Frailty and Mini Dental ImplantsINTRODUCTIONMany dental implant patients are older and can have atrophic edentulous, bimaxillary jaws. Along with edentulism many are aged and may be frail. Frailty is typically diagnosed (ICD10 Code: R54) when three of the following five criteria are met: low physical activity, weak grip strength, low energy, slow walking speed, and unintentional weight loss (1).There can be ancillary diagnoses. Sarcopenia (ICD10-M62.84) is a loss of skeletal muscle that is primarily associated with aged patients with comorbidities. Frailty and sarcopenia are closely related but frailty may include cognitive and social issues (1,2,3).The baby boomer generation is aging and with that many of these people will become frail. Many will also be partially or completely edentulous with atrophic jaws. This makes adequate retention and function of dental prostheses unlikely. A denture adhesive may not be adequate for good denture stability and function, especially in the mandible. Minimally invasive mini dental implants may provide adequate to excellent retention of a complete denture for better nutrition and quality of life.Mini implants used to retain an overdenture may provide adequate function for the frail patient. Because these patients are frail and can be bimaxillary atrophic, a minimally invasive treatment may be appropriate. Minimally invasive treatment can be instituted to minimize physiologic stress and costs.CASE REPORTA 77 YO male presented for treatment with a chief complaint of “I can’t eat with these dentures”. Visual and panoramic radiographic examinations revealed bimaxillary edentulism with atrophy and an unstable mandibular complete denture. This polypharmacy patient had been diagnosed as frail and was not able to physically tolerate an extensive surgical or prosthetic procedure. The fit and flat zero-degree occlusal scheme of the existing dentures was adequate. The lower denture was well-fitting, but the residual ridge was inadequate for appropriate retention. The maxillary complete denture did not have excellent retention on the atrophic ridge. The patients primary care physician was contacted, and the procedure was explained, and medical clearance was obtained. Treatment options and a definitive treatment plan were discussed with the patient, and informed consent obtained.After local facial and lingual infiltration with1.6cc articaine (Septocaine), four mini-implants (IntraLock 2.5X13mm) were surgically placed in the anterior mandible in type 1 bone density. Proprietary drills and instrumentation were used in accordance with the manufacturer’s instructions. The implants were immediately loaded with the retainers embedded by pick-up in the existing complete mandibular denture (Fig. 1,2). The attached tissue was adequate for the mini-implants and no soft tissue flap was raised. The lower denture immediately had much better retention that impaired much better function. The maxillary complete denture increased in retention due to the stability of the mandibular denture. The patient functioned uneventfully and followed for eight years upon his death. The improved oral function may have prolonged this patient’s life.THE DIAGNOSIS OF FRAILTYMany elderly patients are diagnosed as frail. This means that these people may be seriously harmed by an extensive oral surgery. A fatality may even occur. There are several sets of criteria for a diagnosis of frailty (1,2,3).Frailty may be defined as an aging-related syndrome of physiological deterioration (2,3). This causes the patient to be vulnerable to a variety of old age disorders and diseases. Symptoms present as weakness and fatigue, complex medical issues, and relative intolerance to medical interventions. There is no standard definition of the diagnosis of frailty. There are frailty screening tests for assessing health risk assessment and epidemiology.One single parameter for the diagnosis of frailty is the TUG test, the time measured for a patient to get up of a chair walk ten feet (3 m), turn around and then return to be seated again (4, 5,6). 10 seconds or less is “normal”. 14 seconds or greater indicates a high risk for falling.A set of other parameters are: unintentional weight loss of more than 10 lbs., weak hand grip strength, self-reported exhaustion, walking speed slower than 0.8m/second, and low physical activity (2). If a patient has none of these criteria, then there is no frailty. If 1 or 2 of these are met, then there is intermediate frailty. A diagnosis of frailty is met when 3 or more of these criteria are met (2).Another set of parameters are: self-reported fatigue, inability to climb one flight of stairs, inability to walk one city block, having more than 5 illnesses, and more than 5% unintentional weight loss (5,6). Again, if 1-2 criteria are met then there is intermediate frailty and if 3 or more are met then there is a diagnosis of frailty (5,6). Women with cirrhosis have a higher frailty rate than men with similar disease severity (7Lai, 8Sheikh). There are other criteria to be used to diagnose frailty but there is no agreed upon standard.DISCUSSIONFrailty is associated with African American heritage, low education, low income, poorer general health, and comorbid chronic conditions (2,3). The frailty phenotype is predictive for incidence of falls, decreasing mobility, disability, hospitalization, and death.Patients can be frail at any age depending on their physical condition as a result of age, disease or disability. Many of these patients cannot financially afford extensive treatment. Nonetheless, they are still in need of nutrition, and a decent quality of life for appearance and speech. Mini implants are generally relatively inexpensive and easy to place in appropriate sites (9).  The bone density is important. Type 1 and 2 densities are appropriate, but any less dense site may not provide adequate resistance for immediate occlusal loading (9). Load resistance immediately depends on the mechanical resistance in dense bone until osseointegration occurs (9). Mini implants for this purpose have a processed rough surface that is intended to osseointegrate (9).Osseous site dimensional requirements for mini-implants are similar to the requirements for standard sized dental implants except that the bone width can be much less. The decreased osseous width is associated with more dense bone (9,10).Atrophic bone in the maxilla may not be dense enough to resist occlusal loading. However, there can be very dense osseous islands that can provide appropriate implant support. Thus, it is incumbent on the clinician to evaluate preoperatively the quality of the maxillary bone. Hounsfield units (HU) on cone beam computerized tomographs can give an indication of bone density but HU is not completely reliable (10). HU does provide an approximation of bone density. Intraoperative sensibility by the operator is the ultimate test for bone density. Nonetheless, density is not uniform in bone. Thus, one not so dense site may be just a millimeter or two away from a very dense osseous site (10). This means that if an implant is placed into a less dense site the surgeon may elect to relocate the osteotomy 1-2mm away and find that bone to be very dense.Bite force capacity may be an important preoperative parameter. A patient with a high bite force capacity my overload the retaining mini-implants. Since these patients are frail, the biting force they generate can be as low as 30 newtons (11). Such a low biting load would not cause a luxation of a properly placed mini-implant (11).Mini implants that retain a denture should be long as anatomically possible to prevent overload (9). A preoperative cone beam computerized tomogram is appropriate to identify anatomical landmarks to be avoided. Atrophic bone may be thin and needs to be measured so the risk of a perforation is minimized (9). Even though length does not add as much resistance to loading as width, every bit of osseous contact is required for a long-term successful outcome (9). The long length may contribute enough resistance to tolerate a happenstantial increased load such as caused by a fall or biting on a seed.There needs to be adequate attached tissue or soft tissue that is immovable or that may be augmented with a tunnel dermal allograft or porcine collagen xenograft (12). A donor site type free gingival or submucosal graft may not be tolerable for the frail patient (12). Additionally, immovable mucosa may suffice for protection for the epithelial attachment around the implant, be it a mini or standard sized (Fig. 3). The key factor is the prevention of muscle tension on the epithelial attachment (9,12).The mini-implants can be immediately loaded with retainers embedded in an existing well-fitting, occlusally correct, complete denture, by pick-up, when the ridge is composed of dense atrophic bone. As the mandibular ridge atrophies the facial and lingual cortices approach one another. After a time, the intraosseous surfaces of the cortices may be 1-2 mm apart (Fig. 4). This allows placement of a small diameter mini-implant that engages the facial and lingual dense cortices for excellent initial stability. The dense cortices provide excellent stability allowing the mini-implants to be immediately loaded.A lingualized or flat zero-degree occlusal scheme are best to prevent significant lateral or off axial loads on the retaining implants (13,14,15,16)Even though these mini-implants have small diameters they are very durable and resistant to fatigue (13). One study demonstrated that mini-implants withstand a million laterally directed load cycles without fracture (13).An overdenture retained by four mini-implants are generally not as retentive as Locator® retainers (14,15,16). Nonetheless, if there is adequate ridge length, additional implants can provide more retention that can be excellent (14,15,16). Flat zero-degree denture teeth or lingualized occlusal schemes may be most appropriate to minimize lateral loads (14,15,16).If a mini-implant fails, there is typically only minor bone loss. A larger implant failure may have a much larger volume of bone loss that may present a risk for fracture of a thin atrophic mandible (14,15,16).Progressive geriatric disorders such as dementia and Parkinson’s disease will limit the patient’s ability to cooperate and follow instructions. This may put this patient’s oral health at risk. Successful dental treatment of frail patients should include an understanding of how the patient is medically, socially, and emotionally functioning. (14,15,16,17)Frail geriatric patients are a diverse group with multiple disabilities. Their life experiences can complicate clinical dental care.  The treatment process should be based on a philosophy that addresses the best interests of the patient. (14,15,16,17)The patient and clinician working in tandem decide the treatment (17,18,19). The patient is informed of the risks and benefits. The treatment should be determined by the patient’s health, functional needs, quality of life and not their age. Elderly patients heal in the same fashion as younger patients (17,18,19). Patients older than 80 may have less bone loss and fewer implant failures than younger patients (18,19).CONCLUSIONSFrail patients need adequate nutrition and a decent quality of life. Many of these patients are edentulous and can be bimaxillary atrophic. Improved quality of life may be provided with mini-implant treatment in atrophic jaws especially in elderly patients in their waning years. A CBCT may be appropriate to identify anatomical structures to be avoided. Anatomically appropriate long-length mini-implants that are immediately loaded to retain a denture may be an appropriate treatment for the frail patient. A flat zero degree or lingualized occlusal scheme may be most appropriate. An unlikely high bite force capacity may indicate a contraindication for a denture retained with mini-implants. Post-treatment, careful follow-up is needed to insure adequate function and outcome. There are advantages for these patients with mini-implant treatment. A failed mini-implant causes much less bone loss than a standard-sized implant failure. Additionally, mini-implant treatment has a relatively low associated cost. Contemporary CBCT enables mini-implants to be placed by general dentists.The author claims no financial, commercial or political conflicts of interest.Consent: Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy”ABBREVIATIONS: CBCT= cone beam computerized tomogramFIGURE CAPTIONSFigure 1- The patient presented with an atrophic edentulous ridge that was treated with 2.5mm diameter mini-implants and immediately loaded.Figure 2- The patient was treated with small diameter, mini, implants to retain the mandibular complete denture.Figure 3- Immovable mucosa is adequate for epithelial attachment protection.Figure 4- As the alveolar ridge atrophies, the facial and lingual cortices approach one another and provide dense facial and lingual bone which provides excellent stability the mini-implant. The flukes of the implant engage the cortices for excellent stability.REFERENCES1-     Torpy JM, Lynn C, Glass RM. 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