AVULSED TOOTH TREATMENT OPTIONS

 Postdelivery Appointments 

Follow-up appointments have shown the patient to be thrilled with the treatment. She stated that it had made a huge change in her life and had given her much more confidence. After experiencing the level of stability made possible with the MDIs in the mandible, the patient is now considering a similar procedure for the maxilla. Despite the fact that stability in the maxilla was not an initial concern for the patient, she now feels that if it can be made better, she would like to pursue treatment to improve her confidence even more.

DISCUSSION 
This case demonstrates 2 variances from the standard protocol for MDI placement, in that a flap was performed and the implants were not immediately loaded. As a dentist who has been traditionally trained in implant placement, I personally prefer to create flaps in cases with atrophic mandibles. While not strictly required for MDI placement, a flap allows the clinician greater certainty of placement in the middle of the crest. In cases where more bone is available, a flapless procedure is quite straightforward. 
Because the patient in this case was relatively young, the decision was made to not immediately load the implants in order to allow the bone and soft tissue to mature more fully. This simply provides more assurance that the implant will survive in the long-term with a young patient in robust health. Immediate loading is often very suitable for older patients, due to the fact that their occlusal forces may not be as strong, and they are seeking an immediate quality of life improvement rather than an implant that will survive for 10 years or more. However, in this case it was determined to allow for a longer period of bone maturation prior to engaging the retentive feature of the overdenture. Fixation of the implant at placement is an essential requirement for success of the MDI system, as well as with conventional endosseous implants. 
It is critical that the clinician utilize an array of different clinical findings and technology to assist with long-term treatment decisions. Most recently, I have incorporated the usage of the Periotest (Medizintechnik Gulden). While not required in the MDI protocol, I am using it in addition to a torque wrench to establish another quantitative value prior to immediate load cases, as it provides additional information. It is also a test that can be performed throughout the life of the implant, which helps me follow implant specific integration over time. Most importantly, however, is that the implant after placement demonstrates zero mobility visually upon percussion.
In this case report, a moderate divergence of the left implants is exhibited in the final panoramic radiograph. This clinical result occurred despite parallel 1.1-mm drills placed in the osteotomies prior to implant placement. This clinical finding can occur due to several reasons, including the partial osteotomy protocol, self-tapping nature of the implant, quality of bone, and the clinician’s surgical decision making. The partial osteotomy surgical protocol combined with the self-tapping nature of the implant and soft bone can allow for minor variations in the implant path. It is essential for the novice or experienced clinician to guide the placement of the implant in the path desired for an ideal outcome. The presence of anatomical structures such as the mental foramen and a potential anterior loop of the inferior alveolar nerve may dictate implant placement. Therefore, it is very common to see a distal implant divergence, due to the clinician’s tendency to position the implant mesial to the neurovascular complex. Finally, divergence of implants is successfully managed by the versatility of the MDI system’s MH-1 o-ring housing design. This prosthetic attachment design allows for a firm retentive feature within a 30° implant divergence. The patient has been seen on a 4-month recall basis for the past 2 years, demonstrating excellent retention, minimal o-ring wear and excellent crestal bone levels. Most importantly, the patient feels that the implant-retained overdenture is a huge success.

CONCLUSION 
Many dentists have likely seen denture patients who have suffered great losses in their quality of life, and have been making do with temporary measures like adhesives and over-the-counter relines for far too long. MDIs give dentists an important tool to reach this pool of patients and provide them with an affordable and less invasive path to denture stabilization. As the patient in this case demonstrates, added stability can bring back the quality of life to a large population of patients.