Pumpkin on a toothpick
Should mini implants be used for crown and bridge restorations on implants? Dr. Stacey Simmons shares a case study and discusses why these clinical situations should probably be left to regular diameter implants.
A profound analogy, but sometimes more can be said with less. This was my initial impression when this 18-year-old male presented to my office for his six-month recare appointment. A number of concerns immediately came across my mind for this “final” restorative prosthesis, which was to service the patient in lieu of his congenitally missing second premolars.
To begin with, there was, without argument, adequate space present for traditional, wider-based platform implants in these sites. So why were mini implants used? As it was understood by the parents, it was the newest technology and standard of care. Their concerns of function, tooth replacement, esthetics, and financial burden were addressed (it was done on trade). This conveys an important point — patients have relatively simple expectations, and when met, they are happy.
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I felt an obligation to express my concerns to the parents about potential long-term complications.
Hygiene. It can be agreed upon that if an implant can’t be kept clean, then the potential for failure and difficulties rise exponentially. A 90-degree angle between the implant and crown is virtually impossible to keep clean and maintain. As amazing as some hygienists are, it is impractical to expect that a curette can get into that space to clean it without making hamburger of the tissue. The implants were cemented on, so they are not easily retrievable. The emergence profile is nonexistent. Do natural teeth look like this? I would submit that when restoring implants, it is our job to mimic the shape and emergence profile of natural teeth as closely as possible. When we don’t, then we lose the inherent cooperation and benefits that the tissue can provide. To help the parents understand this concern, I showed them an example of a traditional implant vs. the “pumpkin on a toothpick” implant. The side-by-side comparison spoke for itself.
Longevity and function. Premolars don’t get the brunt of mastication forces, but they definitely get their fair share. If the occlusal forces are not centered over the implant just right, then we observe a first-class type of lever that can cause long-term stability issues. It could be argued by some that the 20 mm implant length could render a certain amount of support, but again, the aforementioned point must be referenced — there is/was adequate space for wider based platform implants to be placed.
Esthetics and lack of pain/discomfort. The implants indeed looked like premolars. Making something look good in dentistry is easy. But this is where we have to be careful. Patients don’t know if a crown margin is closed or if a resin is leaking; it is, therefore, up to the provider to maintain a standard of care, own the work, and be behind it 100%. Unless something hurts (and lack of pain does not always mean there isn’t anything wrong), this patient will be happy with the status quo until challenged. That brings me to my last point — financial burden.
In the event that there is failure due to hygiene difficulties, function issues, etc., there will be a time and financial investment for this patient to revisit surgery and restore these teeth, again. Will this patient be pleased? Probably not. Although the work was done on trade, the patient will be getting the short end of the stick, and that does not sit well with me.
With all this being said, there is recognition for the use and application of mini implants in dentistry and my argument is not to undermine the relevance of that use (i.e., mini implant-supported dentures). We must meet the patient’s needs, but just as important, we must set and maintain a standard of care that justifies and supports our decisions should they ever be challenged.
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Dr. Stacey Simmons grew up in Hamilton, Mont. She did part of her undergraduate work at Purdue University and then received her bachelor’s degree in exercise physiology from the University of Utah. After applying to both medical and dental school, she decided that dentistry was her career of choice. She received her DDS degree from Marquette University School of Dentistry in Milwaukee, Wisc., in 2004. In private practice, she focuses her care on prosthodontics and cosmetic dentistry. She is a guest lecturer in the Anatomy and Physiology Department at the University of Montana. Outside the office, she trains for triathlons and spends time with her family. You may contact Dr. Simmons by email at email@example.com.