Narrow Diameter Dental Implant

Reporter ： R3 康磊Moderator ：賴玉玲主任 林怡君醫師

Outline

● Introduction● Biomechanical properties● Biological evaluation● Clinical evaluation● Clinical consideration● Case reports● Conclusion

Introduction

Implant in narrow ridge→ Ridge augmentation

‧ Increase morbidity‧ Longer healing time‧ Infection secondary to wound dehiscence

Narrow diameter dental implant ?

Terminology of Narrow Diameter Dental Implant

‧ Small diameter implant‧ Narrow diameter implant‧ Mini implant‧ Transitional implant‧ Provisional implant

No consensus on definition

Terminology

Glossary of Oral and Maxillofacial Implants (EAO, AO, AAP, ACP 2007):

Mini implant: - implant fabricated of the same biocompatible materials as other

implants but of smaller dimensions.

I. Mini dental implant: < 3.0 mm For interim usage

II. Narrow diameter dental implant: 3-3.5 mm For conventional implant usage

Sierra-Sánchez et al. 2014Bidra et al 2013

Mini Dental Implant (< 3.0 mm)

Mini Dental Implant (< 3.0 mm)

Brand Nation Diameter (mm) Thread length (mm)

Material Surface

3M MDI USA 1.8, 2.1, 2.4, 2.9 10, 13, 15, 18 Ti-6Al-4V SLA

Dentatus MTI Sweden 1.8 7, 10, 14 Ti Machined

Dentatus Atlas Sweden 1.8, 2.2, 2.4, 2.8 7, 10, 14 Ti-6Al-4V Machined

Dentatus Anew Sweden 1.8, 2.2, 2.4 7, 10, 14 Ti-6Al-4V Etched

MDL USA 2.0, 2.5 10, 11.5, 13, 15, 18 Ti-6Al-4V RBM

miniSKY Germany 2.8 6, 10, 12, 14 Ti SLA

Narrow Diameter Dental Implant (3-3.5 mm)

Narrow Diameter Dental ImplantBrand Nation Diameter

(mm)Thread length (mm) Material Surface

NobelActive Switzerland 3.0, 3.5 10-15, 8.5-18 Ti TiUnite

ITI Roxolid SLActive

Switzerland 3.3 8-16 TiZr SLA

ITI SLA Switzerland 3.3 8-14 Ti SLA

3i Osseotite USA 3.25 8.5-15 Ti Double etched

NarrowSky Germany 3.5 10-16 Ti SLA

Ankylos C/X Implant

USA 3.5 8- 17 Ti Acid etched

Outline● Introduction● Biomechanical properties● Biological evaluation● Clinical evaluation● Clinical consideration● Case reports● Conclusion

Biomechanical Risks● Risk of fracture ?● Increased bone stress ?

Deformation Strength of Narrow Implant

In vitro study● Grade IV cp Ti implants● 4.1 vs 3.3 vs 3.0 mm implants● 30° off-axis loading

Allum et al. 2008

Deformation Strength of Narrow Implant

More risk of elastic deformation in narrow diameter implants

Allum et al. 2008

manufacturer Diameter Max. load

Standard diameter Straumann RN 4.1 mm 989±107 N

Narrow diameterStraumann NN 3.3 mm 619±50 N

Straumann RN 3.3 mm 515±39 N

NobelDirect 3.0 mm 572±53 N

Deformation Strength of Narrow Implant

In vitro study● Ti-6Al-4V implant● 3.3 vs 3.75 vs 5.0 mm implant● 30° off-axis loading

Shemtov-Yona et al. 2012

Deformation Strength of Narrow Implant

Lower strength of narrow diameter implants

Shemtov-Yona et al. 2012

Diameter Mean load

5 mm 1584±115 N

3.75 mm 952±103 N

3.3 mm 674±57 N

Bone Stress• Finite element analysis• Mini vs Narrow vs Standard implant• Model - implants inserted into anterior mandibular region - cortical layers: 1.2mm

Istabrak Hasan et al 2010

Bone Stress

Istabrak Hasan et al 2010

implant Bone stress

Standard diameter

tioLogic 3.7 x 15 mm 95 Mpa

tioLogic 3.7 x 17 mm 95 Mpa

tioLogic 4.2 x 15 mm 90 Mpa

tioLogic 4.2 x 17 mm 55 Mpa

Narrow diametertioLogic 3.3 x 15 mm 105 Mpa

tioLogic 3.3 x 17 mm 105 Mpa

Mini dental implantMini 2.5 x 15 mm 206 Mpa

Mini 2.5 x 17 mm 195 Mpa

Higher stress in mini dental implantsSimilar result for narrow & standard diameter implants

Outline● Introduction● Biomechanical properties● Biological evaluation● Clinical evaluation● Clinical consideration● Case reports● Conclusion

Biological Evaluation

• Soft tissue: biological width• Hard tissue: bone-implant contact

Biological Width‧ Dogs, mandible‧ MiniSky (2.8x10 mm) vs NarrowSky (3.3x10 mm)

‧ Non-submerged, submerged placement‧ Histological analyses

Calvo-Guirado et al 2010

Biological Width

Narrow (3.5 mm) Mini (2.8 mm)

Non-submerged submerged Non-submerged submerged4 wks 3.2± 0.1 mm 2.0 ± 0.3 mm 4.3± 0.5 mm 3.3 ± 0.5 mm

8 wks 3.7± 0.2 mm 2.4 ± 0.3 mm 4.8± 0.1 mm 2.9 ± 0.2 mm

Calvo-Guirado et al 2010 Similar to standard-diameter implants

Bone-implant Contact

Narrow (3.5 mm) Mini (2.8 mm)8 wks (non-submerged) 42.5±8.7 % 41.5±0.1 %8 wks (submerged) 49.3±5.2 % 43.1±0.7%

Calvo-Guirado et al 2010

Similar to standard-diameter implants

Bone-implant Contact (TiZr vs Ti implant)

‧ Dogs, mandible, 8 wks F.U.‧ 3.3 mm ITI implants‧ Sandblasted & acid-etched surface‧ TiZr vs Ti implant

Thoma DS et al 2011

Bone-implant Contact

TiZr (3.3x8 mm) Ti (3.3x8 mm)

2 wks BIC 81.9 ± 6.7 % 79.3 ± 7.1 %4 wks BIC 81.3 ± 7.8 % 83.4 ± 5.9 %8 wks BIC 86.9 ± 6.8 % 82.9 ± 9 %

Thoma DS et al 2011

High BIC values of narrow diameter implants

Outline● Introduction● Biomechanical properties● Biological evaluation● Clinical evaluation● Clinical consideration● Case reports● Conclusion

Clinical Evaluation

● Survival rate - Diameter - Length - Bone density - Restoration type - Position

● Bone level

Survival Rate (3.0 mm)Author / year F/U Position Failure/Total N Reason Survival

rate

Polizzi 1999 63M 12, 22, 32-42 1/30 Fracture (69 M) 96.7%

Reddy 2008 12M 12, 22, 32-42 1/31 Mobility (4 M) 96.7%

Sohn 2011 23M 12, 22, 32-42 0/62 (-) 100%

Galindo-Moreno 2012 12M 12, 22, 32-42 4/97 3: loosening1: infection

95.9%

Oyama 2012 12M 12, 22, 32-42 0/17 (-) 100%

Mazor 2012 12M 2 for 1molar 0/66 (-) 100%

Survival Rate (3.25 - 3.5 mm) Author / year Diameter F/U Position Failure/Total Reason Survival

rate

Andersen 2001 3.25 mm 36M 12-22 2/32 1: not integrated1: mobile (6 M)

93.8%

Hallman 2001 3.3 mm 12 M Max + Mand 1/160 Not integrated 99.4%

Zinsli 2004 3.3 mm 60 M Max + Mand 5/298 3: infection2: fracture

98.7%

Romeo 2006 3.3 mm 84 M Max + Mand 3/122 infection Max: 98.1% Man:96.9%

Survival Rate (3.25 - 3.5 mm) Author / year Diameter F/U Position Failure/

Total NReason Survival rate

Veltri 2008 3.5 mm 12 M Max 0/73 (-) 100%

Arisan 2010 3.3 mm3.4 mm

60-124M

Max + Mand

14/316 7: not integrated

92.3%

Malo 2011 3.3 mm 132 M Posterior 12/247 (most in 6 M) 95.1%

Lee 2012 3.3 mm3.4 mm3.5 mm

144,58.8 M

Max + Mand

9/541 6: infection1: not integrated2: screw fracture

98.1%

Survival Rate (Implant Diameter)Diameter Author / year Failure(%)

3.0 mm Polizzi 1999, Reddy 2008, Sohn 2011, Galindo-Moreno 2012, Mazor 2012, Oyama 2012

0-4%

3.25 mm Anderson 2001 6%

3.3 mm Hallman 2001, Zinsli 2004, Romeo 2006, Malo 2011, Arisan 2010, Lee 2012

1-17 %

3.4 mm Arisan 2010 Lee 2012

10%0

3.5 mm Zinsli 2004Lee 2012

2%1%

Survival Rate (Implant Length)

Implant length & number of failure

Need further research

Author / year 8 mm 9.5 mm 10 mm

Zinsli 2004 1 3

Arisan 2010 1 6 7

Survival Rate (Bone Density)

• 84 M F.U.• 3.3 mm ITI implant (grade IV Ti)Implant failure- D2 bone: 1 (0.8%)- D3 bone: 1 (0.9%)- D4 bone: 4 (7.8%)*

Romeo et al 2006

‧ 11 yrs retrospective study‧ 3.3 mm implants in posterior area‧ Nobel , Grade IV cp Ti

Odds ratio of implant failure- Partial bridge VS single Implant → 4.56 : 1

Survival Rate (Multiple vs Single Implant)

Malo et al 2011

Survival Rate (Implant Position)

‧ 5-10 yrs retrospective study‧ 3.3 mm & 3.4 mm narrow implant

‧ Anterior: 99.21% ‧ Posterior: 92.06%*

Arisan et al 2010

Survival Rate of Narrow Diameter Implant

Lower implant survival rate: • Lower bone density• Posterior area• Implant supported bridge

Bone Level‧TiZr 3.3 mm narrow implant vs Ti 4.1 mm implants

‧1 year post loading

→ No significant differences

Benic et al 2013

TiZr (3.3 mm) Ti (4.1 mm)

bone loss (mm) 0.41 0.40

Bone Level● 2 vs 3 NDI supporting mandibular overdentures● 3.3 mm narrow implants (Straumann ITI)

→ Non-significant

2 implants 3 implants P-value6 M bone loss 0.3 ± 0.3 0.4 ± 0.3 0.266

12 M bone loss 0.5 ± 0.2 0.6 ± 0.8 0.214

24 M bone loss 0.8 ± 0.5 0.8 ± 0.9 0.342

El-Sheikh et al 2012

Outline● Introduction● Biomechanical risks● Biological evaluation● Clinical evaluation● Clinical consideration● Case reports● Conclusion

Indication

- Narrow ridge- Limited inter-dental space Upper lateral incisors or lower incisors- Limited inter- implant gap

Courtesy of Dr. 賴玉玲

Advantage

• Less invasive procedure & associated complications

• Reduce surgical intervention• Lower cost• Beneficial to medically compromised p’t or

elderly p’t

Contra-indication (Relative)

- Bruxer- Lower bone density- Reduced bone height

Outline● Introduction● Biomechanical risks● Biological evaluation● Clinical evaluation● Clinical consideration● Case reports● Conclusion

Case Reports

31y/o, male

Courtesy of Dr. 陳勁竹

Tooth 43

Bone width 3.5

Bone height

Tomo > 15

Pano > 15

Apical > 15

Implant type Nobel active

Implant ∅ 3

Implant length 11.5

4M Post Implant Placement

5 M Post Implant Placement- Soft Tissue Grafting

1.5M Post FGG - 2nd Stage Surgery

1M Post 2nd Stage Surgery

Temporary Prosthesis

Case Reports

51yrs, female

Courtesy of Dr. 陳軒弘

12,22 Pre-implant Surgery Evaluation

• Multiple missing teeth: loss of interdental papilla• Loss of proximal bone level of 13 & 23• Contact point to crest > 5 mm

12,22 Pre-implant Surgery Evaluation• Width of crest: 2-3 mm• Labial concavity• Without bone housing in ideal implant placement

12 & 22 Implant Surgery

Ridge width at crestal level: 2-3 mm

Ridge Split & Expansion

3i full osseotite certain NT 3.25x13 mm

Osseous graft placement

Guided Bone Regeneration

Guided Bone Regeneration

Resolut LT absorbable membrane

2 Weeks Post Implant Placement

Stitches removal

5 Months Post Implant Placement

• 12-22 soft tissue depression

12-22 Soft Tissue Augmentation

30x10 mm connective tissue graft placement

2 Weeks Post Soft Tissue Grafting

Stitches removal

8 W Post Soft Tissue Grafting - 2nd Stage Implant Surgery

2nd Stage Implant Surgery

Suture

6 Months Post Temporization

2015/04/16 (Temporization)

Outline● Introduction● Biomechanical risks● Biological evaluation● Clinical evaluation● Clinical consideration● Case reports● Conclusion

Conclusion

‧Narrow diameter implants (3.0-3.5 mm) may be an alternative viable treatment

‧Careful case selection