Atlas Narrow Body Implant Showing Significant Bone Loss: How Do I Save this Case?

What were the length and diameter of the implants at the time of insertion? Did you have a cone beam scan prior to implant insertion? Did you use a surgical stent at the time of implant placement? Was the stent milled or generated using the Cone Beam Scan data to assure ideal implant placement? It sounds to me as if the implants were prematurely loaded. You may have to remove both, graft the sites and wait for healing. At that time, have a Cone Beam Scan taken with a radio-opaque guide so you can maximize the data you receive. This should improve your predictability. Be sure that the denture is significantly relieved all the way around the implants. IF there is minimal retention of the denture, this could lead to premature prosthetic loading in a non-controlled manner.

I think you shoul remove all of them, and change you tx plan. Do you have a pre-op scan ?

Loose is done. There is no salvaging a loose implant. You have no option but to remove the fixture in #22 and the #26 areas. If the other two are OK leave them but they won't bear the load for long. you need to add additional support (use traditional implants, pick a company) if wou hope to maintatin the others. It is very unlikely the fixtures were actually out of occlusion during the healing phase. Edentulous patient do all sorts of things we cannot even imagine when inserting dentures and chewing. Only a burried fixture is even remotely out of occlusion and that's even questionable. Get the fixtures out before you lose more bone. Sorry

Dr. R has not told us what the condition of the bone was at time of placing the Atlas Implants. The protocol to placing the Atlas narrow diameter implants (by Dentatus) is that they are generally placed in type 1 or 2 bone in the mandible; and that the corresponding and supplied drills are of a narrower diameter than the implants; so that upon installation.....they are rigid and can be immediately loaded by incorporating the supplied silicone putty into the prepared trough made in the denture.....the retention is very gentle. Obviously something was overlooked at the time of the insertion of the implants. As with everything else in life, there is a learning curve.......if the area is given a chance to heal and the bone remodels within four months, a second attempt can be made, and this time it will probably be successful...good luck Dr. R.... we all have our failures in implant dentistry....but this is how we learn and how new techniques evolve. In the meantime Dr. R. do contact Mr. Bernard Weisman, president of Dentatus, and the inventor of the Atlas system, and he will be very happy to review the case with you and offer his more than 50 years of experience as an expert in dental matters; and when you speak with him, please do give him my regards. Gerald Rudick dds

The best way to save this case , in my opinion is to remove these nails and place standard implants. Allow them to integrate and restore them at three months. You have taken a cheaper route and the patient got what they paid for, most likely. I can only assume that the surgical fees were significantly less expensive than traditional implants. Please don't tell us you charged more , because it takes you longer to do this procedure. As a young surgeon , about 16 years ago , one of our state board dentist, tried to convince me that he should charge more than me for impacted wisdom teeth , because it took him four times as long to remove them. Needless to say, my response to that statement, while he was watching me bail him out of a jam, left me with no more referrals from him. Sometimes the liability associated with the bad referral, Is not worth the work. Boy, does that mean I've been at this for too long. Oh well, those failing narrow implants, are just that. It wouldn't hurt to go watch a seasoned doctor place a few before you embarked on the facet of treatment. How do you like that delivery, dr. Sepsis? Bv

've been using IMTEC minis and encountered a similar situation once ,....amongst some individual losses. It is a learning curve, however the advantages in the use of minis or narrow implants are a fact. You just described the problems; insufficient length, and I guess a lot of lateral forces when attempting to relieve the denture. Minis or narrow implants can be loaded as long as they are properly inserted .As mentioned above remove loose implants asap, check your protocol, have a scan available and keep in mind that merely relieving the denture doesn't mean there are no lateral forces.Also keep in mind occlusal forces,number of implants and medical conditions. Keep up and good luck!!

Dear Dr R. first of all it is great that you presented your failure with osseonews. Never mind some discouraging posts. About your case I don't think you have given us enough material from which to draw a conclusion. Any thing could have gone wrong. And at any step of implantation and even the prosthetic stage. The list could be endless. Could you give us some more information?

The Atlas is a good system, but the implant needs to be rock solid immediatly after placement or failure is going to result very time. There should be a torque force at least equal to that you would expect for immediate loading of the larger diameter implants when the small diameter immediate load implants are used. Drill the osteotomy as minimal as you can to get the implant into the bone. If there is any movement of the implant after placement into the bone it must be removed and another site selected. You may find that moving 2-3 mm is all that you need to do. Remove that loose implant from the #22 site and discard it. Place another 4 mm or so away from that site right away or just wait one or two months and go back to the same site, use a longer implant for initial stability if you can. Do not load the implant if torque forces are not around 30-40 nueton cm at the time of placement.

Sorry I failed to coment on the other implant. Please also remove the implant in the # 26 area you should be able to just back it out. Both of these implants can not be salvaged. When planning a mini implant over denture case use 4 implants minimum in the lower jaw and 6 minimum in the upper jaw.

Dr R Good for you to discuss your failed case. Sometimes whilst reading these forums I am lead to believe that many of us were born as experienced implant practiitoners , and have never seen failure. :o) ....or that we have patients who demand only the ultimate in contemporary dentistry no matter what it takes. Hundreds of thousands of mini implants have been placed ,with very successful cases . Minis work no doubt about it ....BUT they are trickier than many think. It requires prosthodontic skills as well as surgical skills, all at the same visit. Surgeons don't like them because it was marketed to general practitioners by all the major companies and its a much more accessible alternative to standard implants. The surgical protocol is entirely different to standard implants. Infact if you place minis like standards you get failure. If you don't retrofit the denture properly to be ..implant "retained" and not implant "supported" .....you get failure. I have stabilised numerous dentures within a couple of hours, without major trauma and most often without a flap...on elderly and frail patients. Often I don't need more than one anaesthetic cartridge to place 4 minis in anterior mandible. (Also the total cost of the case is less than one standard restored implant) The trauma induced is comparable to a simple extraction. It is a great great service to stabilise lower dentures,for minimal trauma and minimal cost of a population group who arguably need our skills the most but can least afford it . Just another string to our bow for those of us that do not have the privilege of working with only wealthy patients. Ive had failures too..the good thing about these is that there is minimal damage and minimal post op healing. ------------------------------- Another very useful aspect of these implants is when you remove multiple teeth, with a view to ultimately placing standard implants for say a fixed full arch case. They can temporarily and immediately stabilise a denture or even a fixed acrylic bridge, while we wait for sockets to heal and standard implants to be placed and subsequently heal before restoration. Its just a useful adjunct to my implant practice .

All the above comments are great , this case cannot be saved so time to compromise and remove the two that are an issue , ASAP or you may be having to remove a tip when they fracture. Then use the other two to stabalize the denture whilst you place "regular" implants which can integrate. You could send to an ALL on Four practioner as they are getting great results as well. Peter

Dr. Gupta, I'll bet you a dollar , that my patient pool is poorer than yours. We( five surgeons ) do all of the indigent trauma within a 300 mile radius of a highly populated area. I am the only surgeon that sees Medicaid patients every day, in my town. I do not exclude. These people , even at the bottom end of the socioeconomic chain, get the same exact care and respect, as the wealthiest man in my town. If they can't afford, but need a cbct , they get one for free. If they are edentulous and kind and willing to take care of themselves , they get implants for free, sometimes. I personally take offense , at that blind suggestion. Still ,the only mini's , that I place are for ortho or temporization. My moto , since day one , has been go to work," do the right thing" and" we will be rich". Good day! Bv

Mini implants do work if protocol is followed. I see failures with minis mostly because occlusion is not right. Like Dr. SenGupta said, you have to have as much prosthetic skill as surgical one. I see lots of complaints cominig out without knowledge of the type of implants after first a few failures. Also another factor that contributes to the failure is overheating of the bone, hence causing necrosis around the implants. Both cause failures of minis within first week or two. Keep learning and you will start seeing good result just like anything else in dentistry.

There is lot of talk of many mini implant failures, yet the number of failed case presentation is so low. Let the failed cases be presented with complete documentation. Let the profession know the facts. Often the very same company which make the regular two piece "real" implants are the ones making the one piece minis. There is a 'cases' section here on osseonews. Why don't many of you who have seen failures post some x-rays and clinical pictures here? Let us decide for ourselves, for or against minis. Let us get the real picture.

Sanjay, I'm not denying that mini's work for some people. I choose not to use them. I built my duck camp on 14 inch ,metal I - beams, because it is 18 feet in the air and it floods every year, with heavy current from the Mighty Mississippi river. Some duck hunter's camps are biult on 3 inch metal pipes. I'll sleep in my camp , when the river is roaring under it . It Is a preference. I didn't buy a cheap laser or scanner either. Studies proove that we can do orthognathic surgery without post op abx. , but I still use them. I believe the money I spend at my facility is an investment and when I walk in the door every morning , I know I am using the best that I can buy. You can't, for a second, tell me mini Implants are as good as standard implants. If you do, I'm not " buying it". Bv

BV - I neither hunt nor build from steel. I do believe that there is, in construction of physical structures and in the fabrication and support of intraoral dental prostheses, the possibility of either over-engineering or under-engineering. With appropriate diagnosis, there is the ability to restore patients with less cost and more minimal surgery. Would I prefer to restore a full, fixed dentition on 4 and 5 mm diameter implants - yes. Are they needed to stabilize a removable denture - not necessarily. There is literature going back 50 years (Linkow, Chercheve) on narrow diameter implants. Do not discount them for the general public because they don't fit in your "mindset". Not every patient has the time, height of alveolar bone, money, ability to tolerate surgery and/or will to have a narrow ridge rebuilt to enable placement of what you might call "conventional" implants. Bob Horowitz

Bob, show me a single case that can't be restored by the standard implant. So , I have to disagree with part of your suggestion . All patients have enough bone ( height / width ). This is the nature of the genio- glossul and genio- hyoid attachments . The mandible inevitably reaches a steady state of atrophy , primarily because the patients can't use their denture anymore. Although there are probably no studies to proove this; I am pretty certain that the first osteotomy creates significantly more heat than the subsequent ones. This is why our reconstruction screws are never integrated( or one reason ) . So, the one issue I have with the mini protocol is the lack of steps. By slowing increasing the diameter of the implant sight we are leaving more vital bone, assuming you believe this( I will not use a nondental analogy any more,............... on this question). The main problem ,I suppose, is that these systems are used as " starter kits " for some( I understand that this is sarcasm ) and a lot of doctors are drilling into bone for the first time in their life, subsequently burning bone, leaving the fixture to fail. The suggestion that three cuts with the bur is more surgery, is true, but I imagine that the difference is just a bit more than negligible. So , I'll "change my tune". I no longer discount the mini, I just suggest it's cheaper and possibly more demanding to place ,correctly. You all have said it yourself , it is more difficult to restore. So again, as a preference, I'll stick to my personal protocol. Bob , please understand this is all in fun, in that we are all passionate enough to be spending time going back in forth, on these interesting issues, but there is literature that goes even further back on placing subperiosteals, but I don't know one surgeon or dentist that still places these. I have taken quite a few out, however and in the best scenario, it is quite a mess. Good day. Bv

You bring up an interesting point; the over engineering one. Not far from the daniel Laskin editorial , that I begged so Many to read. Bv

Sanjay , I am trying to be objective, but I have placed the mini's , and when I remove them, once we are done with them , they are never truely integrated. I have removed well over 50 , that were placed elsewhere . I have to assume these were placed, by the less learned. Bv

Dr. Horowitz: if you go back to Dr. Linkow's literature, you will note that he did not use short pins, nor did he use them singly. He used long pins in a tropical manner for a single restoration. That said, Dr. Linkow also stopped using the pins when something better came along. Yet Dr. Linkow said they work well, but tripodal! I will be glad to verify with Dr. Linkow! One needs sufficient an ideal metal to bone contact (millimeters squared).

Baker- Ii will tell you that I've had mini's fracture on removal. They do integrate as we've shown histologically out of NYU. My biggest issue is one that you brought up and I mentioned before. NDI's (minis, whatever you want to call them) are one more way that implant companies have, in the past, tried to get less learned and less experienced dentists to join in the implant band wagon. The key was, is and should always be diagnosis. With that, we can fully educate ourselves as to the patient's current situation and educate them as to their best, long-term alternatives for therapy. Richard - i have had the pleasure to work with Dr. Linkow and I agree with your statements. My point was that he started with anything that he could find to place in an edentulous area. The macro/micro/nano surfaces of narrow diameter implants have improved as has the prosthetic retention. Fun - yes. When we stop having fun with all of this it is time to hand up our gloves and go fishing, hunting, skiing, whatever else we should be doing in our time off. Bob

Bob, I to have a personal relationship with Dr. Linkow. We in implant dentistry owe him and other early pioneers a huge debt of gratitude! I have a 30% failure of minis. I do flap. I think the failures are dur to several reasons (not mine but overall): with a flap less procedure, you can get epithelial tissue in the osteotomy resulting in contamination of the implant bone interface; not enough bone/ metal interface; the thread shape and pitch is that of a machined thread which should be ok in D1 bone, but the diameter is too narrow; the minis need at least one millimeter of cortical bone. I remember when Dr. Elis Levi lost a mini in Dr. Linkows sinus. The minis will have a place but the parameters forvwhen and how have to be reestablished. It is not the same as a wider root form. Just like blades are didderent than foot forms, disc are different than root forms and subs are different. There is more to this field than meets the eye. The standards for success are sometimes different from modality to modality. I appreciate your input.

Bob, if u can't find Daniel Laskin's editorial, I would like to send it to you. While we may have some differences in opinion, you "get it" and would love the short prophetic read . My office number can easily be googled . Have a good one. Bv

Richard, I respect your honesty, in this situation. I think your suggestions for etiology of failure are spot on, aside from the fact that probably most of these smaller implants are being placed by the inexperienced . I would guess the universal failure rate maybe 40 to 50%. These odds are not acceptable in any arena. I don't know what the answer is, but possibly educating the newbees, as to the simple fact that one day courses , as advertised by imtec are simply unrealistic. I'm tossing the white rag! Bv

Perhaps the best method for minis, would be to flap, place as directed and delay load by at least 4 months. We have to use common sense!

Richard - Though I am usually in favor of delayed/conventional loading, there is a huge body of literature on immediate "provisionalization" and "loading". This even includes a VA study on overdentures on 2 astra implants that were immediately "loaded". As we (you, Baker and myself) have all stated, the key is diagnosis and subsequent optimization of the receptor site. In this way, the surgeon can maximize the bone-to-implant contact and initial stabilization of the implant. These techniques are usually not taught in the "conventional" mini course. When I was giving courses for Intra-Lock on the subject, I started with a section on 2D and 3D diagnosis, surgical stents,... I and others that I know (Dr. Ziv Mazor for one) have also done the same with Dentatus (that sells Atlas). We can only hope that the other companies follow the educational nor just the sales routes. Bob

I fully agree with the waiting period, before loading any implant, unless I'm using the mini as the interim and it is the rare case. Because of the literature that bob is alluding to, I have shortened integration times on "perfect cases ". I even ask my ortho colleques to allow some time for " integration", on those. Bv

Thanks Bob, I was just rambling on. I agree with you. My issue is some manufacturers preach over use or some docs over use. I am presently reviewing a case where a patient lost all 4 minis within one month. This was a mandibular symphysis case w/rpd. I have a 30% failure rate with minis used as provisionals, either arch!

Dr Lee, You are correct, we ALL start as beginners! Dr Gupta, I will have to learn from you. We all can learn from each other. Just thing how neat it would be , to get together and swap ideas and techniques and show cases.

Which is why I keep saying that there should be case presentations of successes of minis and the failures as well and let the profession draw it's conclusions! I am not sold either way as yet for or against. I am just saying "please show us the mini cases, success and failure both" and we shall draw our conclusions.

Well said , sajay. I to, would like to see some ten year success stories with the mini. Also, in my little town, the first person I call, when I have an implant problem or question is a general dentist, not an omfs. The second guy, is a periodontist. Neither call themselves" implantologist", by the way. Please don't tell anyone! The last state omfs meeting, that I attended, I asked ten surgeons if they placed mini's and they all said, no. I'm afraid in Louisiana it wouldn't even be considered" the standard of care". Again , we are a little slow on newer equipment . Out of almost 400 dentist there are 4 in office scanners. Bv