Short 7mm Megagen EZ Plus implants: comments on prognosis?

i don´t quite understand. there are 7mm implants inserted which are 7mm above the canal this is poor planning and poor execution. short implants are a compromise for limited bone not for plenty of bone in order to stay over half a centimeter above the canal. i suggest i may take some training patients deserve better than this sorry this is my sincere take on that post op xray

Relax, man! It's Ok! But like alupigus said: take some training.

once they are osseointigrated they will have very good prognosis there is nothing wrong with them except they should have been driven one mm apically .good job

This not poor planing! With the advent of new surface technology, we can use shorter implants. It appears that they are approximately 3.5mm above the canal. I think they will be successful.

I would have placed at least 10 mm implants possibly 11.5 length looks like there is about 5mm to the inferior alveolar canal. I can't really criticise the placement since I don't know why you stopped so short? Bleeding? Poor bone quality or patient discomfort? I like to place the shorter implants in the molar area at least 10 mm and the longer implants 11.5-12 in the premolar areas to simulate the natural tooth root length . Also I feel that if there is any future bone loss over the next 10 years I feel safer knowing that a longer implant is in place to compensate. Also I look at the patients natural root length and what I feel is the occlusal force that will be generated a football player vs a little old lady. However these implants should be fine please don't splint them that can lead to a hygiene problem. What will always save you is a balanced occlusion. Take a good course perhaps with a guided or depth control emphasis. You really can't be held to the standard of an experienced surgeon who is comfortable with the inferior alveolar nerve and it is great that you posted this to evaluate your work,it shows you care. This was not a case for a short implant placement but you got decent width which will save you. Continuous improvement is the goal as you build confidence and experience!

Thank you everyone for your feedback. I could have placed 1-2 mm deeper, but since I'm relatively inexperienced, with every mm closer to the alveolar nerve, my blood pressure skyrockets. The comprehensive implant continuum course I attended recommends 4mm away from IAN since there's the goal is 2mm away from nerve plus 2mm margin of error. Now the new question is : To splint or not to splint these implants. If you splint - you will distribute the force better. If you don't splint, oral hygiene might be better. How about splint them, try to keep the crown margins supragingival (or use screw retained) and keep the interproximal embrasures large so patient can use superfloss or interdentla brush.

The main problem of this case is the absence of a prosthetically driven general treatment plan. I would begin with “mouth cleansing” and making partials to establish correct occlusion and cosmetic parameters. You may not splint the implants because there are no naturally powerful antagonists.

Dr OP You may want to consider buying some 5mm ball bearings and using them as a radio graphic guide. I also suggest using drill stoppers. I use the ones from AB dental. They are great. Also lookup the Y factor. Read this and understand this. These little tidbits will keep you out of some trouble. Also obtain some of Dr Linkow's text. He does a marvelous job explaining the anatomy of the inferior alveolar nerve. Hom Lay Wang and two docs did a great job on a literature review on IAN injuries. Some of the references are off, but all in all a great paper. I hope this helps. We all started as beginners. I would rather see you a little timid, that be a wild man.

There is plenty of bone for longer implants.

i ask myself questions... in prosthetics one learns about horizontal cantilever(s). laws of physics works only horizontally? there is nothing such as vertical cantilevers? like lateral excursions on short implants? major advantage of not splintig SHORT (!!!) implants for hygiene where patient obviously doesn´t give a shoe for hygiene BUT put´s your shorties at risk??? i can´t believe what i read here. man, stop doing implants, get TRAINED!!!!!!!! all this empiric guessing gives our profession and especially the field of implant dentistry a bad name. STOP IT!!!!!

Good orientation , good spacing , respectable implant , short implants now clinically acceptable , mandibular bone . Seems fine to me . Obviously there are debating points about short but the work is fine.

Consider using drill stops if you get nervous near IAN. Don't they teach these at beginner courses? With a drill stop there is no risk of slipping or drilling to deep and harming your patient. Look into it. It's a tool every beginner should have. I've placed thousands, and I still use them sometimes.

I thank everyone again for your posts. Those of you kept telling me to get trained - I attended a comprehensive 1 year NYU course with hands-on practice on cadaver 3 years ago. I have since kept up with the literature regularly. Although I am still a bit inexperienced compare with most of you, I am not doing surgeries blindly. So far, 80 successful placements with 2 failures (1 with flap came open, 1 with potential residual infection on immediate placement); Now I do all my implants 2 stage and avoid immediate placements (until I got more experience anyway). For this particular case, this patient have a short mandible. I do use drill stops and am fully aware of position of IAN nerve to my implant drill. I am aware that I am about 3mm-4mm away from the nerve if I place a 7mm implant. The next implant length in the megagen ezplus series are 8.5mm....which means I would have to be 1.5-2.5mm away from the nerve. Little beyond my comfort zone, especially I heard cases involving paresthesias due to nerve damage or temporary paresthesia due to nerve compression. However, I decided to tackle this case planning to place 7mm implants it has shown in the literature that short implants have been successful. But I still wanted to get some feedback what other doctors feel about my case execution.

Well said Op. I would add that you could have then placed more subcrestal if these megagen implants are meant to be placed that way. I would take a mid place paxray if you are concerned that you're getting close to t I'd nerve. If on the mid place paxray you're fine then you can continue to place deeper.

OP, good you are on the right track , ignore unhelpful comments they will grow up one day to find out they do not really know as we all do. With increasing medico-legal it is now suggested in the UK that less than 4 mm is legally indefensible . Yes I know we all work1 mm to the nerve and lateralise if needed but the world is changing legally , and your use of newer Implant types and caution is to be applauded. Pilot rads and stops are helpful as said As to splinting the issue of co-axial forces can come into play , best to restore individually in my opinion ( yes I know what CM says in his book ). But the only issue is what about the rest of the mouth , this patient has a "train crash "of an oral situation which needs an overall assessment for occlucal balance. Peter

OP don't take it so hard. I still get anxious around the nerve. Imwouldmrather see you a bit cautious than not!

I am intrigued with the shorter implant systems and I will check them out. We RA all trying to predict the future here, it is always amazing to me that implants work. I do agree with balancing the occlusion. Remember what you do best, the occlusal principles that were taught in dental school. I check with my prosthodontic specialist for backup. Assemble a good local team and leav no stone unturned, we all learn from each other. I think the hard part is with new technology avoiding the sales pitches and weighing evidence and experience. I have to be honest, I would have placed longer since the bone was there. The clinical situation needs to drive the treatment vs using a technology to compensate. I have found that the general dds places implants since the have been burned with poor placement with specialists I hope it is not for the money. I think it is best to practice with what works well in your hands. I live in my team approach world and learn from all. As an OMS I see the pitfalls of attempting surgeries that are beyond ones reach being taught by implantologists, however a tremendous amount if early research was done by generalist implantologists and periodontists NOT oral surgeons. I am grateful for their hard pioneering work which makes me able to place implants in my backyard, the bone I understand from trauma,exodotia and orthognatics. I hope I can give back and share my expertise Thanks doctors!

OPS, great job. There are plenty of long term short implant papers available. A well designed short implant can have the same effective bone to implant surface support as a much longer traditional cylinder implant. Wolf's law is better engaged with a shorter rounder implant, one which is not limited by splinting. The short, round implants, like the Bicon 6.0 x 5.7, transfer lateral forces down and around the bottom and back up the other side, with little or no dead load surface area. You dont need to drill deep just because bone is there. Yes, in many threaded cylindrical designs, they last longer if longer, but short implant research has shown you can design around the need for overly long implants. After using short implants, I wonder how one can just lean back on the old mantra that 11-18 mm implants are the norm, the standard. If 6 mm can do the job, is it prudent to drill twice tht deep? John

I am astonished that most of the comments were debating available bone height, yet only one comment referred to using a ball bearing marker to determine height on a panex, and NO-ONE suggested a cone beam scan to ACCURATELY measure available bone height. Why all this talk about fear of breaching the IAN because you are unsure of its position? Do a scan and know where you are going. This should be the standard of TxPx Personally I like length and allow a minimum 2mm clearance. I also like to splint for mutual strength and support (a la CM)

Further to my previous comment, pas rarely show the nerve (remember it may NOT be in a canal) with any accuracy. Pas during surgery are a useful adjunct to a pre-op cone beam scan as you have markers of known length to compare with but really are not necessary. The accuracy of cone beams is approx 0.1mm (several papers have recently been published - sorry I don't have the references to hand).

I really would like to hear some more comments about the results of the clinical examination of the jaws and the teeth. Because there is a lack of information about the occlusion and the contacts of the teeth and also the measure of the intercrestal distance between the jaws. X-ray just gave me an estimation about this distance that it was a bit far to use short implants. Crown/root ratio must be verycarefully considered before making the decision and the operation plan. I did not write this for judgement but only to add another perspective to the case. There is more mm.'s to the nerve; I think that longer implants should have been chosen. Sincerely, Dr. Sarac.

i just have a question to the poster of this case....is the patient planned for a proper full mouth rehab? unless yes, i think the discussion on the length and position of implants is only academic. as i also not in the pre-op OPG, the second molar is tilted that wil need correction as also the missing antagonists ?

What I find most interesting is that there is very little discussion re. the WHOLE treatment plan. What is it? You can't properly answer the question about whether the implants are adequete until you know what the implants are going to be chewing against. That being said, although Misch sites a greater success with implants 10 mm or longer, these appear to be nicely placed and will probably do well. Regarding splinting, again I feel that can't be answered until we know more about the patient and his/her treatment plant. Remember these implants are not just for a jaw but a WHOLE PERSON.

Dr.. O.P. Much advice and useful criticism has been given, but at this stage, the important thing is to know how to proceed to restore these implants. If you have enough bone remaining on the bucal and lingual, they should be just fine. The #29 implant seems to be the one closest to the line of oclusal forces, so use it as the insertion plane and make custom abutments on #28 and #30.. Use an open tray impression with the transfers splinted prior to taking the impression. Splint by all means, at least #29 and 30. Ensure adequate emergence profiles permit effective interproximal cleaning. If worried about future problems or if prosthetic space is insufficient, then use screw retention. If the prosthetic space is sufficient and you have a good passive fit, then cement the 3 unit bridge and make sure that there is no cement left in critical areas. For the future, start with a good training course, study the literature on currently accepted techniques and use for instance a transparent computer generated replica of the mandible, showing the path of the Inferior Alveolar Canal for planing and a simulated surgery. From which you can make an excellent surgical guide. This will cost a bit. but give you more confidence before surgery. If worried about going too deep, invest in a set of Verbain drill stops and relieve your stress a bit.. Finally, anyone who does implants, has some cases they would rather no one else see and if they deny this, they are probably lying. Welcome to the learning curve.

I routinely use 8 mm in the molar area and also count 2 mm extra depth margin as a wide implant in a sharp crest will be seated deeper. Also less risk for perforating the lingual 'balcony' (mylohyoid line). Keep calm and carry on.

Good job, Bad plan what is your plan for prosthetic work,you will face a problem with crown over last implant:46 Why did you planned for 3 implants and not 2 Like mentionned by many colleagues why you didnt ask for CBCT,if ur not sure of the lenght. Why you didnt take P.A during or after surgery.easily you could find that u can put 3 or 2 longer implants,8.5is standard. What is ur plan for the antagonist & for the oter side.

The use of short implants is over criticized. Most studies show that it is the first 4 mm of an implant that carries most of the load. It is best to choose a design know for maintaining crestal bone. The following are a few articles showing success rates of short implants. J Periodontol. 2010 Sep;81(9):1242-9. Evaluation of single-tooth implants in the second molar region: a 5-year life-table analysis of a retrospective study. Success rate of 2348 Short Endosseous Implants: 6 Month Post LoadingElian N, Tabourian G, Cho S-C, Sanchez R, Froum S, Tarnow DP. Ashman Department of Implant Dentistry, New York University College of Dentistry Clin Oral Implants Res. 2004 Apr;15(2):150-7.A 7-year life table analysis from a prospective study on ITI implants with special emphasis on the use of short implants. Results from a private practice. Nedir R, Bischof M, Briaux JM, Beyer S, Szmukler-Moncler S, Bernard JP. Volume 78, Issue 2, Pages 166-171 (August 1997) 9 of 21 Hiroshima University School of Dentistry Hiroshima, Japan PII: S0022-3913(97)70121-5 © 1997 Editorial Council of The Journal of Prosthetic Dentistry. Published by Elsevier Inc All rights reserved. Clinical application of short hydroxylapatite-coated dental implants to the posterior mandible: A five-year survival study Eduardo Rolim Teixeira, DDSa, Masayoshi Wadamoto, DDS, PhDb, Yasumasa Akagawa, DDS, PhDc, Tomohide Kimoto, DDSd Clin Oral Implants Res. 2006 Apr;17(2):194-205. Dental implants placement in conjunction with osteotome sinus floor elevation: a 12-year life-table analysis from a prospective study on 588 ITI implants. Ferrigno N, Laureti M, Fanali S. Postgraduate Course in Clinical Implantology and Biomaterials, School of Dental Medicine, University of Chieti, G. D'Annunzio, Chieti, Italy. Erratum in: Clin Oral Implants Res. 2006 Aug;17(4):479. Long term bone level stability on Short Implants: A radiographic follow up study Caterina Venuleo1, Sung-Kiang Chuang3, Meghan Weed4, Serge Dibart2 Clin Oral Implants Res. 2006 Oct;17 Suppl 2:35-51. Impact of implant length and diameter on survival rates. Renouard F, Nisand D. Zhonghua Kou Qiang Yi Xue Za Zhi. 2010 Dec;45(12):712-716. [A long-term retrospective clinical study of short dental implant restoration.] J Oral Maxillofac Surg. 2009 Apr;67(4):713-7. Outcomes of placing short dental implants in the posterior mandible: a retrospective study of 124 cases. Grant BT, Pancko FX, Kraut RA. Journal of Oral and Maxillofacial Surgery Volume 67, Issue 4 , Pages 713-717, April 2009 Outcomes of Placing Short Dental Implants in the Posterior Mandible: A Retrospective Study of 124 Cases Implant Dent. 2005 Sep;14(3):274-80. Performance of short implants in partial restorations: 3-year follow-up of Osseotite implants. Goené R, Bianchesi C, Hüerzeler M, Del Lupo R, Testori T, Davarpanah M, Jalbout Z. THE CHALLENGE OF IMPLANT THERAPY IN THE POSTERIOR MAXILLA: PROVIDING A RATIONALE FOR THE USE OF SHORT IMPLANTS Marianne Morand, DMD; Tassos Irinakis, DDS, MSc, FRCD(C) Survival of Short Implants (≤10mm) in the Posterior Jaws of Partially Edentulous PatientsAn Evidence Based Review Jessica Aiello, BHSc; Kate McMillan, BBa, MBA, CA; Daniel Fingrut, BSc, MSc; Jinhyung Park, BSc, MSc; Vladimir Jokic, BSc.‡ Authors: A Bivio, D Mosca, M Scanferla, M Ghisolfi The use of short dental implants in clinical practice: literature review Journal: Minerva stomatologica J Prosthet Dent. 2004 Aug;92(2):139-44. The use of short, wide implants in posterior areas with reduced bone height: a retrospective investigation. Griffin TJ, Cheung WS. TREATING THE ATROPHIC POSTERIOR MAXILLA BY COMBINING SHORT IMPLANTS WITH MINIMALLY INVASIVE OSTEOTOME PROCEDURES, MIcheal Toffler, DDS Michael Toffler, DDS* Treatment of Patient With Papillon-Lefevre Syndrome With Short Dental Implants: A Case Report Etöz, Osman A. DDS, PhD*; Ulu, Murat DDS†; Kesim, Bülent DDS, PhD‡ J Oral Maxillofac Surg. 2000 Apr;58(4):382-7; discussion 387-8. Use of short endosseous implants and an overdenture in the extremely resorbed mandible: a five-year retrospective study. Stellingsma C, Meijer HJ, Raghoebar GM.

If you are not sure about the situation and feel that these implants will not be able to take a load - go for a transistional loading approach- you will get an idea of how the bone reacts and patterns itself to the load.

Do what i did !! buy a cbct and we wouln't be having this discussion .. yes it's cost effective because you can use it for all your rct and difficult exts..

I can't understand those critisising lenght of the implants used. Some of the doctors show off that they place 11-13 mm in the mandible. If I was a patient I would definitely prefer cautious dentist erring on the site of safety. Those implants will be totally fine.

There are numerous papers and research presentations on Bicon.com also. Relating on the current position that longer is always better, imagine what your patient would think if you told him/her that, even though you could place a workable filling by cutting only 2 mm deep, you are doing to drill twice that deep so as to get as close to the nerve as possible... These patients may live for many decades, get involved in trauma or perio problems, etc.. Is it so bad to leave enough bone beneath your implants to allow their replacement some day?

Would any of you Doctors have bicon implants in your mouth ?? Be honest with yourself

RsDDS, ' amazed at that comment. Of course, I'd prefer a screw less, shorter implant. Do you have research demonstrating any more problems with Bicon designs than other? Some of the brands touting superiority are under class action suits ... Why would you want one of those in your mouth? Lets try to stick with facts over aspersions, please. John

Rsdds, It took me some time to accept Stryker now Bicon. I would have no objections having a Bicon in my mouth but only in the posterior. I would not have one (singly) in the anterior. I have had only one failure with a Bicon. That was recently, in a patient with Lyme Disease. All in all, they are a work horse in the posterior. SB OMS gave great advice as per the drill stoppers. I use them routinely in the posterior mandible. I measure several times (5mm ball bearings) and cut once. Factor in a zone of safety. As for the comment about comfort level, my treatment plans are influenced by my comfort level. I feel more comfortable doing a sub or blade vs an extensive and questionable graft procedure. Some ou you may not. It what the doctor believes to be best for the patient.

If an anterior Bicon implant with 2.0 or 3.0 Morse taper well is subject to strong rotational forces via a very wide crown or high angled abutment, they can be rotated loose, dislodging the crown. A few years back they added 2.5 wells for anteriors and bis which have a more parallel taper and are not knocked loose in normal restorative and use situations. As always, the wise surgeon has a variety of choices available in order to best serve the patients' needs. John

If I had to have lower implant placed short system like bicon would be my choice. I would be happiest to have a treating dentist using these implants rather than someone wanting to demonstrate on forum like this that they are comfortable with placing implants 1mm short of IAN. Not in my jaw thanks

The advantage of the Bicon is that surface (BIC) area of a shorter implant is the same or greater than a longer implant. The plateau design lends to this and to stability in the bone. Quantum is a similar type as per surface area design. It has a more utilitarian prosthetic approach. I have not had any prosthetic issues with Bicon in the posterior. It's my go to implant for decreased bone height cases and for bruxers. The proof is in the pudding. Bicon has been around for 25 to 30 years. As I stated previously, I have only had one failure with a Bicon over a 19 year period of use. There was a 10 year period when all I used was Bicon with bone expansion techniques and very little use of rotary instruments. These are all great cases. In an ideal world, as far as root forms go, I would use Bicon in the posterior and an internal hex in the anterior. I also understand that an OMS or periodontist has to go along with their referral base, and gently reeducate them. In my area (Northern Virginia) there is a strong 3i presence.

Short implants is a a great choice for vertical atrophic maxillas and mandibles with specific indications and training. For the presented case I believe that can work very well with conical abutments (gum level)and a screw retained prostheses all three splinted. Oral hygiene is perfect if prostheses has a goog design. I give some of the literature to prove you that short implants for the experienced surgeon is a choice standing up in the Pyramide of ' Evidence Base' Rehabilitation of postrior atrophic edentulous jaws: prostheses supported by 5 mm short implants or by longer implants in augmented bone? One-year results from a pilot randomised clinical trial Esposito,Marco , Pellegrino Gerardo ,Pistilli Roberto,Felice Pietro Eur J Oral Implantol 4 (2011) Survival of Short Dental Implants for Treatment of Posterior Partial Edentulism: A Systematic Review Atieh M., Zadeh H.,Stanford C.,Cooper L. INT J ORAL MAXILLOFAC IMPLANTS 2012;27:1323-1331 Five-Year Clinical Evaluation of Short Dental Implants Placed in Posterior Areas: A Retrospective Study. Eduardo Anitua, Gorga Orive, Jose Javier Aguirre, and Isabel Andia. J Peridontol 2008;79:42-48 Rehabilitation of postrior atrophic edentulous jaws: prostheses supported by 5 mm short implants or by longer implants in augmented bone? One-year results from a pilot randomised clinical trial. Marco Esposito, Gerardo Pellegrino, Roberto Pistilli, Pietro Felice .Eur J Oral Implantol. 2011 ;4 (1):21-30 Posterior atrophic jaws rehabilitated with prostheses supported by 6 mm-long, 4 mm-wide implants or by longer implants in augmented bone. Preliminary results from a pilot randomised controlled trial. Marco Esposito, Gioacchino Cannizzaro, Elisa Soardi, Roberto Pistilli, Maurizio Piattelli, Valeria Corvino, Pietro Felice. Eur J Oral Implantol. 2012 ;5 (1):19-33  Vertical augmentation with interpositional blocks of anorganic bovine bone vs. 7-mm-long implants in posterior mandibles: 1-year results of a randomized clinical trial. Pietro Felice, Gerardo Pellegrino, Luigi Checchi, Roberto Pistilli, Marco Esposito. Clin Oral Implants Res. 2010 Dec ;21 (12):1394-403  Rehabilitation of the Atrophic Posterior Maxilla Using Short Implants or Sinus Augmentation with Simultaneous Standard-Length Implant Placement: A 3-Year Randomized Clinical Trial. Francesco Pieri, Nicolò Nicoli Aldini, Milena Fini, Claudio Marchetti, Giuseppe Corinaldesi Clin Implant Dent Relat Res. 2012 Mar 15;:

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