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There have been recent reports of successful use of fragmented autogenous dentin being used as a graft material in implant dentistry. This may reduce morbidity and the need for a second donor site or for the use of alloplasts or allografts. This article discusses the background, preparation, and use of autogenous dentin as an oral osseous graft material. A series of cases where autogenous dentin is used to graft immediate dental implant sites is presented. After 21 months, one case biopsy showed only bone and no remnant dentin. Pulverized autogenous dentin may be an appropriate graft material in implant dentistry.

Mini dental implants can be used to support crowns and partial and complete dentures in compromised edentulous sites. Lack of bone width or site length may be treated with mini implants. Mini implants have less percutaneous exposure and displacement that may reduce complications. Nonetheless, mini implants transmit about twice the load to the supporting bone, and thus, control of occlusal loading is important. In fixed prosthetics, rounded flat cusps, splinting, implant protective occlusal schemes, and placement only in dense bone sites are features of successful mini implant treatment. With removable prosthetics, multiple mini implants may be needed for appropriate retention and load resistance. Maxillary lateral incisor and mandibular incisor sites may be best suited for mini implant treatment. However, past research on dental implants has been directed at standard sized implants. While mini implants are indeed dental implants, they behave somewhat differently under functional load, and the clinician should be circumspect and very judicious in their use. This article is a mini review and not a systematic review. The topics covered are not pervasive because each would require a monograph or textbook for a complete discussion.

When planning an implant-supported restoration, the dentist is faced with surgical and prosthetic technical issues as well as the patient's expectations. Many patients wish an immediate solution to an edentulous condition. This may be especially true in the esthetic zone, and that zone is determined by the patient. The dentist may consider when it is feasible to load the supporting implants with definitive or provisional prosthetics. In this work, many parameters were theoretically assessed for inclusion: bone density, cortical thickness, insertion torque, parafunction, bite load capacity, number of implants under load, implant/crown ratio, implant diameter, and length. After assessment, the most influential parameters were selected. An iteration, using patient age, implant diameter, bite load capacity, and cortical thickness, is now presented to aid the implant dentist in determining the feasibility for immediate functional loading of a just-placed dental implant in a healed site. Extensive testing is required to develop this concept. According to this iteration, most immediate functional loaded implants would fail. A future refined and definitive formula may enable the clinician to safely and immediately functionally load an implant with a definitive prosthesis. For access to the applet, please go to https://implantloading.shinyapps.io/shiny_app/.

Adequate bone remodeling may be a primary parameter for long-term successful complication-free dental implant treatment. A 1.8-mm osseous thickness around dental implants is thought to be the minimum thickness for adequate vasculature for osteocyte nutrition and function. A dental implant does not provide progenitor cells or angiogenic or osteogenic factors. Thus, the surrounding bone may need to have a 1.8-mm thickness to accommodate the vasculature necessary for nutrients for appropriate remodeling. Additionally, the 1.8-mm dimension may provide for mechanical load resistance. There is no evidence to illustrate the physiologic need for the 1.8-mm dimension. This dimension requirement is based on clinical outcome observations. Basic science research for bone survival around dental implants is needed.

Enterococcus faecalis appears in many tooth root infections and is not eliminated by root canal therapy. It can reside in tooth root canals and the surrounding bone. This species may vegetate in bone after extraction of an infected tooth and colonize a dental implant after placement in the healed site. A colonization may cause fixture loss or marginal bone loss. These colonizations are generally multibacterial and pathogenic properties can be shared via plasmids. However, E faecalis is not detectable with some culture techniques and thus can be missed. It is usually not a dominant species in these infections. Nonetheless, E faecalis may be a "keystone" player in dental implant bone loss or peri-implantitis. That is, E faecalis may be the pathogenic determinant for any particular peri-implantitis infection of a multiple-species infection.

After dental implants are manufactured there can be a loss of biological activity that may be reactivated by exposure to ultraviolet (UV) radiation, that is, photofunctionalization. The titanium surface is energy conditioned by UV radiation. This imparts a slight positive surface energy and hydrophilicity to the titanium dental implant surface. This conditioning renews biological activity lost after a shelf life of as little as 2 weeks. The UV radiation has chemical and biological effects on the osseous-implant interface. Photofunctionization for as little as 15 minutes accelerates healing and increases bone to implant contact. The most effective time exposure and UV wave length are in need of identification to produce a surface most conducive for osseointegration.

A hard or coarse diet may impart a substantial off-axial load to dental implant-supported prostheses and may induce a component, implant midbody fracture or late loss of integration. This may be especially true when there is a large crown to implant ratio. A patient who is able to generate an excessive bite force along with chronic cyclic loading with hard or coarse foods may have implant body or component fractures. There are no established parameters for crown to implant ratio or for detrimental bite loads. Implant longevity may be dependent on many factors, including the supporting bone quality and volume, crown to implant ratio, implant width and length, the prosthetic occlusal scheme and bite force/arch location, and the patient's dietary load.

Dental implants may fail to osseointegrate in sites of endodontic failure. This may occur as a result colonization by various anaerobic and facultative bacterial species. If an implant is placed in a site where vegetative bacteria are residing, the implant may fail to integrate if a bacterial colonization proceeds coronally. If the implant apical cortical bone is thin or if there is an apical fenestration, the colonization may proceed through the thin or nonexistent bone through the covering mucosa, relieving inflammatory pressure to create an apical (retrograde) peri-implantitis. Enterococcus faecalis may be the prime culprit in these types of implant failures. After thorough debridement, the implant may be immediately placed after extraction of an endodontically failed tooth, and the patient treated with an appropriate antibiotic. Alternatively waiting for postextraction healing and subsequent implant placement can be done. Nevertheless, either way may allow for the formation of bacterial vegetative forms or biofilms. The implant surface may be colonized when the surface is exposed to the bacteria. Thorough debridement is crucial. Nonetheless, organisms may persist. Randomized controlled trials are needed to elucidate this issue.

Atrophic or severely deficient edentulous single tooth dental implant sites require osseous augmentation before any dental implant surgery. This may be accomplished by several procedures, allowing for several months of healing in order to achieve osteogenesis. After the initial site preparation, an implant may be placed and then allowed to heal for 3-6 months before the prosthetics are placed. This entire procedure may take several months to a year to complete. With the technique described herein, these cases were treated with an allograft ring or cylinder of bone that allowed for immediate placement of an implant. The allograft augmentation and implant placement are done at the same appointment. This technique shortens treatment time and may be valuable in treatment of failed implant sites. Further study is needed to refine and improve this technique.

After provisional or definitive cementation of fixed implant-supported prostheses, spontaneous gingival proliferation may occur to fill the cervical embrasure areas of the prosthesis. Adequate oral hygiene, osseous spacing between the supporting implants and attached or immovable soft tissue may be the conditions that allow this phenomenon. This proliferation embrasure fill eliminates interproximal gingival voids, that is, black triangles, and makes the outcome more esthetically acceptable. Since interproximal prosthetic deign and implant positioning may be the primary factors for the fill, the gingival fill may be, in fact, an epulis.

Small-diameter, or mini, dental implants have been successfully used to support removable and fixed oral prostheses. These implants impart about twice the per-square-millimeter force on the supporting bone and this should be addressed during treatment planning. In the posterior jaws, bite forces are of a higher magnitude than in the anterior jaws and may induce an overload of the supporting bone and failure of the osseointegration. Thus there should not be occlusal contact in functional excursions that induce off axial loads. The cases presented herein demonstrate that mini dental implants may be used successfully to support fixed partial dentures in mandibular sites in highly selected patients. Attention should be given to the bone density of the site, very slow seating rotation of the implant with intermissions or cooling during insertion, observation of a 4-month healing time, flapless placement, treatment of any existing periodontitis, an insoluble cement, and exclusion of occlusal contact in functional excursions. Importantly, a narrow, rounded occlusal table should be used to minimize off axial loads and an insoluble luting cement should be used to prevent loosening of the crowns due to dissolution of the cement and an overload of the retained implant with any residual cement-retained in the retainer. The implant that supports the cement retained retainer will be subjected to leveraged rotation that may destroy the osseointegration and result in exfoliation of the implant.

A long-term dialysis patient with end-stage renal disease (ESRD) also referred to as chronic kidney disease (CKD) due to IgA nephropathy complicated by severe secondary hyperparathyroidism and renal osteodystrophy was successfully treated with dental implant-supported fixed prostheses. Phosphate binders, vitamin D, calcium cinacalcet calcimimetic therapy, and dialysis 3 times weekly had been instituted with standard divalent ion serum assessments. Successful control of the patient's secondary hyperparathyroidism was achieved. Long and wide diameter implants were used with an anterior guidance occlusion scheme to reduce the per-square-millimeter off-axial implant force delivered to the bone. Patients with ESRD and renal osteodystrophy may be successfully surgically and prosthetically treated with long wide dental implants supporting fixed full arch splinted dental prostheses with an appropriate occlusal scheme.

Frictional heat can be generated during seating of dental implants into a drill-prepared osteotomy. This in vitro study tested the heat generated by implant seating in dense bovine mandible ramus. A thermocouple was placed approximately 0.5 mm from the rim of the osteotomy during seating of each dental implant. Four diameters of implants were tested. The average temperature increases were 0.075°C for the 5.7-mm-diameter implant, 0.97°C for the 4.7-mm-diameter implant, 1.4°C for the 3.7-mm-diameter implant, and 8.6°C for the 2.5-mm-diameter implant. The results showed that heat was indeed generated and a small temperature rise occurred, apparently by the friction of the implant surface against the fresh-cut bone surface. Bone is a poor thermal conductor. The titanium of the implant and the steel of the handpiece are much better heat conductors. Titanium may be 70 times more heat conductive than bone. The larger diameter and displacement implant may act as a heat sink to draw away any heat produced from the friction of seating the implant at the bone-implant interface. The peak temperature duration was momentary, and not measured, but this was approximately less than 1 second. Except for the 2.5-mm-diameter implants, the temperature rises and durations were found to be below those previously deemed to be detrimental, so no clinically significant osseous damage would be expected during dental implant fixture seating of standard and large-diameter-sized implants. A 2.5-mm implant may generate detrimental heat during seating in nonvital bone, but this may be clinically insignificant in vital bone. The surface area and thermal conductivity are important factors in removing generated heat transfer at the bone-implant interface. The F value as determined by analysis of variance was 69.22, and the P value was less than .0001, demonstrating significant differences between the groups considered as a whole.

Endosseous dental implants may require bone augmentation before implant placement. Herein is described an approach to edentulous ridge expansion with the use of piezosurgery and immediate placement of implants. This may allow for a shortened treatment time and the elimination of donor-site morbidity. Two cases are reported. This technique uses a piezoelectric device to cut the crestal and proximal facial cortices. Space is then created with motorized osteotomes to widen the split ridge. This technique allows for expansion of narrow, anatomically limiting, atrophic ridges, creating space for immediate implant placement. The facial and lingual cortices provide support with vital osteocytes for osteogenesis. The 2 patients presented had adequate bone height for implant placement but narrow edentulous ridges. In patient 1 at site #11, the ridge crest was 3.12 mm thick and was expanded to accept a 4.3 mm × 13 mm implant. The resulting ridge width was 8.88 mm, which was verified using cone beam computerized tomography (CBCT). In patient 2 at site #8 and site #9, the narrow ridge was expanded using the same technique to accept 2 adjacent 3.5 mm × 14 mm implants. The implants were restored to a functional and esthetic outcome.

Bone atrophy occurs after tooth extraction in the posterior mandible, placing the mandibular canal and its neural, arterial, and venous contents closer to the osseous facial aspect and the coronal crest. This proximity places the structure in danger of damage when dental implants are surgically placed to support fixed or removable prostheses. Several options are available to treat these areas for implant-supported fixed and removable complete or partial dentures. Osseous grafting and ridge expansion are surgical options that enable acceptance of standard sized dental implants but have serious morbidities. Additionally, vertical osseous augmentation is not predictable at this time. Narrow diameter dental implants can be placed to avoid the mandibular canal, but some bone volume situations preclude this. Very wide and very short (6.5 × 5 mm) dental implants may be placed at an angle in atrophic sites to successfully support fixed partial dentures. An anterior guidance occlusal scheme may be used in maxillary dentate patients or group function in maxillary complete denture patients. A 100 micron occlusal relief in fixed partial dentures in dentate patients may be required to account for natural tooth intrusion and to prevent occlusal overload of the implant-supported partial denture.

Dental implant treatment can restore oral function to edentulous patients. Recently, mini implants have been shown to be successful in minimally invasive treatment. There are initial reports of mini implants retaining removable prostheses and supporting fixed partial and complete dentures. This article reviews the treatment of edentulous patients with prostheses and mini implants and offers guidelines for successful outcomes.

Psychological stress has been reported to be associated with periodontal bone loss; however, this association has not been studied for peri-implant bone loss. Psychological stress may be a factor in peri-implant bone loss. Alone, stress may not be significant, but in tandem with other factors, certain types of psychological stress may aggravate or accelerate peri-implant bone loss. This association needs to be studied further.

Dental implants can be displaced into the maxillary sinus. Retrieval by endoscopic or Caldwell-Luc techniques have been previously reported. A modified Caldwell-Luc technique is presented here, where a small round lateral osseous window is created. A plastic surgical aspirator tip is cut and modified to fit tightly into the access window. The sinus is filled with saline, and the patient is placed in a lateral recumbent position in the dental chair with the involved sinus on the underside. The saline acts as a vehicle to bring out the implant. The festooned aspirator is then introduced into the access window, and the errant implant can be successfully brought to the window for retrieval.

Dental implant treatment is successful; however, an implant can become infected during or after osseointegration. The two case reports presented here demonstrate, anecdotally, the effectiveness of endodontic calcium hydroxide paste for the surface treatment of infected, healing, or osseointegrated dental implants. Calcium hydroxide may be an appropriate surface detoxifying agent for local dental implant infections. A sequence of calcium hydroxide and 0.2% chlorhexidine gluconate surface treatment may provide a broad range of antimicrobial action for detoxifying recalcitrant infections. Calcium hydroxide should not be left in the surgical site.

This is a case report of dental prosthetic treatment of a 72-year-old patient with cleft palate with a persisting oral nasal communication in the anterior hard palate. The remaining teeth were extracted, and dental implants were surgically placed in the maxilla and mandible to retain removable overdentures. The maxillary complete overdenture had full palatal coverage as opposed to partial coverage. It was retained by 5 implants with low-profile light retentive retainers. The mandibular overdenture was retained with 4 implants of different diameters and brands. Apparent parameters for successful treatment of a removable maxillary overdenture are as follows: denture flanges, flat or lingualized occlusal scheme, light low-profile retainer retention, maximum implant positional spread with parallel placement, and a minimum of 4 rough-surfaced, long, wide implants placed in denser-type bone sites.

Dental implants have enabled a dramatic increase in the quality of life for many partially edentulous and edentulous patents. Immediate loading of newly placed dental implants is a recent advancement that attempts to meet patient demand. However, immediate loading of a just placed implant may induce implant failure to osseointegrate. Some patients can generate a biting force that can reach approximately 1300 Newtons (N) in the posterior jaws. The magnitude of bite force that would cause failure of osseointegration of newly placed implants is currently unknown. It has been proposed that osseointegration would fail if an implant is luxated in bone more than 50 to 150 microns. Fibrous tissue, not bone, would form. This study investigated the quantity of various off-axial forces required to move a nonosseointegrated 4.3 x 13 mm implant 50 microns. The previously published pilot study for this study found that the amount of horizontal force required to displace an implant 50 microns was approximately 150 N. This study found that the force needed to move the implants 100 microns at a horizontal approach, 0 degrees, averaged 50 N, with a range of 23-79 N; at 22 degrees, averaged 52 N, with a range of 27-70 N; and at 60 degrees averaged 87 N, with a range of 33-105 N.

Very small diameter (1.8-3.3 mm) dental implants may be successfully used to support fixed partial dentures in edentulous sites of compromised bone width or length. Very small implants can be successfully used in highly selected sites where there is adequate bone density and bone volume for immediate implant stability. Adequate or augmentable attached gingiva may be a requirement. A small diameter implant presents less of an obstacle for angiogenesis and there is less percutaneous exposure and bone displacement as compared with standard sized implants. In posterior sites, rounded and narrow prosthetic teeth present small occlusal tables to minimize axial and off-axial directed forces. Multiple splinted implants may be necessary to minimize metal fatigue from cyclic loading. Anterior restorations supported by mini implants may need occlusal relief to minimize the effects of cyclic loading.

The fatigue life of mini or small-diameter dental implants is of particular interest because these implants are used to retain and support fixed and removable dental prostheses. The fatigue life of an implant depends on both the implant itself as well as on the physical properties of the bone. However, the capability to predict the fatigue life of a newly placed implant is currently inexistent. This pilot study represents the first step in developing such a methodology and focuses on the design of a cost-effective device to measure the fatigue life of a dental implant. In our measurements, the implant has been mounted in an essentially rigid support, but test specimens can also be bone mounted in vitro. Furthermore, we developed a finite element-based computer model capable of predicting the corresponding fatigue life. The finite element analysis was performed in ABAQUS, and the results predicted by the model correlated fairly well with our initial experimental results. Most of the 2-mm diameter implants fractured after more than a million cycles.

This case report discusses the immediate placement of 3 mini dental implants into 3 fresh extraction sockets. The implants were used to support a splinted fixed partial denture. Immediately placing implants of a very small diameter into fresh extraction sockets to support a fixed partial denture is possible. Some implant sites cannot accept standard-sized implants because of length or width deficiencies. Very small diameter implants may be able to support fixed prostheses in these sites.

Immediate loading of newly placed dental implants is a consideration when attempting to meet patients' demands. However, immediate loading may induce implant failure to osseointegrate, particularly in the case of a patient who can generate a biting force that can reach approximately 1300 Newtons (N) in the posterior jaws. The range of biting forces that prevent osseointegration of newly placed implants is currently unknown. However, it is suspected that osseointegration may fail if an implant is luxated in bone more than 50 microm, in which case fibrous tissue will be formed instead of bone. This pilot study was focused on finding the amount of horizontal off-axial force required to move a nonosseointegrated 4.3 x 13-mm implant 50 microm. The initial data show that the amount of horizontal force required to displace such an implant by 50 microm was on the order of 150 N. Assuming that the angle between the direction of the biting force and the vertical lies between 0 degrees and 20 degrees, our data show that a 4.3 x 13-mm implant may fail to osseointegrate for biting forces that are as low as 440 N. One implication of our study is that implants having smaller diameters may move and fail to osseointegrate for even lower biting forces.

Flapless dental implant placement is possible in selected patients but limited to those sites with adequate or augmentable attached gingiva and available bone volume and density. Inadequate attached gingiva, available bone, and bone density may be augmented by pre-, intra-, or postoperative procedures. Bone ridge contour can be approximated by using a described fast set polyvinyl siloxane site evaluation technique. Assuming adequate length and height, a bone width of 5 mm is usually acceptable for standard diameter implants (3.5-4.2 mm). However, implant placement in sites with parabolic shaped ridges may need to be placed deeper to avoid vertical bone loss and implant thread exposure. Inadequate bone volume, less than 5 mm of bone width, may be developed by ridge expansion (split ridge) techniques. With ridge expansion, complications may arise such as malposition and labyrinthine concussion. Malposition may be corrected intraoperatively or grafted for a later implant placement. Labyrinthine concussion is usually of short duration but may be treated with head maneuvers. Sites with 2 mm or less width of available bone may not be treated flaplessly and may be more appropriately treated with extracortical augmentation grafting.

A case report is presented where an edentulous mandibular anterior site is restored with very small- or mini-diameter (1.8-mm) dental implants. The surgical and prosthetic use of very small-diameter dental implants is discussed. Such implants can be successfully used in appropriate sites where there is adequate bone density for immediate implant stability and an implant-protected occlusal scheme.

The construction of a complete restoration of the dentition by the surgical placement of endosseous titanium implants that support a fixed prosthesis in each jaw is possible. The positionings of the implants and teeth in the prostheses are important factors for a successful long-term result. Distribution of the occlusal biting forces over as many implants as possible is important. Off-axial occlusal biting forces should be diverted to the anterior jaws where the forces are not as great. The posterior teeth should be designed with flat occlusal surfaces that separate during excursionary mandibular chewing movements. Medial mandibular flexure caused by the contraction of the medial pterygoid muscle can be addressed by constructing the prosthesis in segments, so as not to have a rigid entity encased in flexing bone that may induce stress in the bone, potentially leading to loss of implant integration and failure. Segmenting also ensures an appropriate fit of the prosthesis with respect to casting and porcelain firing distortion. Lip support by means of a flange in the prosthesis may be necessary when there has been a large amount of bone loss from edentulous resorption. Cleaning and routine maintenance of the prostheses every 3-6 months is essential.

Triazolam can be helpful for sedating dental implant patients when administered orally or sublingually in low dosages of 0.125 or 0.25 mg, but not exceeding 0.5 mg. It is a fast- but short-acting benzodiazepine with few side effects, and it has a long record of successful use. Its effects can be reversed with incremental intravenous flumazenil, although there is a risk of seizure. Triazolam has not been shown to be carcinogenic, and it has a low potential for abuse and addiction. It is contraindicated in patients who are pregnant, breast-feeding, and those concomitantly taking ethanol, macrolid antibiotics, some protease inhibitors, psychotropic medications, ketoconazole, itraconazole, nefaxodone, or other medications that impair oxidative metabolism mediated by cytochrome P450 3A (CYP 3A). Triazolam should be used with caution in patients taking grapefruit juice, cyclosporine, and other drugs such as calcium channel blockers including nifedipine, verapamil, and diltiazem. The lowest effective dose should be used.

A case of a delayed-onset post-operative altered sensation of the mental nerve is reported with speculations as to etiology. There is a discussion concerning intraoperative radiographs and osteotomy positioning. When postoperative altered sensation occurs, etiologic considerations should always include local anesthetic administration technique. The importance of pulp testing from the first molar to the contralateral lateral incisor is key to determining whether the deficit is in the mandibular nerve or only the mental nerve, which may be a result of mental block local anesthetic administration and not implant placement. This differentiation may be important in treatment and/or legal exposure. The altered sensation was probably caused by the mental block anesthetic technique. The partial anesthetic area in this case was probably a result of crossover innervation from the contralateral mental nerve.

This article describes an osteotome designed for placement of dental implants in narrow sites with less dense bone.

There have been 3 US Supreme Court decisions in the last 8 years that have established new rules of admissibility of expert witness testimony. These will have great bearing on the practice of oral implantology now and in the future.

A surgical flap method that promotes reproduction of the interdental papilla for endosseous dental implant treatment is described. This incision design allows lifting of the gingiva without disrupting the periosteum and its blood supply.