Mini Dental Implants: Advantages and Techniques

In this exclusive interview, we are pleased to speak with Dr. Raymond Choi about MDI’s (mini dental implants). Dr.Choi is the founder of the Global Mini Implant Institute (GMI), an institute that provides dentists worldwide with advanced training to to help improve clinical mini implant success and avoid complications.

Dr. Choi is a 1987 graduate of University of Southern California (USC) School of Dentistry and has taught at the same institution for 10 years as an Assistant Clinical Professor in TMJ/Facial Pain Clinic. He is a general dentist in private practice in Tustin, CA where he focuses heavily on surgical and restorative implant dentistry. Dr. Choi is a credentialed member of American Academy of Implant Dentistry ( AAID ), a Fellow of International Congress of Oral Implantologists ( ICOI ), and a graduate of Misch Implant Institute. He completed his TMJ/Facial Pain Preceptorship at UCLA School of Dentistry and was Director of the Orofacial Pain Section of the Pasadena Rehabilitation Institute.

OsseoNews: Can you give us a brief overview of MDI’s (mini dental implants)?

Dr. Choi: MDI’s represent another stage in the development of implant dentistry. MDI’s are narrower than conventional dental implants and offer many unique advantages. For ridges that are too narrow for conventional implants, in many cases, will still be able to accommodate MDI’s. Many MDI’s can be placed using flapless surgical techniques that minimize trauma and the incidence of complications and lead to more rapid and uneventful healing. The restorative procedures are also much simpler for MDI’s. Also, MDI’s require far less armamentarium.

OsseoNews: Can you give an example of one of these leaps forward in technology and development?

Dr. Choi: One aspect that I particularly appreciate is that with MDI’s, in general, all you usually need is one drill to create an osteotomy for placement of the MDI. In the overwhelming majority of cases, all I need is just one drill, for preparing the ridge for implant placement. That greatly simplifies the procedure. I want to be very clear about this because this is one of the truly great advantages of MDI’s. For any dentist who has done implant placement, they understand what I am talking about.

OsseoNews: So one drill acts as the pilot drill as well as preparing the path for insertion of the implant?

Dr. Choi: That is correct. At most, you will need two drills. As I have said, most the time, you only need one. From an operational perspective, this means less chance of misadventure and you only need to line the drill up once.

OsseoNews: What drill speeds do you use for drilling the pilot hole?

Dr. Choi: The drill speeds I most often use for this ranges between 1200-1600 rpm.

OsseoNews: From a surgical perspective, is it far easier and far safer to place MDI’s in general?

Dr. Choi: The surgical protocol for MDI’s is enormously less invasive compared to that of conventional implants. It is by far easier and safer to place MDI’s especially for those clinicians who have no or minimal surgical training. But after you have place your first MDI, the rest is easy because it truly is so simple.

OsseoNews: How do you place the implants?

Dr. Choi: I prefer to place the MDI’s using manual hand instruments. I like to get a feel for the bone as I am torquing them down. Ability to feel the bone density through tactile sense is very important in making clinical decisions for mini implants. For the first part of the insertion I use a finger driver. Then I switch to a wing thumb driver. For the last part of the insertion, I use either a ratchet or calibrated torque wrench. This new torque wrench can provide us with objective measurements in determining the level of initial stability and preventing implant fracture.

OsseoNews: If you are a novice in placing implants, would you expect that placing MDI’s leads to far less complications than placing conventional implants?

Dr. Choi: Yes, yes and yes. In most cases, there is no reflection of flaps in mini implant insertion and only minimal bone preparation. This means that there are far less post-operative complications such as pain, bleeding, healing of the soft tissues, surgical bone trauma and injury of vital structures. MDI surgery is simple, fast and easy to learn – far easier than for conventional implants. I cannot stress this enough. This is the main reason why so many dentists do not place their own implants – too complicated, too many opportunities for error and just plain too technically demanding.

OsseoNews: If you do suffer a surgical misadventure, is it easier to manage because the MDI’s are narrower?

Dr. Choi: Yes. Because the MDI fixture is narrower, the extent of the problem is far less.

OsseoNews: When a conventional implant must be explanted, the trephination procedure generally creates a fairly large hole in the bone. Would explanting an MDI produce a significantly narrower hole?

Dr. Choi: Yes, it would. Due to its narrower diameter, the MDI would leave a considerably smaller defect in the bone. But let me also make clear that MDI’s rarely need to be explanted or trephined.

OsseoNews: How many MDI’s do you use in the maxillary arch to support a full arch fixed partial denture?
Dr. Choi: Typically I will use 10 to 12 MDI’s with cross-arch stabilization.

OsseoNews: Are MDI’s strong enough to support crowns and fixed partial dentures? Overdentures? Is there a greater chance that they will fracture?

Dr. Choi: Yes, MDIs are strong enough to support overdentures and most crowns and bridges. There are several studies that support the efficacy of MDI’s in these applications. Clinicians, however, need to understand the intricacies of small diameter implants in order to do proper case selections and execute the cases for long term success. Due to their smaller diameter, you might think that MDI’s theoretically have greater chance of fracture. But remember, MDI’s are solid fixtures, not hollow like conventional implant fixtures. Fractures can also be prevented by closely following the procedure protocols and managing the load and force on these restorations.

OsseoNews: What are some of the important diagnostic parameters of fixed applications of MDI’s?

Dr. Choi: There are many and may include bone density, position in the arch, crown height, splinting arrangements, expected force/load and opposing dentition.

OsseoNews: How do you treatment plan for replacing teeth in the posterior maxilla?

Dr. Choi: Clearly this is not a good area for mini implants. This is the most porous, least dense bone in the upper jaw. I would use conventional implants there.

OsseoNews: What about emergence profile in the aesthetic zone?

Dr. Choi: If you need to establish emergence profile in the esthetic zone, I would recommend using conventional implants and selecting diameters consistent with what you want to develop. With MDI’s, you are getting a crown in the shape of a pontic. In some cases, it can be very esthetic and easy to accomplish compared to achieving emergence profile with conventional implants.

OsseoNews: In terms of site selection, would you say that the mandible is basically an ideal site, in general, because of the increased bone density and minimal need for emergence profile?

Dr. Choi: Yes, I would agree with that. However, clinicians can successfully perform MDIs in maxilla through controlling the load by managing the occlusion and employing the concept of splinting. Dentists have successfully used ridge lap pontics for fixed bridges for years. Done properly, these restorations which in some ways mimic pontics can look pretty nice!

OsseoNews: Are the start-up costs for MDI’s significantly less than for conventional implants?

Dr. Choi: It would not be unusual for a dentist to spend $12-15K to get started in conventional implants. For mini implants, it would probably cost only 1/3 of that.

OsseoNews: Are the costs for the individual MDI’s significantly less than for conventional implant fixtures? Do you pass this cost saving on to your patients?

Dr. Choi: Yes, the cost for the MDI is considerably less than that of conventional implants. Because of this, we as dentists can pass on that saving to our patients and make this wonderful service more affordable. Those patients who otherwise may never be able to afford conventional implant treatment can comfortably fit mini implant treatment into their budget. Someone has said the mini implants can greatly reduce “distributive injustice” which exists in the allocation of implant resources and effective procedures among a diverse edentulous population.

OsseoNews: Would you say that it is easier for the staff to maintain an inventory of MDI’s and its armamentarium than for conventional implants?

Dr. Choi: MDI system is so simple that any office staff can manage the inventory without having to learn and understand the procedures and names of so many parts and components.

OsseoNews: Do you feel that because of the simplicity of the procedure and low overhead that you are able to do more implant cases?

Dr. Choi: I have no doubt that is the case. Especially in these tough economic times, more patients can comfortably afford MDI treatments.

OsseoNews: Dr. Choi, tell our readers about the course you will be offering on mini implants in October?

Dr. Choi: I will be giving a 2-day, comprehensive hands-on participation course with multiple video surgeries on MDI’s on October 3rd-4th, at the Double Tree Guest Suites in Anaheim, California. This course is probably the most comprehensive of its kind. Many dentists experience lack of confidence even after taking an entry level course. Some have had some complications and lose confidence to continue. Others have had great success and want to take mini implants to the next level. This GMI course will meet the needs of all such dentists. This is a practical, clinically oriented course that will elevate the understanding of mini implants and thereby improve clinical success rate predictably and avoid complications.

Participants will learn about literally everything you need to know about mini implants. We will discuss the protocols for making an accurate diagnosis and treatment plan of any case and how to evaluate force and loading on implants to ensure long term success. We will discuss treatment planning in detail and the indications and contraindications for MDI’s. There are some cases where MDI’s are absolutely contraindicated and we will discuss how to recognize these cases. We will also discuss how to evaluate and manage situations where the patient presents with a thin, atrophic alveolar ridge. There will be a whole section on fixed application of mini implants reviewing different techniques currently available. We will also discuss potential complications from bruxism, and oral bishosphonates and how to prevent and manage these situations. Occlusion is of paramount importance in any implant treatments, especially with mini implants because of its smaller size. Long term success mini implants heavily depends on proper occlusion whether it is removable or fixed case. Occlusion for MDI’s will be discussed extensively. Participating doctors will also be able to learn and appreciate the subtle nuances of the clinical decision making process through videotaped mini implant surgeries.

In the participation phase, participants will place mini implants in sawdust mandibles under supervision and will evaluate placement for correct depth and angulation. And lastly, we will discuss the business aspects of MDI’s. Incorporating MDI’s into a general practice can be very profitable and also make implants more affordable to your patients. My article on MDI’s which was published in Practical Procedures and Aesthetic Dentistry in 2007 is available on the GMI website.

For details about the course and registration information, please go to www.miniimplanteducation.com

Interview conducted by
Gary J. Kaplowitz, DDS, MA, M Ed, ABGD
Editor-in-Chief, www.osseonews.com