Mono Implant Academy
Comparison of Mono Implants to Traditional Implants
Dental Implant Types
Unibody mono implants are a more recent alternative and are one piece from top to bottom. They have no screw connection and restore everything from a single crown to a full-arch prosthesis. Mono dental implants have several significant advantages over two-piece implants.
First, because there is no interface between the two components in the mono implant, no biofilm can be created at the neck, leading to periimplantitis. The polished neck design of mono implants is the most tissue-friendly version in implantology and creates virtually no peri-implantitis. Peri-implantitis around the interface of an implant to its abutment leads to chronic inflammation and residual bone loss.
A second significant advantage is its strength. Two-piece conventional implants have a hollowed-out design to accept screws to attach components. Mono implants are monolithically titanium through their core as one piece and are stronger even in narrower sizes than their two-piece counterparts.
Three, mono implants and specific designs can be bent and prepped to fit prosthetic designs so that you can place the implants at unique angles to avoid critical structures like the inferior alveolar nerve and bend or prep the abutments to fit your prosthetics. This unique surgical difference allows you to place more implants and more sites without bone grafting.
Fourth, two-piece implants have internal screw connections that can become loose over time and require additional maintenance, a problem negated by mono-one-piece implants.
Dental Implant Procedure
The next appointment is a consultation to go over the findings. This is where any med history complications are discussed, how those will be overcome if they are a candidate, what type of implant and how many implants will be placed, and what the prosthetic solution on the implants will be.
The next appointment is surgery day. Generally, local anesthesia is performed with mono implants because of their minimal invasiveness, making them easier to place and less traumatic to a patient than a simple extraction. Once local anesthesia has been achieved, a series of one to three progressive micro-osteotomies is performed with a surgical implant motor and surgical setup to create a site for the self-tapping, self-threading mono implants to be placed.
This micro-osteotomy is far more conservative and less invasive than a traditional two-piece osteotomy because of the design and style of how mono implants are placed. They are much closer in nature to a mini implant in the surgical procedure than a conventional implant. They osseocondense the bone and self-thread so that at times just a pinprick into the bone is created to give the sharp pointed tip a place to guide.
The surgeon then torques in the mono implant with a specific technique until a minimum of 35 NCM is achieved. If it's less than 35 NCM is achieved, there will be no immediate loading, or the decision will be made to splint the implant to adjacent teeth or to adjacent mono implants. If greater than 35 NCM is achieved, the surgeon has the option to immediately load the dental implant with a single or multi-prosthesis that day.
Antibiotics are prescribed, and very rarely are any analgesics prescribed after the procedure, along with post-op instructions to take care of the recently placed implant in the subsequent four-month period while osseointegration occurs.
Implant Materials - Discuss the materials used in dental implants, including ceramics, metals, and composites. Detail the pros and cons of each material and how these affect the implant's durability, biomechanics, and overall success rate.
There are two main types of implant materials on the market. One is a medical-grade titanium alloy, and the other is zirconia implants. Zirconia implants are newer to the market and have less short and long-term research related to them. Only a few manufacturers in the world are making zirconia implants. Zirconia implants provide the benefit of a polished neck, which is very tissue friendly and creates no peri-implantitis, much like titanium mono implants. They are also considered more esthetic because of the white abutment, which in the world of crown and bridge dentistry, is easier to mask than gray titanium. This gives them an advantage in the esthetic zone.
The main type of dental implant is medical-grade titanium with treated surfaces of varying types. In the bone contact interface, the majority of titanium implants have surface treatments that make them irregular and rough for osteoblast attachment and osseointegration with bone. Titanium has always been a very bio-friendly version of metal, which is why it is used in implants all over the body by osteopathic surgeons. Mono implants have a combination of surface-treated titanium in the bone interface for good osseointegration and a polished neck at the soft tissue zone, which is soft tissue friendly and creates virtually no peri-implantitis.
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Another example is if a patient is a smoker; again, this can be a risk factor for successful implantation because it decreases their ability to heal on a site. Suppose a patient has had IV bisphosphonates in the past. In that case, this can create a unique circumstance called IV bisphosphonate-induced necrosis of the jaw. Any trauma to the bone creates a scenario where bone can't be healed, and necrosis occurs due to decreased circulation. The risk is high, whether it's an extraction or a dental implant.
Another unique circumstance is if they have had head or neck radiation for cancer treatment. This creates a potential scenario called osteoradio necrosis of the jaw. Radiation treatment essentially fries the capillaries in your jawbone and creates a low blood flow that does not bring oxygen to trauma sites or allow healing. Because the bone can't heal from lack of blood supply and lack of oxygen, any trauma to the bone can result in poor healing and necrosis. The only treatment for this is several dozen hyperbaric oxygen chamber treatments in a hospital setting to pump oxygen into the bone, rapidly followed by the surgical procedure to help improve healing chances.
So, again, medical history is essential, even though this is a critical factor for a limited spectrum of patients that are candidates for implants.
Dental imaging is another vital factor for dental implantology. A CBCT has become a standard of care because it shows sagittal slices of a width of bone, where specific critical structures are, and dips in landmarks like the sinus or where the inferior alveolar nerve is or where the mental nerve comes out of the mandible. This keeps the surgeon out of trouble and gives you a 3D picture instead of a 2D picture of prospective bone sites.
There's always a one-week and a one-month follow-up, with each appointment having a radiograph to check the initial x-ray stabilization of the implant and ensure the implant is not failing. We do a mobility check, and we always keep a close eye on the occlusion and ensure it is very light in the occlusion at most during the four-month integration, especially with no interferences and excursions and any grinding movements.
Comparison with Other Tooth Replacement Options - Compare dental implants to other tooth replacement options such as dentures, bridges, and partials, considering factors such as cost, esthetics, function, and longevity.
Dental implants have become the standard of care for tooth replacement for several reasons. They are permanent and fixed, and you don't have to remove them in and out. This makes it more natural for patients and allows them to have better, stronger occlusal forces to eat more types of foods than using plastic teeth with plastic bases.
You also do not have to touch or prep the adjacent teeth as you do in a bridge. So it's less invasive because you are keeping the adjacent teeth out of the equation and adding potential complications to them.
Furthermore, partial dentures put pressure on adjacent teeth, which tend to increase periodontitis and bone loss and slowly wiggle them out over time. So you're not putting those adjacent forces with a dental implant.
Implant Restoration Techniques - Detail the techniques and materials used for implant restoration, including direct and indirect restoration options, such as custom abutments and overdentures.
For a single tooth, there are two main ways to restore implants. With conventional two-piece implants, screw-retained crowns have now become the standard of care when appropriate. This is where the abutment and crown are one piece of zirconia, a middle screw that screws into the implant, and a composite covering is placed over the access. This allows you to re-access the screw if it ever loosens because statistically, 28 to 32% of all screws loosen over ten years.
The other style with two-piece implants is to create a custom abutment that is screwed into the implant, and then a conventional crown is cemented over the custom abutment. The maxillary and mandibular anterior regions sometimes require this because of the palatal and lingual angles of the implants that are necessary to place in the bone. This angulation challenge prevents you from putting the screw-retained in the esthetic zone. The only negative is that if the screw ever loosens, you have to drill off the crown or drill through it to access the screw and generally ruin the crown in the process.
With mono dental implants, there is no option of doing screw retained. It is recreating titanium versions of crown preparations above the gums and doing conventional crown and bridgework on it. Every crown and bridge is cemented with temporary or permanent implant cement. Regarding full-arch prosthesis on conventional implants, the standard of care has generally been screw-retained full-arch prostheses such as All-on-4, where there are lingual access holes, and the prosthesis are screwed.
With full arch mono implants, the prosthesis is cement-retained, either with temporary cement or permanent cement. Temporary cement allows you to remove the prosthesis if needed, and permanent cement locks them for life.
Implant Surface Coatings
However, although osseointegration takes longer, generally up to six months, for smooth surfaces, the original implant design was to have a smooth polished implant surface. Several basal implant manufacturers worldwide have polished titanium implants in the alveolar bone area, and studies have found that they integrate just as well. More double-blind university-based studies are needed to be done comparing polished implants in alveolar bone versus surface-treated implants in the alveolar bone to see if there truly is a difference.
Computer-Assisted Implant Surgery - Explain the role of computer-assisted implant surgery and how it can improve the accuracy and predictability of the implant placement.
Computer software is used to develop implant treatment planning and help print 3-D guides with an overlay of INTRAORAL scans and CBCTs that has become fairly standardized as part of the treatment planning. Computer overlay programs allow you to virtually place the implant, size, and shape and manufacture the three-dimensionally into a CBCT image to the bone to visualize the implant and where you will put it before surgery day. This is a standard of care to ensure that your preselected implant is the right width, length, and shape to fit in the bone.
Your software also helps you analyze bone type and bone density. The imaging also allows you to print a guide that allows you to do guided implant surgery. Guided implant surgery does not work 100% of the time and has some caveats.
First: irrigation through the guided sleeves is difficult, which risks heating up the bone and killing it when doing the initial osteotomy.
Second, they take away the feel of the bone because mechanically, the feel is felt through the sleeves of the guides and not directly into the bone. It's hard to determine if you need to under-prep the bone even more than you first proposed to get good primary stability, and they are an added expense that increases the overhead of implant surgery.
Three, this author believes in the use of surgical guides that are computer-assisted in certain scenarios, but primarily only for the initial pilot hole to get the initial position and initial angle just right. From there, if any additional drills are used, this author recommends using free-hand drills after the initial pilot drills using a guide.
Immediate Loading Implants
Over the four-month osseointegration period, you can slowly start increasing forces after month two to do what's called progressive loading and help osseointegrate the bone further, but not in the first 60 days because that's when the majority of osteoclasts and osteoblasts bone occurs. Patient satisfaction is greatly increased with immediate loading of implants because they have an esthetically looking tooth or a restoration or multiple restorations the day of implant surgery without having either nothing or partials or dentures or clear retainers.
Immediate loading implants also significantly decrease treatment time because you can place the implant on the day of an extraction. And if you get enough integration, put a crown on it and take what would normally be an 8 to 12-month process and reduce its time frame to four months total.
Complications and Risks - Detail the potential complications and risks associated with dental implants, including infections, implant mobility, bone resorption, and peri-implant mucositis.
The majority of studies show that in the posterior mandible, conventional two-piece implants have a success rate of 98% over ten years, and in the maxilla posterior, and 94 to 96% success rate over ten years. So even though the majority of implants are successful, there is the risk of failure.
Bone density is a large factor, but patient history and compliance are also prominent factors. If not enough primary stability is achieved at 35 NCM or more, and you attempt to immediately load the implant without splinting it, the micro-movements of the implant can create implant mobility and failure. The implant will have to be surgically removed and regrafted or re-implanted with a larger size to get more primary stability after a curettage procedure.
Bone resorption is a common complication around two-piece implants because of the biofilm interface at the abutment-implant connection. Platform switching has been an attempt to reduce this and successfully lowered the amount of bone resorption. However, bone resorption is still common, even with the platform switch design.
Peri-implantitis is one of the more common complications with implants. Again, conventional two-piece implants create a biofilm at the interface where the two pieces meet because it is never tighter than what a bacteria can migrate into. This creates chronic inflammation, and chronic inflammation of the tissues leads to eventual bone loss at the neck of the implant. Polished one-piece Necks of mono implants create an environment that is the most tissue friendly and creates virtually no peri-implantitis around the implant.
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Occasionally we find peri-implantitis around the implant, and the area has to be flapped open, debrided, grafted, sewn back up, and followed up with chlorhexidine rinses to allow the tissue to heal. At every hygiene appointment, radiographs and mobility tests are done around the implants to ensure osseointegration is maintained.
Implant-supported Overdentures - Discuss the pros and cons of implant-supported overdentures, including the costs, esthetics, and long-term wear characteristics.
Dentures are the least desirable option for tooth replacement because they are made of plastic and cannot sustain normal occlusal forces for chewing harder foods; they are mobile, so they always move on the soft tissue to some degree.
Adding dental implants to the bone in creating implant-supported overdentures is a significant upgrade to a denture. It creates a button-snap-on prosthesis that clicks into the implants and creates virtually no mobility in the soft tissue, and retains the prosthesis in the mouth. This allows patients to eat more foods because there's no movement, and they can achieve higher occlusal forces.
It also allows patients with loose dentures to have confidence that they will stay in their mouth during a conversation, during eating, and in public situations. They are a more cost-effective scenario than cemented full-arch implant retained prostheses and represent a good happy medium between loose dentures and the best solution, full-arch fixed restorations on implants
Upon initial insertion of an implant, while you may have achieved high primary stability above 35 NCM, in the first 30 days, that actually dips down in primary stability because of the osteoclasts bone-eating activity. It isn't until day 30-60 and beyond when the osteoblasts start laying down the additional new bone, that the curve comes back up to good high primary stability of the implant. That is why the first 60 days are so critical, especially with patient compliance and occlusal forces and achieving an initial high primary stability.
Once the four-month process has been achieved, the osteoblasts have laid down bone in all areas, and titanium oxide has been created at the surface to have a fusion of bone to titanium. After this four-month period, you can begin more normal occlusal forces as long as they're within the long axis of the implant.
Restorative Driven Implant Placement
Unfortunately, with modern two-piece implants, because they are larger and of different sizes and shapes, they can't compete with mono implants. We have to perform bone grafting procedures and sinus lifts, and unique angles with abutments that force us to adapt our patient's bodies to meet the needs of the implant.
Mono implants are put in basal bone, in cortical bone and have unique shapes and angles, all you to bend the necks and prep the necks. They allow you to do a wax-up of a patient's mouth to the Ideal occlusion and the ideal esthetics, place the implants in the unique angles and depths and adapt the neck and head above the gum tissue to precisely fit the predetermined outcome of what's best for the restoration. This is unique and easier achieved with mono implants than with conventional implants.
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