O-ring housing?
GC: The minimum — and this would relate not only to
small-diameter implants but also conventional-diameter
implants — is about 4 mm, and that’s very borderline. I
would like 5 mm of acrylic resin around the housing.
BB: OK. From a lab perspective, if we’re going to process
a new denture, we would recommend some kind of
a casting.
GC: Exactly. Especially if the occlusion is intense. A very
thin chrome-cobalt framework processed into the denture
with a finger extending over the top of the housing adds
strength and will prevent the attachment from breaking
through the denture.
BB: If you’re going to have a new denture made, do you
typically want the lab to process the housings in, or do you
prefer to pick them up chairside?
GC: Now, I know who I’m talking to, and I know you
guys do excellent work; however, if the dentist is using
a lab that has not done this, picking them up is far better.
I have to say only about 5 percent of mine have been
picked up. I strongly prefer to have the lab do it, but the
lab has to know what it’s doing.
BB: If you’re going to pick them up chairside, and say
you’re dealing with four implants, how many housings
could you pick up at once, versus trying to pick up all
four at the same time?
Making minis succeed means adequate numbers of
implants and adequate planning. It means parallelism.
It also means not having too much soft tissue coronal to
the bone. It means adjusting occlusion impeccably well
after the prosthesis is delivered.
– Mini Implants: An Interview with Dr. Gordon Christensen – 15

GC: You know as well as I, if there is too much material placed into the well that they have cut in the denture, the
denture will lift right off the base. I would recommend a small vent hole be drilled somewhere in the palate, or in
the lingual if it’s a mandibular overdenture, so that as they chew on that material for several minutes, the denture can
completely seat. I don’t like to do more than two at a time. Then I want to make sure the occlusion is correct and that
there is material oozing out of the vent hole. To just stuff a large amount of resin in the denture and have the patient
bite down is, again, stupid. The prosthesis will not be completely seated.
BB: Is there a particular material you prefer to use when you’re picking up the housings?
GC: There are many out there, as you know, but I prefer Sterngold pick-up material.
BB: OK, very good. To wrap things up, do you have any tips or techniques you would recommend to our audience as far
as minis, either from the surgical or the prosthetic side, that you would like to share at this time?
GC: The list I gave you addressed the main reasons for mini failure. There are people placing them in Type IV bone.
There are people placing them in Type II bone, with nothing on the internal portion of the cortical plate. We know what
makes them fail. We know what makes them succeed. Let’s just kind of cap it off with that.
Making minis succeed means adequate numbers of implants and adequate planning. It means parallelism. It also means
not having too much soft tissue coronal to the bone. It means adjusting occlusion impeccably well after the prosthesis
is delivered. And — something I haven’t mentioned yet — in the event that the bone is of questionable quality, it means
waiting, with soft denture reline, for several months before loading. It may be three to four months until they are actually
loaded. However, most of the small-diameter implants I have placed were loaded immediately.
But there is a cautionary note, and that is recognizing what makes them fail. If clinicians respect the several points
I’ve mentioned, the minis will work. If they don’t respect those points, the minis will indeed fail, much faster than
conventional-diameter implants.
BB: That brings us to the final question. How can clinicians obtain more information on small-diameter implants and
get adequate training?
GC: There are numerous courses given by manufacturers, and they’re fine. But as with any implant, I usually suggest
to a person who wants information about large-diameter implants or mini-diameter implants that they take an eclectic,
broadly based course first.
We have our own course that we have given now since the advent of minis. It’s a two-day course presented in Provo,
Utah, and it covers several brands of small-diameter implants. The course has been highly popular, and I cannot give
enough of them — every time I open one up, it’s filled. The website is www.pccdental.com.
If clinicians do that and still feel uncomfortable, there are courses given by the specific manufacturer once they have
decided which implant system they would prefer to use. Some laboratories are giving courses as well.
BB: As always, it was a pleasure speaking with you. I appreciate you taking the time to share your insights with me and
the Inclusive audience.
References
1. Shatkin TE, Shatkin S, Oppenheimer BD, et al. Mini dental implants for long-term fixed and removable prosthetics: a retrospective analysis of 2,514 implants placed
over a five-year period. Compend Contin Educ Dent. 2007;28:92–99.
2. Bulard RA, Vance JB. Multi-clinic evaluation using mini-dental implants for long-term denture stabilization: a preliminary biometric evaluation. Compend Contin Educ
Dent. 2005;26:892–97.
3. Griffitts TM, Collins CP, Collins PC. Mini dental implants: an adjunct for retention, stability and comfort for the edentulous patient. Oral Surg Oral Med Oral Pathol Oral
Radiol Endod. 2005;100:e81–e84.
4. Vigolo P, Givani A. Clinical evaluation of single-tooth mini-implant restorations: a five-year retrospective study. J Prosthet Dent. 2000;84:50–54.
5. Morneburg TR, Pröschel PA. Success rates of micro-implants in edentulous patients with residual ridge resorption. Int J Oral Maxillofac Implants. 2008;23:270–76.
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Mini Dental Implants for Every Dentist
by Raymond Choi, DDS
Go online for
in-depth content
In this article, I will discuss the exciting world
of mini dental implants, from their benefits
and limitations to their indications and contraindications.
I will also present a case study
that covers the surgical placement of “minis”
in the edentulous mandible, as well as prosthetic
protocols for the patient.
18

Introduction
Since the 1980s, conventional implants have drastically
changed the way we practice dentistry. Mini implants are
just as their name implies — a smaller version of conventionally
sized implants. They are made of the same material,
and they have the same design and surface treatment.
Everything about them is virtually identical, except for
their size. In the coming years, I am very excited to see
how much more we will be able to do with mini implants.
Benefits of Mini Implants
A primary benefit of mini implants is their minimally
invasive surgical protocol. As you will see in the case
study that starts on page 20, you only need to take a small
pilot drill and go through the soft tissue until you touch
the bone. Then you start drilling in order to get through
the superior cortical bone of the ridge. As soon as you tap
through that ridge, stop drilling.
That’s all there is to the surgical protocol for mini dental
implants. It truly is minimally invasive, and there is hardly
any postoperative discomfort and soft-tissue healing
due to very minimal bone drilling. Even patients who are
medically compromised can tolerate this process, whereas
they could not tolerate the vigors or the invasiveness
of conventional implant surgery.
A second benefit of mini implants is that they can be
immediately loaded. This means that on the day the
implants are placed, they can be activated and the case
can be loaded. In most lower edentulous mandible cases,
implants can be placed and loaded in a single treatment
session, which shortens the overall treatment duration
and minimizes patient discomfort.
A third, and perhaps the most important, benefit of mini
implants is their affordability. Very often, the treatment
cost of mini implants is a fraction of that of conventional
implants. Many patients who would not be able to afford
A primary benefit of
mini implants is their
minimally invasive
surgical protocol.
Lower edentulous cases —
patients who are wearing
loose lower dentures — are
the number one indication
for mini implants.
conventional implant treatment, especially in this tough
economy, will be able to benefit from mini implants
because of their affordable cost.
Limitations of Mini Implants
Because FDA approval of mini implants only came about
11 years ago, no long-term studies are available. The
long-term outlook of mini implants currently is not well
known. However, there are many short-term — five- to
six-year — studies available, which state the success rate
of mini implants is quite comparable to that of conventional
implants. In time, I believe there will be some good
long-term studies to validate the clinical efficacy of mini
dental implants.
Indications of Mini Implants
Lower edentulous cases — patients who are wearing loose
lower dentures — are the number one indication for mini
implants. University of the Pacific School of Dentistry
published a study in 2008 in which more than 600 smalldiameter
implants were placed. Over the study’s six-year
period, a 92.6 percent success rate was achieved. With a
university study like this, I think it is safe to say that lower
edentulous cases can be routinely helped when treated
with mini dental implants.
Of course, any removable prosthesis can be stabilized
using mini implants. This includes upper dentures —
although protocols are slightly different — and partial
dentures, as well as stayplates.
Another indication of mini implants is the fixed application.
Yes, you read that right: fixed crown & bridge applications.
Many dentists have been doing crown & bridge
applications on minis and have had success. Yes, they
– Mini Dental Implants for Every Dentist – 19

are smaller, and we have to be a little more cautious in
using these implants in areas where there are a lot of
heavy functional and parafunctional forces. But this is
one area you will see more from. For now, they should be
performed in areas where there are limited mesial-distal
spaces and buccal-lingual bone width.
Contraindications of
Mini Implants
Because mini implants are simply a smaller version of conventional
implants, all the contraindications we know of
for conventional implants apply to minis as well. Although
the minimally invasive surgical protocol of minis allows
us to help a lot of people who could not be helped with
conventional implants, we should be cautious, as I stated
above, about using minis in areas under heavy functional
and parafunctional forces.
We should be cautious …
about using minis in areas
under heavy functional and
parafunctional forces.
Case Study:
Surgical Mini Implant Placement for Edentulous Mandible
Figure 1: Edentulous mandible with resorbed alveolar ridge
Figure 2: Implant sites marked with dye
Figure 3: Pilot hole drilled through the cortical plate
Figure 4: Implant delivered to prepared site
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Figure 5: Implant advanced with finger driver
Figure 6: Implant advanced with winged thumb wrench
Figure 7: Final seating with torque wrench
Figure 8: Implants in situ
The patient in our case study has been edentulous for many years. There is hardly any mandibular ridge left (Fig. 1).
First, locate the mental foramen through manual palpation. Once you locate the mental foramen, mark the ridge with
an indelible pencil. Measure 7 to 8 mm anterior from that location, and that will be the most distal implant position. As
you can see, I have planned to place four minis between two mental foramina (Fig. 2).
Then, take a very thin pilot drill and go through the soft tissue until you feel the bone (Fig. 3). Once you feel the bone,
step on your rheostat and the drill will go through the superior cortical layer. This can take a few seconds, but when
it goes through you will feel a change in density because the drill drops more easily into the cancellous bone. At that
point, stop drilling. In most cases, that is the extent of drilling I recommend.
Next, carry the implant into that site (Fig. 4). You will start the insertion process using a series of hand instruments.
Establish the direction of the mini implant with the first driver and slowly insert the implant into place (Fig. 5). As you
go farther, you will encounter more resistance because of the dense bone. This is a good time to change out to other
hand instruments that can deliver a higher torque (Figs. 6, 7).
Once the implants are in place (Fig. 8), measure the resistance torque of the implants with a torque driver and determine
if the implants can be loaded immediately. As far as the surgical placement of the implants, this is pretty much it.
Afterward, there is hardly any bleeding because we really haven’t made any incisions or raised a flap. It is truly a simple
and minimally invasive procedure.
– Mini Dental Implants for Every Dentist – 21

Figure 9: Bite registration using existing prosthesis
Figure 10: PVS material applied to tissue surface of denture to identify
implant positions
Figure 11: Relieving existing denture
Figure 12: Receptor sites to accommodate metal housings
Figure 13: Block-out shims covering the head of each implant
Figure 14: Metal housings placed over the implant heads
Prosthetic Mini Implant Protocol for Edentulous Mandible
Now, let’s discuss prosthetic protocol for a loose lower denture using mini implants. Before you begin surgical placement,
you will take a bite registration of the upper and lower dentures intraorally (Fig. 9). This will become very useful
after you place the mini implants.
Then, find any really fast-setting chairside material. This could be a bite registration material, PVS, chairside relining
material, soft relining material, Fit Checker — anything that sets fast. You’ll load that material onto the tissue side of
the denture (Fig. 10), and then seat it in the patient’s mouth. Take it out after a couple minutes and you will see holes
corresponding to the locations of the O-balls of the mini implants you’ve just placed.
Next, score into your plastic — the tissue side of the denture — with some kind of a drill (Fig. 11). These holes will then
be enlarged at the laboratory, until they are big enough to be seated passively over the mini implants and metal housings
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Figure 15: Pick-up material placed in relieved areas
Figure 16: Block-out shims removed after pick-up of metal housings
Figure 17: Metal housings with retentive O-rings
Figure 18: Proper occlusion verified
in the patient’s mouth (Fig. 12).
Before you finalize the process, put a plastic shim over the shoulder of each mini implant to prevent locking of the
denture when you do the chairside pickup (Fig. 13). After doing that, put on the metal housings of your choice (Fig. 14).
Make sure the denture fits completely passively over the metal housing-implant complex. The vertical dimension and
occlusion should also be confirmed.
Once that is done, take a dimensionally stable chairside hard reline material and load it into the holes you just created
on the tissue side of the denture (Fig. 15). Take it to the patient’s mouth and have the patient bite at the centric using
the bite registration that you took at the beginning of the procedure.
After seven to 10 minutes of setting time, remove the prosthesis from the patient’s mouth. Make sure you remove the
shims from the patient’s mouth as well (Fig. 16). After the prosthesis is cleaned up and polished at the laboratory, it is
ready to deliver to the patient (Fig. 17).
The patient should be given postoperative instructions. Generally speaking, patients should be told to keep the denture
in place for the first 24 to 48 hours (Fig. 18). A follow-up appointment should be scheduled for the patient to come back
in a week or two-week period.
Conclusion
As you just read, the placement of mini implants is a simple process that is affordable for the patient and relatively
stress free for the clinician. Every clinician should take proper implant training courses before he or she starts placing
mini dental implants. Once you start doing them, I think you will really enjoy placing mini implants, and your career
and practice will never be the same.
– Mini Dental Implants for Every Dentist – 23

Predicting the Performance of
Mini Implant-Retained Prostheses
Using Finite Element Analysis
by Grant Bullis and Vaheh Golestanian
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n Discussion n n n n n n
Patients with resorbed residual ridges may not have adequate bone volume for standard implants. If site augmentation
isn’t an acceptable option for the patient, then small-diameter “mini” implants can be used to retain a prosthesis
when there is sufficient bone volume and density for primary stability.
Mini implants can provide anchorage points for orthodontic treatment and retention for removable prostheses, such
as dentures. They are indicated for several situations where conventional implants are not suitable 1 :
For patients with inadequate bone width
For older or medically compromised patients (flapless insertion of a mini implant preserves continuous blood
flow to the area)
For financially challenged patients who cannot afford conventional implant treatment
For patients who are unwilling to undergo extensive bone augmentation
For patients who are unwilling to wait the several months of healing frequently associated with conventional
implant treatment
When mini implants are used to retain a denture, a sufficient quantity of implants must be placed to adequately
distribute loads generated during mastication. Using multiple mini implants to retain removable prostheses reduces
the forces experienced by individual implants. If too few implants are used, cyclic occlusal loading may fatigue the
small-diameter implant neck to the point of fracture. 2 The quantity of mini implants used can vary, but four implants
in the anterior mandible is a common configuration.
Patients with implant-retained mandibular overdentures opposing complete maxillary dentures can generate significantly
higher maximum bite forces than those with conventional complete dentures. 3 Care must be taken with
prosthesis design and implant placement to minimize off-axis loading. The prosthesis may be relieved in centric
occlusion to reduce cyclic loading and occlusal force impact. 2
One method available to analyze occlusal force transfer from the prosthesis to the implants and the supporting bone
is finite element analysis (FEA). The history of FEA dates back to 1943, when Richard Courant used triangular mesh
elements to study torsion of a cylinder. 4 There are several FEA software programs currently available. They are used
extensively by the automotive and aerospace industries to simulate, visualize and optimize structures for strength
and stiffness.
Human tissue and bone are challenging to model accurately. Bone is not a homogeneous material, and its quality
and quantity can vary considerably between individuals. When applying FEA to implant biomechanics, some simplifications
and assumptions are necessary in order to build a model that can be solved. These assumptions can have
a significant effect on the accuracy of the results. They include 5 :
The detailed geometry of the bone and the implant to be modeled
Material properties
Boundary conditions
The interface between the bone and the implant
FEA gives engineers and product designers a powerful tool to evaluate the efficacy of their designs under simulateduse
conditions. It allows them to apply boundary conditions and forces to their designs and evaluate their expected
performance. At Glidewell Laboratories, we use this technology to assess product designs before, and in conjunction
with, physical prototypes. 6
– Predicting the Performance of Mini Implant-Retained Prostheses Using Finite Element Analysis – 25

n Simulation Techniques
For our simulation, we used a stereolithographic
(STL) model of a mandible created
from an optical scan. The STL model was
imported into a CAD program. Four 2 mm
mini implants were placed anterior to the
mental foramina. Cylindrical features with
diameters and depths corresponding to
the surgical site preparation were subtracted
from the implant sites.
Figure 1: Four mini implants placed in the STL model
The model was printed using a rapid prototyping
machine. The printed model had
four holes at the locations of the implants.
Mini implants were placed in these locations
(Fig. 1). Soft tissue was then added
over the implant sites (Fig. 2).
Figure 2: The STL model with implants and soft tissue
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A denture was then fabricated to fit the
model (Fig. 3). O-ring housings typical of
those used to retain dentures were incorporated
into the denture at each implant
site.
Figure 3: The model and the denture
Next, an STL model of the denture was
created from an optical scan. The model
was then imported into a CAD program.
In the CAD program, all the parts (jaw,
implants, O-rings, implant housings and
denture) were assembled (Fig. 4).
Figure 4: CAD assembly of jaw with implants, O-rings and implant housings
– Predicting the Performance of Mini Implant-Retained Prostheses Using Finite Element Analysis – 27

n Boundary Conditions
and Meshing
The mandible was restrained at the temporomandibular
joint. A force of 200 N
was applied approximately at the locations
shown by the arrows (Fig. 5). The
assembly was meshed and refined. A default
element size of 2.5 mm was defined.
Figure 5: Forces and constraints applied to the assembly
n Analysis and Results
After establishing the boundary conditions
and meshing on the assembly, FEA was
conducted on the assembly. The analysis
took approximately 1.5 hours to complete
due to the complex shape of the model
and the small size of the elements. The results
of the FEA indicated that bite forces
are distributed relatively evenly across the
implants, except when force is applied at
the middle of the denture, and that stresses
are higher in the outer implants compared
to the middle implants (Fig. 6).
Figure 6: Simulation results
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n Conclusion n n n n n n
The results of the simulation indicate a safety factor of 3x relative to the strength of the implants when
a 200 N force is applied across a mandibular overdenture retained by four mini implants in the symphysis
region. The number of implants, bone quality and anterior-posterior spread of the implants are
significant factors in how effectively occlusal loads are distributed. It must also be considered that occlusal
loads that are significantly divergent to the axes of the implants introduce stress gradients at the
implant sites that are not apparent in this simulation.
The forces that act on removable implant-retained prostheses have complex spatial and temporal distributions,
which currently are not practical to define and simulate. The prosthesis incorporates compliant
attachments to the implants that undergo semi-restrained axial loading. Defining the bone-biomaterial
interface also presents significant challenges. The displacements at the interface are small. In addition,
bone is not a homogeneous material and its structural characteristics can vary greatly between patients.
To simplify the model enough to perform an analysis, assumptions have to be made that affect the accuracy
of the results.
More research on the composition and simulation of the interaction of anterior excursive forces on
implant-retained overdentures is necessary to better approximate actual-use conditions. Finite element
analysis is an approximate method of predicting how implant and prosthetic designs will perform. Testing
is ultimately necessary to confirm that the results of the analysis are predictively valid.
n References n n n n n n
1. Ahn MR, An KM, Choi JH, Sohn DS. Immediate loading with mini dental implants in the fully edentulous mandible. Implant Dent.
2004;13(4):367–72.
2. Flanagan D. Implant-supported fixed prosthetic treatment using very small-diameter implants: a case report. J Oral Implantol.
2006;32(1):34–37.
3. Rismanchian M, Bajoghli F, Mostajeran Z, Fazel A, Eshkevari P. Effect of implants on maximum bite force in edentulous patients.
J Oral Implantol. 2009;35(4):196–200.
4. Courant R. Variational methods for the solutions of problems of equilibrium and vibrations. Bull Amer Math Soc. 1943;49:1–23.
5. Geng J, Yan W, Xu W, eds. Application of the Finite Element Method in Implant Dentistry (Advanced Topics in Science and Technology
in China). Springer. Jointly published with Zhejiang University Press; 2008.
6. Golestanian V, Leeson D, Bullis G, Zhang W. Design of zirconia abutments for dental implants by finite element analysis approach.
SME Technical Paper. 2010. 10 p. Report No: TP10PUB113.
– Predicting the Performance of Mini Implant-Retained Prostheses Using Finite Element Analysis – 29

Mandibular Denture Retention:
The Mini Implant Solution
by Stephen A. Wagner, DDS and A. Burton Melton, DDS
This is a historic moment for dentistry,
especially for dentists who provide removable
complete dentures in their practice. More patients than ever
before are edentulous and in need of complete dentures — and
their number is rising. Until recently, these patients were destined to
wear prostheses that, in many cases, were unstable or even unwearable.
Their ability to chew was limited and, even with clinicians’ best
efforts, their overall level of satisfaction was disappointing.
That all changed in 1984. We now have dental implants in our
armamentarium and proven techniques that allow the average dentist
to provide stable, retentive dentures that offer patients a great deal
of satisfaction. Previously, the biggest impediment to providing this
service was cost: the cost of placement, the cost of the implants themselves
and the cost of the final denture. Mini implants have changed
all of that, making the implant-retained denture and the satisfaction
that comes with it an attainable reality for virtually all patients. 1
Figure 1: Case at 21-year follow-up appointment
The case in Figure 1 shows three mini implants that were placed
21 years ago. The mandibular overdenture was remade after 10 years
of service. The O-ring housings can be seen in the intaglio surface of
the denture (Fig. 2).
◊ What Are Mini Implants?
The FDA granted clearance to standard-diameter implants (implants
with a diameter of 3 mm or larger) in 1976. Since then, dental implants
have become the foundation of an industry and have been
used with great success and increasing sophistication. But even today,
implant placement is limited by a lack of bone structure to support
the implant body, a lack of attached gingiva in the desired implant
area and the cost of the implants themselves.
Enter mini implants. Most mini implants are less than 3 mm in diameter
and feature a one-piece construction. They offer either an O-ring
retention system or, more recently, proprietary retentive elements
such as the ERA ® (Sterngold; Attleboro, Mass.) and implant-based
Figure 2: Intaglio surface of mandibular overdenture
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More patients than ever before are
edentulous and in need of complete
dentures — and their number is rising.
Locator ® Abutment (Zest Anchors; Escondido, Calif.). The cost per implant is low, ranging in price from
about $70 to $150, and many of them come with the retentive fixture included in the cost of the implant. 2
Mini implants are indicated where bone is limited, especially in the labial-lingual dimension, and when
patient cost is an issue. These factors come into play particularly in the severely resorbed anterior edentulous
mandible, where use of a traditional implant may require extensive bone modification, such as bone
grafting. They must be used in areas with attached mucosa and placed as close to parallel as possible.
Many companies currently produce mini implants, including Dentatus, Dental Implant Technologies, Implant
Direct, OCO Biomedical, IMTEC, Intra-Lock International and Sterngold. And legions of companies are introducing
their own mini implant systems every year.
◊ Indications of Mini Implants
In these authors’ opinion, mini implants are perfect for retaining mandibular dentures. The implants should
be placed mesial to the mental foramina to avoid damage to the mandibular nerve. All implants should be
placed through attached gingiva and where parallelism of the implants is possible.
In the maxilla, the use of mini implants is limited primarily by the surgeon’s inability to place the implants
in a parallel fashion. The anatomy of the edentulous maxilla often requires the implants to be placed with
the heads of the implants buccal to the implant body. This compromises the parallel placement of the implants
and, in turn, decreases the ability of the restorative dentist to successfully place the O-ring abutments
on the retentive element of the implant body. If mini implants with integrated Locator Abutments (OCO
Biomedical) are used, the implants can be placed with some degree of non-parallelism, but parallelism of
all implants is preferred.
◊ Parallelism Is Key
Mini implants with O-ring abutments must be placed as parallel as possible to obtain effective retention with
the denture and to prevent wear of the O-rings over time. This requires a skilled surgeon with impeccable
technique, a surgical guide that angles the surgeon’s drill in a predetermined direction, or any number of
commercial devices designed to obtain parallelism at the time of surgery.
In general, the remaining bone found in the anterior edentulous mandible is conducive to parallel implant
placement, but the bone of the residual edentulous maxilla is not. The pattern of bone loss in the maxilla requires
that the implants be placed with the heads of the implants labial or buccal to the implant body, resulting
in divergent implant placement. In many cases, the retentive O-ring in the denture cannot effectively engage
the undercut of the implant, preventing it from becoming an effective retentive feature of the final denture.
◊ Does Diameter Matter?
Narrow-diameter implants were designed for use in residual ridges that were too narrow for regular implants.
They were first considered transitional implants that were to be used for temporary stabilization prior
to engaging standard abutments. Narrow-diameter implants are also indicated when the bone in the implant
site is limited in a buccal-lingual dimension and bone grafting is not possible or permitted.
One theoretical disadvantage of a narrow-diameter implant is the reduction of resistance to occlusal loading.
However, in animal studies, the retention of an implant was directly connected to the length of the implant
– Mandibular Denture Retention: The Mini Implant Solution – 31

and not to the diameter, suggesting that a narrow-diameter implant of
significant length is acceptable in most situations. This is an area that
will require further study before a definitive conclusion can be made.
◊ Optimal Number of Implants
Most clinicians feel that four implants placed in the area of tooth #22,
#24, #25 and #27 are optimal for retention and stability of a mandibular
denture when using mini implants with O-ring retention elements.
Two implants do not afford enough retention in most cases. Placing
five to six implants in the symphysis often creates a situation where
the implants are overcrowded, which prevents effective use of the
implants (Fig. 3). Increasing the number of implants often results in a
straight-line configuration, thereby creating a fulcrum on which the
denture will rotate (Fig. 4). 3
The most effective placement of implants is 5 mm mesial to the mental
foramina with two implants placed as anteriorly as possible, without
overcrowding. The goal is to place the implants with a maximum
anterior-posterior dimension, thereby creating a stable four-implant
“table leg” position and providing maximum stability for the implantsupported
denture. 4
Figure 3: Too many implants
◊ Surgical Technique
When placing mini implants in the anterior, the clinician must decide
whether to place the implants directly through the mucosa using
a “flapless” technique, or to expose the bone of the anterior mandible
with a releasing incision and identify the position of the mental
foramina and placement of the implants with the basal bone exposed.
The flapless technique has the advantage of speed because
the time required to lay a flap is eliminated. Most implant companies
promote this technique because it relieves any fear associated with
the flapping open of the mucosa. It is believed that most general
dentists with limited surgical experience will feel more comfortable
with this procedure.
Figure 4: Implants with no anterior-posterior spread
The main disadvantage of a flapless technique is that the clinician
essentially is performing the procedure blind, which greatly limits his or her ability to evaluate the shape and
quality of the existing bone, as well as the final result. Critics often assume that implants placed using a blind
technique are not secured in bone at all, but rather placed in bone and in the soft tissue of the lingual floor of
the mouth. This would be caused by the implant drill being guided to the lingual by the sloping ridge shape
of a residual mandibular alveolus. Regardless, there is no way for the surgeon to evaluate the postoperative
placement unless a cone-beam CT (CBCT) scan is taken. A panorex radiograph will not show the labiallingual
positioning of the implants, only their position in the mesiodistal plane.
These authors believe that narrow-diameter implants should be
placed using a technique that exposes the body of
the anterior mandible, which allows the
surgeon to adequately evaluate implant
placement.
32

Mini implants are indicated where bone is limited,
especially in the labial-lingual dimension,
and when patient cost is an issue.
Using a flapless technique should be limited to treating those few patients with an obvious, rounded alveolar
ridge with adequate bone or those cases where digital treatment planning and guided surgery are utilized.
◊ Surgical Planning
Surgical planning for mini implants should include the use of a completed denture or trial denture constructed
with the proper vertical dimension of occlusion (VDO). An existing denture that does not demonstrate
the proper VDO or tooth placement is not sufficient. A radiograph that demonstrates the quality and quantity
of bone in the proposed surgical site is required. Depending on the situation, this can be a panographic
radiograph or a CBCT scan. It must be understood that the distance between the inferior bony margin of the
mandible and the alveolar ridge is increased and cannot be relied upon to give an accurate measurement
with most panoramic radiographs. A panorex also does not give any indication of the three-dimensional
shape of the mandible. A CBCT typically produces a panoramic radiograph that can be used to accurately
measure the inferior and superior length of the anterior mandible and produce cross sections of the anterior
mandible, which will demonstrate the lingual concavity of the mandible, if present.
◊ Using a Surgical Stent
A surgical stent can be used to aid the surgeon in determining the position of the mental foramina in cases
where a flapless technique will be used. First, an impression of the mandibular alveolar ridge is made.
Next, the surgeon attempts to identify the mental foramina by palpation, then transfers that position to the
resultant cast. A resin stent is made and two 5 mm ball bearings are inserted into the base to indicate the
positions of the mental foramina. A panorex radiograph is then made with the base in place to determine
the accuracy of the positioning of the mental foramina. Any discrepancy between the placement of the ball
bearings in relation to the radiographic presentation of the mental foramina should be noted. This will
enable the surgeon to place the distal implants in the maximum anterior-posterior placement. Utilizing
a surgical guide based on a CBCT scan provides another approach to precisely place the implants in a flapless
procedure.
◊ Positioning the Implants
The ideal position of a four-implant overdenture is two implants placed as distally as possible and
two implants placed as anteriorly as the arch of the mandible permits. Research has shown that the distal
implants must be positioned at least 5 mm mesial to the mental foramina. Invading the 5 mm boundary can
temporarily injure the mental nerve or cause permanent nerve damage in the area. The anterior
implants should be placed in the area of tooth #24 and #25 in such a way that does not position
them too close together.
It is not uncommon to find two implants positioned so close together that one implant prevents
the attachment of one of the retentive elements. However, the goal is to create the greatest anteriorposterior
spread possible for a stable table-leg effect. If the implants are too close to each other in an
anterior-posterior position, the denture will rock around a fulcrum created by the implants, which will
make the denture feel unstable when seated in the patient’s mouth.
◊ Mandible Versus Maxilla
Mini implants, when used to support complete dentures, are more appropriate for the mandible than the
maxilla. More specifically, implants have the highest success rate when placed in the alveolar and basal bone
– Mandibular Denture Retention: The Mini Implant Solution – 33

of the anterior mandible as determined by the right and left mental
foramina. In most cases, the bone is dense and the implants can be
placed parallel to one another and still be positioned in solid bone.
This bone differs from the bone of the maxilla. In many cases, the
bone of the maxilla is poorly trabeculated, and the structure of the
bone dictates that the implants be placed divergent to one another.
This divergence can decrease the implants’ retentive ability and, in
some cases, can prevent the O-ring retainer from attaching to the
undercut of the implant body.
◊ Immediate or Delayed Loading?
Many of the implant companies recommend that you immediately
load a mini implant at the time of surgery. They reason that an implant
placed in solid bone will withstand the retentive stresses created by
the prosthesis and will give the patient the immediate satisfaction of
a solid denture.
Figure 5: Implants placed in the mucosa
However, these authors recommend delaying the definitive placement
of the O-ring retainers and instead to use a soft denture reline material, such as COE-SOFT (GC America;
Alsip, Ill.), to provisionally retain the denture during the healing phase following implant placement. The
O-ring retainers can be placed at a later date following complete healing of the bone and soft tissue, and the
patient still will experience the sense of security that comes with an implant-retained denture.
◊ Role of Attached Gingiva
Every implant must be placed through keratinized attached epithelium. Unfortunately, many implants are
placed through unattached mucosa (Fig. 5). When this occurs, the tissues will not heal properly and will
continuously be irritated by the movement of the labial or buccal vestibules. Thus, it is very important that
adequate attached gingiva be identified before mini implants are prescribed. 5
◊ Conclusion
Traditionally reserved for provisional applications during the osseointegration phase of standard-diameter
implants, small-diameter or mini implants are quickly proving to be a viable alternative for a variety of permanent
applications. Among the most common is the retention of a full denture in the edentulous mandible.
With their low cost compared to standard-diameter implants, relatively noninvasive surgical protocol and
ability to be prescribed in instances of severely resorbed alveolar ridges, mini implants have resulted in the
increased satisfaction of a growing number of denture-wearing patients, and provide fresh hope to those
who may confront this challenge in the future.
References
1. Christensen GJ. The ‘mini’-implant has arrived. J Am Dent Assoc. 2006;137(3):387–90.
2. Bryant SR, MacDonald-Jankowski D, Kim K. Does the type of implant prosthesis affect outcomes for the completely edentulous arch? Int J Oral
Maxillofac Implants. 2007;22 Suppl:117–39.
3. Bulard RA, Vance JB. Multi-clinic evaluation using mini-dental implants for long-term denture stabilization: a preliminary biometric evaluation. Compend
Contin Educ Dent. 2005;26(12):892–97.
4. Rodriguez AM, Orenstein IH, Morris HF, Ochi S. Survival of various implant-supported prosthesis designs following 36 months of clinical function.
Ann Periodontol. 2000;5(1):101–08.
5. Nedir R, Bischof M, Szmukler-Moncler S, Belser UC, Samson J. Prosthetic complications with dental implants: from an up-to-eight-year experience in
private practice. Int J Oral Maxillofac Implants. 2006;21(6):919–28.
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Clinical Tip:
A Technique for Obtaining Accurate
Full-Arch Implant Impressions
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in-depth content
One of the most critical requirements for
implant-borne restorations is a passive fit of
the prosthesis. If this is not obtained, the resulting stress
could result in loosening of the abutment screws or, in
the worst-case scenario, damage to the implants or surrounding
bone. 1–7 In the past, casting large frameworks
resulted in inherent errors. Frequently, the restorative
dentist would cut and solder the framework until a passive,
stress-free fit was achieved. 8–10 With the evolution of
CAD/CAM technology in dentistry, frameworks can now
be virtually designed and milled to an extreme level of
accuracy (Figs. 1, 2). 11 Therefore, it is imperative that clinical
and laboratory procedures, including taking the final
impression and fabricating the master cast, be executed
in such a way as to optimize the fit of screw-retained
prostheses. 1,4,8,9 by Bradley C. Bockhorst, DMD
Figure 1: CAD workstation with virtual framework design
One of the most
critical requirements
for implant-borne
restorations is a
passive fit of
the prosthesis.
Figure 2: The framework is milled from a solid block of titanium.
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With the evolution of CAD/CAM technology in
dentistry, frameworks can now be virtually designed
and milled to an extreme level of accuracy.
Numerous impression techniques have evolved to improve
accuracy. 12–16 One technique involves tying opentray
impression copings together with floss, then splinting
them together with self-curing resin. Another technique
entails the fabrication of an implant verification jig (IVJ).
In this procedure, a conventional implant-level impression
is made and the master cast is poured. Temporary
cylinders are splinted together on the model with resin or
acrylic to fabricate the IVJ. The splinted assembly is then
tried-in clinically. If the IVJ seats passively, the accuracy
of the master cast is verified. If the IVJ does not fit passively,
it is sectioned and reluted together in the mouth.
The IVJ is then removed, implant analogs are attached to
the copings, and the bases of the copings are seated in a
stone base. Then, the IVJ is used to reposition the offending
implant analog in the master cast. In both of these
techniques, the copings are rigidly splinted together to
prevent movement.
Figure 3: Sectioned IVJ on soft tissue model
Following is a clinical technique we have found to be
simple but accurate. It involves luting a sectioned IVJ
together intraorally, then picking up the assembly with an
open-tray impression technique.
In this case, six implants were placed in the patient’s mandible
to support a screw-retained denture. Following a
four-month healing period, a preliminary implant-level
impression was made and a soft tissue model was fabricated.
Non-engaging temporary cylinders were luted
together with Triad ® Provisional Material (DENTSPLY;
York, Pa.). A disc was used to cut thin slices between the
cylinders, and the sections were numbered for easy identification
(Fig. 3). A custom tray was then fabricated with
access openings for the guide pins (Fig. 4).
Figure 4: Custom open-face impression tray
– Clinical Tip: A Technique for Obtaining Accurate Full-Arch Implant Impressions – 37

To verify a passive fit
of the IVJ, tighten one
guide pin at a time.
Figure 5: Healing abutments are removed.
Clinical Procedure
(Clinical dentistry by Drs. Hugh Murray and Al Manesh)
The healing abutments were removed from the implants
(Fig. 5). The sections of the IVJ were seated as they
were on the model and the guide pins were tightened
(Fig. 6). If necessary, periapical radiographs can be taken
to verify complete seating of the temporary cylinders on
the implants. The custom tray was tried in (Fig. 7). The
heads of the guide pins should extend through the access
openings. The tray should be adjusted if it comes into
contact with the guide pins or the IVJ.
Figure 6: IVJ sections are seated and the guide pins are tightened.
NOTE: If an overdenture is the planned prosthesis,
the custom tray can be border-molded following standard
procedures.
The IVJ sections were then luted together (Fig. 8). Once
set or cured (Fig. 9), the IVJ was removed and inspected.
Additional material can be added, if necessary, to strengthen
the joints.
Figure 7: Custom tray is tried in.
NOTE: In this case, Triad DuaLine was used. The curing
light provides an initial set. The assembly should
be placed in the Triad Curing Unit for a complete cure.
The assembly was reseated on the implants. To verify
a passive fit of the IVJ, one guide pin was tightened at
a time. No lifting of the IVJ should occur (Fig. 10). The
adjacent guide pin was tightened. The previous screw
was removed and the fit verified. This procedure was
repeated for each implant (Fig. 11).
Figure 8: IVJ sections are luted together.
Rope wax can be placed over the access openings to control
excess impression material (Fig. 12). The intaglio surface
of the tray was painted with adhesive. Impression
material was injected under the IVJ (Fig. 13).
NOTE: This is important: The area under the IVJ
should be completely filled with impression material
to capture the soft tissue contours.
Figure 9: The resin is light-cured.
38
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The combination of an
extremely accurate
impression and
CAD/CAM fabrication
of the framework
has brought implant
prosthetics to
a new level.
Figure 10: Fit of IVJ is verified.
Figure 11: The procedure is repeated for each implant.
The filled tray was completely seated, ensuring that
the guide pins extended through the access openings
(Fig. 14). Once the impression material had set and the
guide pins were completely loosened (Fig. 15, next page),
the impression was carefully removed and examined for
accuracy (Fig. 16, next page). The IVJ was picked up in
the impression.
Figure 12: Access openings are covered with soft wax.
NOTE: The non-engaging cylinders allow the impression
to be pulled even if the implants are divergent.
Master Cast Fabrication
Implant analogs were seated on the temporary cylinders
and the guide pins were tightened. A soft tissue model
was poured (Fig. 17, next page).
Figure 13: Impression material is injected under the IVJ.
Precautions
While this technique is relatively straightforward, there
are situations that could complicate the procedure. The
patient must have adequate vertical opening to accommodate
the guide pins. The more posterior the implants,
the more challenging it can become to seat the tall guide
pins. Shorter screws may be an option. If there are trajectory
issues, angle-shouldered/multi-unit abutments may
be required. In these cases, the final impression should
Figure 14: Custom tray is seated.
– Clinical Tip: A Technique for Obtaining Accurate Full-Arch Implant Impressions – 39

e made at the abutment level, rather than at the implant
level. Whether angled abutments are necessary can be
determined by working the case up through a trial denture
set-up. The trajectory of the implant can then be
evaluated in relation to the positions of the teeth to be
replaced on the model. Once the appropriate abutments
are selected, the sectioned IVJ and custom tray can be
fabricated and the final impression made.
Conclusion
Splinting temporary cylinders together intraorally and
then picking the assembly up in an open-tray procedure
provides an accurate impression technique. The combination
of an extremely accurate impression and CAD/
CAM fabrication of the framework has brought implant
prosthetics to a new level. Taking one’s time and paying
attention to detail during the impression procedure will
simplify the rest of the restorative process and result in a
superior prosthesis.
Figure 15: Once the impression material has set, the guide pins are
loosened.
References
1| Taylor TD. Prosthodontic problems and limitations associated with osseointegration.
J Prosthet Dent. 1998;79:74–78.
2| Goodacre CJ, Kan JY, Rungcharassaeng K. Clinical complications of osseointegrated
implants. J Prosthet Dent. 1999;81:537–52.
3| Jemt T, Book K. Prosthesis misfit and marginal bone loss in edentulous
patients. Int J Oral Maxillofac Implants. 1996;11:620–25.
4| Kan JY, Rungcharassaeng K, Bohsali K, Goodacre CJ, Lang BR. Clinical
methods for evaluating implant framework fit. J Prosthet Dent. 1999;
81:7–13.
5| Skalak R. Biomechanical considerations in osseointegrated prostheses.
J Prosthet Dent. 1983;49:843–48.
6| Branemark PI. Osseointegration and its experimental background.
J Prosthet Dent. 1983;50:399–410.
7| Zarb GA, Schmitt A. The longitudinal clinical effectiveness of osseointegrated
dental implants: the Toronto study. Part III: problems and complications
encountered. J Prosthet Dent. 1990;64:185–94.
8| Cobb GW, Metcalf AM, Parsell D, Reeves GW. An alternate treatment
method for a fixed-detachable hybrid prosthesis: a clinical report.
J Prosthet Dent. 2003;89:239–43.
9| Misch CE. Contemporary Implant Dentistry. 2nd ed. St Louis: Mosby.
1999;69:549–93.
10| Watzek G. Endosseous Implants: Scientific and Clinical Aspects. Chicago:
Quintessence. 1996:342–54.
11| Ortorp A, Jemt T, Back T, Jalevik T. Comparisons of precision of fit between
cast and CNC-milled titanium implant frameworks for the edentulous
mandible. Int J Prosthodont. 2003;16:194–200.
12| Lee H, So JS, Hochstedler JL, Ercoli C. The accuracy of implant impressions:
a systematic review. J Prosthet Dent. 2008;100:285–91.
13| Chee W, Jivaj S. Impression techniques for implant dentistry. Br Dent J.
2006;201(7):429–32.
14| Cabral LM, Guedes CG. Comparative analysis of four impression techniques
for implants. Implant Dent. 2007;16(2).
15| Assif D, Marshak B, Schmidt A. Accuracy of implant impression techniques.
Int J Oral Maxillofac Implants. 1996;11:216–22.
16| Carr AB. Comparison of impression techniques for a five-implant mandibular
model. Int J Oral Maxillofac Implants. 1991;6:448–55.
Figure 16: The impression is pulled.
Figure 17: The master cast is poured.
40
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Utilizing Digital Treatment Planning
and Guided Surgery in Conjunction
with Narrow-Body Implants
by Timothy F. Kosinski, DDS, MAGD
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in-depth content
I
mplant dentistry is undergoing some amazing transformations. With the help
of CT diagnosis and digital treatment planning, general dentists can predictably
surgically place and restore many different designs of dental implants
to improve quality of life for their patients. Innovations in design and materials
have made our job as clinicians less complicated and more successful. Implant
dentistry has entered into the mainstream mindset as well, with many patients
asking about the benefits of dental implants. However, we sometimes are presented
with challenges relating to bone quality or quantity, anatomic restraints
and esthetic complications. The therapeutic goal of implant dentistry is oral
rehabilitation and improved form and function. When we include dental implants
in our diagnostic armamentarium, we provide patients with hope for a long-term
positive result. Modern technology and design enable us to surgically place
implants in compromised areas.
– Utilizing Digital Treatment Planning and Guided Surgery in Conjunction with Narrow-Body Implants – 43

The patient in this case, a 64-year-old white female, had
been edentulous for more than 25 years. Although her
maxillary conventional complete denture was retentive
and provided lip support for esthetics, her mandibular
conventional complete denture was never completely
stable and dramatically diminished her perceived quality
of life. Although well made, the mandibular conventional
denture provided her with decreased chewing
function. As the years progressed, the denture became
less tolerable due to the instability of the appliance, and
the patient’s interest in dental implant reconstruction became
more apparent. There were no apparent medical
complications for this procedure. Oral and radiographic
examination revealed good vertical height of the mandibular
ridge.
CT diagnosis allowed us to visualize the patient’s available
bone in three dimensions and to virtually place the
implants prior to any surgical intervention. CT scanning
has fast become an important tool in the diagnosis and
treatment of dental implant position and placement. Especially
in areas of the mouth where bone contours are difficult
to determine with conventional radiography and oral
palpation alone, CT scanning software allows for determination
of bone quantity and quality. 1 For the less experienced
clinician, this tool also helps determine potential
risks involved in surgical placement. Correct position in
bone and angulation are determined prior to any surgical
intervention. CT planning software also helps eliminate
potential manual placement errors and can match the surgical
planning to the eventual prosthetic reconstruction.
Finally, the software allows for surgery to be less invasive
and more predictable because there is no longer a need
for full-thickness flap procedures. Instead, the implants
are placed using a flapless approach, which is more
comfortable for the patient and allows for improved postoperative
healing.
When considering dental implant placement in the mandibular
arch, compromised conditions can result in poor
positioning or angulation, which will make fabrication
CT diagnosis allowed us to
visualize the patient’s available
bone in three dimensions and to
virtually place the implants prior
to any surgical intervention.
of the final prosthesis difficult. The main objective in
dental implant placement is improving stability of the
denture and providing retention, thus increasing chewing
efficiency. Over time, the implants will minimize further
bone loss.
A patient’s understanding of the benefits of dental implant
therapy is certainly a motivator to patient acceptance.
Wearing a removable appliance can be difficult to tolerate
physically and emotionally. Creating an appliance with
improved retention and stability helps alleviate functional
and psychological concerns.
The 3.0 mm I-Mini ® IOT/O-ball dental implant (OCO
Biomedical; Albuquerque, N.M.) is proving to be an outstanding
small-diameter implant for immediate overdenture
stabilization. It is a one-piece implant designed with
a ball that serves as the male component to the long-used
O-ring system. The design is intended for immediateload
and immediate-function capability. The mini cortical
thread pattern at the top of the implant locks into the
cortical bone, and a bull-nose “auger” design at the apex
condenses bone around the tip and the threads. Dual stabilization
locks the implant into place, providing a true
mechanical lock. The minimally invasive system offers an
outstanding choice in areas of narrow bone. An advantage
of this system is that a transitional prosthesis can
be immediately placed. In this case, the patient’s existing
mandibular complete denture was relieved and relined to
immediately stabilize her prosthesis. 2
The surgical technique used to place the 3.0 mm I-Mini
IOT/O-ball implants was simple and precise. Chairtime
was reduced dramatically following diagnosis using
CT scanning software and virtual placement of the dental
implants using Blue Sky Plan ® treatment planning software
(Blue Sky Bio; Grayslake, Ill.).
The technology behind digital treatment planning and
guided surgery is based on long-used planning algorithms.
CT scans and 3-D software improve predictability
and safety for the clinician, especially in areas of anatomic
concern, such as a thin mandible, as demonstrated in this
case. The surgery is driven by the demands of the final
esthetic and functional prosthetics. Final tooth position
is established prior to any surgical intervention to ensure
compatibility between the surgical placement and the clinician’s
and the patient’s expectations of the final result.
CT planning and placement systems provide an increased
level of comfort and safety for patients by reducing surgical
and restorative chairtime. This is accomplished by utilizing
an accurate three-dimensional plan prior to surgical
placement of the implants. 3 There are several advantages
to doing this. The case is more easily presented to the
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patient. There is reduced surgical chairtime and reduced
prosthetic chairtime because the implants are properly
positioned. And in compromised situations, there is reduced
stress to the clinician because accurate surgical
placement is predetermined, which results in fewer clinical
surprises that could cause the clinician to abort the case.
Prior to the CT scan, the dental lab fabricated a scan appliance,
which aids in visualizing the optimal prosthetic
outcome. The teeth are then properly positioned in wax,
or the patient’s existing denture can be duplicated if it is
well fitting. Either way, a hard appliance is processed to
illustrate what the case will look like when finished,
before it is even started.
In this particular case, the patient’s existing conventional
complete denture was duplicated. All appropriate dental
anatomy was included. The scan appliance was placed
into the mouth during the CT scan. 4 Doing this enables
the clinician to see the ideal position of the teeth in a
3-D model. The entire 3-D image is analyzed, and the
implant planning and simulation of implant placement
completed using the computer. The surgical placement of
the implants can be done in a conventional manner using
the newly created surgical guide to help direct the drills
in the ideal direction. Often this can become a flapless
procedure. The implants are then simply placed in the
desired depth and direction using the computer software
and the surgical guide. 5
In this case, a surgical guide based on the virtual plan
and fabricated by Glidewell Laboratories was utilized.
It consisted of 1.8 mm sleeves, which allowed for directional
determination of the dental implants to be placed.
This surgical guide was fabricated using the information
Final tooth position is established
prior to any surgical intervention
to ensure compatibility between
the surgical placement and
the clinician’s and the patient’s
expectations of the final result.
created by the CT scanning software. The guide was
used to determine correct directional placement of the
implants in the patient’s symphysis area. Because bone
and soft tissue were compensated for in the fabrication of
the surgical guide, no reflection or flap was needed in the
placement of the implants.
Although placing mini implants is marketed as a simple
procedure, the clinician must understand the patient’s
anatomy, including the quantity and quality of the bone,
as well as the location of the inferior alveolar nerve.
This can be accomplished by reflecting a soft-tissue flap.
Or, if you select a flapless approach, as in this case, a
CBCT scan can be taken and the implants planned in a
virtual environment.
Figure 1 shows the preoperative bone morphology in a
two-dimensional radiograph. Clinically, there appears to
be a thin mandibular ridge (Fig. 2). However, the 3-D view
Figure 1: Preoperative radiograph of the edentulous ridge
Figure 2: Occlusal view of the thin mandibular ridge
– Utilizing Digital Treatment Planning and Guided Surgery in Conjunction with Narrow-Body Implants – 45

Figure 3: CT scan with virtually placed implants
Figure 4: Surgical guide based on the virtual plan
Figure 5: Surgical guide in situ
Figure 6a: Small-diameter drill aligned with the implant site
Figure 6b: Small-diameter drill going through sleeve of surgical guide
Figure 7: Preparation through soft tissue in a flapless procedure
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Figure 8: A 1.8 mm pilot drill used to depth
Figure 9: Digital radiograph of pilot drill at proper angulation and depth
Figure 10: Final 2.4 mm drill for 3.0 mm implant
Figure 11: Implant hand-tightened into the osteotomy site
reveals a relatively short, wide ridge with a thick cortical plate (Fig. 3). Utilizing the patient’s existing denture as a scan
appliance, we were able to plan the case from a surgical and a prosthetic perspective. Four 3.0 mm I-Mini IOT/O-ball
implants were planned in the symphysis. The implants were angled slightly to the labial to maximize the length, thus
establishing bicortical stabilization and locating the O-ball head of the implants under the anterior teeth of the denture.
The surgical guide with directional sleeves for the pilot drill was fabricated based on the CT scan of the patient’s existing,
well-fitting conventional complete denture (Figs. 4, 5). A small-diameter pilot drill was used through the sleeves of
the surgical guide to create proper angulation and position of the four small-diameter implants (Figs. 6a, 6b). Perforations
were made through the soft tissue and ridge crest, allowing for directional placement of the implants (Fig. 7).
The directional guide was then removed and a 1.8 mm drill used to depth as determined by analysis of the CT planning
software (Fig. 8). The directional openings were used to correctly angle the drills to the predetermined depths —
14 mm for the #23 and #25 implants, and 12 mm for the #22 and #27 implants. A radiograph was taken to ensure proper
depth (Fig. 9). A 2.4 mm drill was then used to the predetermined depth to create the osteotomy site for the 3.0 mm
mini implant (Fig. 10). Because we were using a self-tapping implant, there was no need to use a thread former. The
final drill used to form the osteotomy was side-cutting only. The pilot drill alone determined the depth of the implant
placement. There were no intermediate-sized drills used in this technique.
The implant was then hand-tightened to establish initial stability, and a torque ratchet was used to thread the implant
to the desired depth (Figs. 11, 12). Compensation of soft tissue can be determined by using the CT scan, or it
– Utilizing Digital Treatment Planning and Guided Surgery in Conjunction with Narrow-Body Implants – 47

Figure 12: A ratchet used to position the implant into the bone
Figure 13: The implant torqued to over 50 Ncm, indicating excellent
primary stability
Figure 14: The first mini implant in place
Figure 15: Digital radiograph of the first implant in position
can be established by measuring the soft-tissue depth with a periodontal probe following anesthesia. In this case,
the initial implant was inserted with a torque of over 50 Ncm (Fig. 13), which indicates outstanding primary stability
of the implant. It is absolutely critical that the implant be stable after placement. There must be no mobility. As the
implant bottoms out, the bone is condensed at the apex by the threads and at the crest by the mini-thread at the bottom
of the tapered collar. Once the implant was placed, an additional few turns were given to condense the bone at the tip
and wedge the cortical thread into the cortical bone, creating a mechanical lock at the top and bottom of the implant.
Figures 14 and 15 show the first implant in position intraorally as well as radiographically. Subsequent implants were
placed using the same protocol (Figs. 16, 17). Figures 18 and 19 show the four implants ideally placed in the mandibular
symphysis and the final radiograph. Note there is little bleeding, as this was a flapless procedure. Also note that the lingual
plate is more coronally positioned than the labial plate, and the implants are positioned in the center of the ridge.
Next, the patient’s existing mandibular complete denture was relieved and a chairside soft reline material was placed
to stabilize the denture (Fig. 20). The patient experienced immediate improvement of the retention and stability of her
mandibular denture (Fig. 21). She also experienced minimal discomfort following placement of the conditioning material.
After integration progresses, a new mandibular implant-retained overdenture with O-rings will be used to create
retention, stability and an increased quality of life for our patient. Figures 22a and 22b (page 50) show the postoperative
CT scan as compared to the virtual plan.
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Figure 16: Preparation of the subsequent implant sites
Figure 17: Placement of the remaining implants
Figure 18: Four small-diameter implants ideally placed in the symphysis
area
Figure 19: Postoperative radiograph of implants in position
Figure 20: Soft reline of patient’s existing denture over the implant
heads
Figure 21: Existing dentures in place. New denture will be fabricated
with O-ring retention housings following osseointegration.
– Utilizing Digital Treatment Planning and Guided Surgery in Conjunction with Narrow-Body Implants – 49

Figure 22a: Postoperative CT scan compared to preoperative plan
Figure 22b: Digital plan based on the CBCT scan
The OCO Biomedical 3.0 mm I-Mini one-piece overdenture implant system allowed us to strategically place predictable
implants to improve the patient’s functional ability. This was a difficult case because the patient had lost significant horizontal
and vertical bone. As cost is a factor, especially in today’s economy, the small-diameter implant was an excellent
option for this patient to improve stability and retention of her mandibular denture. The use of CT diagnosis improved
my confidence in proper placement of the dental implants using a flapless procedure, which is much less invasive than
cutting a long, full-thickness flap. The patient experienced little to no discomfort following the procedure and appreciated
the immediate improvement in the fit of her mandibular denture.
This case demonstrates just one of the innovative techniques available to clinicians and our patients. CT scans and
digital planning software make the surgical placement of dental implants simple and effective. Anatomical anomalies
are virtually determined prior to any surgical intervention. Using this system, implants can be ideally placed and maintenance
is routine.
REFERENCES
1. Williams PA, ed. Overdenture construction of implants directionally placed using CT scanning techniques. Dental Implantation and Technology. Nova Science Publishers.
2010;197–208.
2. Fortin T, Champleboux G, Bianchi S, Buatois H, Coudert, JL. Precision of transfer of pre-operative planning for oral implants based on cone-beam CT-scan images
through a robotic drilling machine: an in vitro study. Clinical Oral Implants Res. 2002;13:651-56.
3. Fortin T, Bosson JL, Isidori M, Blanchet E. Effect of flapless surgery on pain experienced in implant placement using an image-guided system. Int J Oral Maxillofac
Implants. 2006;21(2):298–304.
4. Kosinski T, Kline R. Case presentation: overdenture alternative with narrow-body implants. Implant News and Views. 2006;8(5):1.
5. Kosinski T. CT planning for implants: don’t let a panoramic fool you. Inclusive. 2010;1(4):43–50.
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Billing Patient Medical Plans:
There’s Nothing Illegal About It!
Go online for
in-depth content
by Olya Zahrebelny, DDS
Dentists have always wondered whether they could legally
bill their services to medical plans. Traditionally, this has
been an area of great concern. It is a commonly held misconception
that only physicians can obtain medical benefits for services provided,
whereas dentists, with perhaps the exception of oral surgeons, can only
access benefits from dental plans. Nothing could be further from the
truth. A large number of routine procedures performed in general and
specialty dental practices are billable to and, more importantly, are covered
by patient medical benefit plans. In addition, many procedures that
are typically billed only to dental plans can also be billed simultaneously
to the medical carrier, with no fear of legal ramifications. However, some
basic premises and rules must be followed.
Medically Billable Procedures
It is a commonly
held misconception
that only physicians
can obtain medical
benefits for
services provided.
Procedures can be divided into “oral” and “dental”
procedures. “Oral” procedures are those performed
on the bone and soft tissue. “Dental” procedures are
those performed on or in the tooth itself. Procedures
that are covered under medical contracts fall into these
four categories:
1. Inflammation and infections — problems not
treatable by entry through the tooth
2. Pathology — hard and soft tissue
3. Dysfunction — skeletal dysplasias, sleep apnea,
oral dysfunction
4. Trauma — anything and everything related
to traumatic injury
– Billing Patient Medical Plans: There’s Nothing Illegal About It! – 53

Let’s take a look at individual treatment categories and the procedures
that are medically billable in each.
Don’t be afraid
to bill procedures
to medical plans.
Learn the codes
and the language,
the documentation
and claim-filing
requirements, and
the billing protocol.
Diagnostic: This includes examinations, consultations, radiographs
(orthopantographs, cephalometric X-rays, occlusal films, lateral jaw
projections) and other diagnostic procedures such as photos, models and
diagnostic/surgical/healing stents that are required for surgery and/or fall
into any of the aforementioned four categories. This also includes impacted
teeth (including wisdom teeth, supernumeraries, congenitally missing
teeth). Injections that are needed to determine the cause and origin of
pain, as well as bacterial testing, are also covered under this category.
Medical (i.e., Non-Surgical) Treatment: All non-trauma-related
emergency procedures, such as incision and drainage (I&D), curettage
of periodontal abscesses and irrigation of tissue overlying wisdom teeth,
are typically covered under the medical contracts. Also included in this
category are nightguards, TMD orthotics and sleep apnea appliances.
Fluoride trays for at-home use are also billable when indicated for patients
undergoing radiation/chemotherapy, and for those with psychological/GI
disorders such as anorexia and bulimia.
Surgical Treatment: The removal of teeth in non-traumatic and nonemergency
situations, including any type of impactions, as well as teeth
requiring removal prior to radiation therapy, transplantation of organs or
other similar circumstances on the recommendation of the physician, are
also covered benefits. In addition, the biopsy or excision of any hard- or
soft-tissue lesions is billable to medical plans. The surgical placement of
implants and periodontal hard- and soft-tissue (non-cosmetic) procedures,
such as osseous contouring, gingivectomy, alveolectomy, removal of tori/
exostoses and frenectomy, are included in this category.
Treatment for Traumatic Injury: Any and all treatment of the teeth, supporting
structures and surrounding tissues that are damaged during a traumatic
incident is covered under the comprehensive portion of the medical
plan. This includes, but is not limited to, restorative, endodontic, surgical,
implant replacement, removable and fixed prosthodontic treatment, as well
Procedures Billable
by All Dental Providers
• Exams
• Consults
• Orthopantograms, CT scans, jaw X-rays
• Appliances — TMD/sleep apnea/habit breaking
• Cancer screenings and biopsies
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Procedures Performed Mainly
by Specialists
General dentists and specialists can bill the previously
mentioned procedures. There is also a wide array of
procedures performed by specialists that are medically
billable and should be routinely submitted to a patient’s
medical plan for reimbursement. These include, but are
not limited to, the following:
1. Periodontal
• Osseous surgery to correct defects
• Soft- and hard-tissue grafting (non-cosmetic)
• Soft- and hard-tissue augmentation (non-cosmetic)
• Implants
2. OMFS
• Sinus elevation
• LeFort procedures
• Implants and related procedures
• Treatment of anomalies affecting function
• TMD surgery
• LAUP
• Laser procedures
• Dermatologic/plastic surgery procedures
It is prudent … to
bill dental plans only
for tooth-related
procedures and
then to bill all other
procedures to the
medical plans.
3. Endodontic
• Apicoectomies
• Hemi-sections
• Endodontic therapy related to traumatic injury
4. Orthodontic
• Nightguards
• Palatal expanders for skeletal anomalies
• Habit-breaking appliances (including those for
tongue thrusting and thumb sucking)
5. Pedodontic
• Emergency procedures
• Analgesia/anesthesia for the control of behavior
problems in the office
– Billing Patient Medical Plans: There’s Nothing Illegal About It! – 55

as orthotics, stents and the like. None of these procedures are restricted to
a specific specialty, and may be performed by any dentist that is licensed
and properly trained to perform the procedure in question.
When a large
comprehensive
treatment is
planned, the
diagnostics can
be billed to both
plans in order to
satisfy the medical
deductible.
NOW WHAT?
The various aforementioned procedures are billable, for the most
part, to both medical and dental plans and can be billed simultaneously.
It is prudent, however, to bill dental plans only for tooth-related
procedures (procedures on or in the tooth, not involving traumatic injury)
and then to bill all other procedures to the medical plans. Not
only will this leave the paltry annual dental benefits for strictly “dental”
services, but will also allow the patient the luxury of having more necessary
services performed with a decreased out-of-pocket expense. When a
large comprehensive treatment is planned, the diagnostics can be billed
to both plans in order to satisfy the medical deductible. This, in turn,
allows for maximum coverage for the surgical portion of treatment, such
as periodontal and implant services.
CONCLUSION
Don’t be afraid to bill procedures to medical plans. Learn the codes and
the language, the documentation and claim-filing requirements, and the
billing protocol — and then go for it! Not only will the patient be able
to undergo all the necessary treatment in a shorter time frame, but the
out-of-pocket costs will also be much more manageable, resulting in a
happy and satisfied patient and a dentist thrilled with the ability to complete
the total treatment in a shorter time period.
v v v v v
Dr. Zahrebelny’s 2011 medical billing manual, “Accessing Medical Benefits in the Comprehensive and
Surgical Dental Practice” (aka the “Z Book”), and further information can be obtained by e-mail request
at drz@thezgroupllc.com.
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