1. Year graduated from dental school:_________

2. City and state where I practice:_______________________________

3. Type of practice:
a. Endodontist b. General c. Oral surgeon
d. Orthodontist e. Pediatric dentist f. Periodontist
g. Prosthodontist h. other (specify)

4. I have been involved with implant dentistry for _________ years.

5. I accomplish:
a. both surgical and prosthodontic implant procedures
b. implant surgery only
c. implant prosthodontics only

6. I have used small diameter implants for_________ years.

7. I have chosen to use __________________________ (brand & company)
small diameter implants instead of another brand because: __________

8. I am willing to be contacted by CRA for additional questions:
Name:________________________________________________________
Phone number:________________________________________________

9. My opinion of the service potential for the mini implant concept overall is:
a. highly positive b. positive c. don't know
d. guarded e. negative

Please answer remaining questions for the system you listed above in Question 7 only.

The next several questions (10-30) are for those doing surgery. (If you do only implant prosthodontics, go to question 31.)

10. I attended the company's in-house training:
a. yes b. no

11. Instructions (printed &/or electronic) provided by the company are:
a. excellent b. good c. fair d. poor

12. Organization of the surgical kit is:
a. excellent b. good c. fair d. poor

13. Instruments provided by the company are:
a. excellent b. good c. fair d. poor

14. When placing small diameter implants with one stage surgery, I have
raised a flap on _________% of surgeries.
Main reason for raising a flap has been:__________________________

15. I have placed about _________ (number) small diameter implants.

16. When adequate bone is present, implant placement without a flap is:
a. simple b. moderately difficult c. difficult

17. Implant placement with a flap is:
a. simple b. moderately difficult c. difficult

18. I feel that the minimal amount of facial-lingual bone for mini placement is:
a. 2mm b. 3mm c. 4mm d. 5mm
e. 6mm f. other ___________________________

19. I feel that the minimal amount of crestal-apical bone for mini placement is:
a. 8mm b. 9mm c. 10mm d. 11mm
e. 12mm f. 13mm g. 14mm h. other______________________

20. About _________% of the small diameter implants I have placed have failed.
Failure occurred about _________ months after placement (avg or range).
Of these failures, _________% were placed in the maxilla & _________% were placed in the mandible.

21. I have noticed coronal bone loss of more than 1mm around ____% of the implants.

22. I have placed mini implants for the following situations:
a. mandibular complete denture
b. maxillary complete denture
c. single unit anterior-mandible
d. single unit anterior-maxilla
e. single unit posterior-mandible
f. single unit posterior-maxilla
g. assistance for tooth support of multi-unit fixed prostheses-anterior
h. assistance for tooth support of multi-unit fixed prostheses-posterior
i. extra support &/or retention of removable partial dentures
j. provisional use while conventional-sized implants are integrating
k. in orthodontic therapy
l. other__________________________________________________________

23. I have had _________ (number) mini implants break off during service.

24. Technical support from the company has been:
a. excellent b. good c. fair d. poor

25. When considered from a surgical standpoint, I prefer this brand of small
diameter implants over other brands I have placed.
a. yes b. no c. I have not placed other brands of small diameter implants

26. My fees for surgical placement of small diameter implants are (in US dollars):
1 implant: $________ 2 implants: $________ 3 implants: $________
4 implants: $________ 5 or more implants: $_________

27. My fees for surgical placement of conventional sized implants are:
1 implant: $________ 2 implants: $________ 3 implants: $________
4 implants: $________ 5 or more implants: $_________


I do not place conventional sized implants.

28. Other brands of small diameter implants I currently place are: ________

29. Reasons I place mini instead of conventional sized implants include:
1st
2nd

30. Accessories I find most helpful for surgery are:
a ______________________________________________________
b ______________________________________________________

The next several questions (31-42) are for those doing implant prosthodontics. (If you do only surgery, you are finished with the questionnaire.)

31. Organization of the prosthodontic kit is:
a. excellent b. good c. fair d. poor

32. Instructions from the company are:
a. excellent b. good c. fair d. poor

33. Instruments provided by the company are:
a. excellent b. good c. fair d. poor

34. Clinical use of the prosthodontic component is:
a. simple b. moderately difficult c. difficult

35. I have restored about _________ (number) small diameter implants.

36. Technical support from the company has been:
a. excellent b. good c. fair d. poor

37. When using these small diameter implants I use:
a. custom laboratory-made abutments or attachments _________% of the time
b. manufacturer abutments or attachments _________ % of the time

38. I have had _________ % of the abutments fail in service.

39. When considered from a prosthodontic standpoint, I prefer these small
diameter implants over other small diameter implant brands I have used.
a. yes b. no c. I have not used other brands of mini implants

40. I _________ continue to use these small diameter implants when
considered from a prosthodontic standpoint.
a. will b. will not

41. I have restored these small diameter implants for (circle all that apply):
a. mandibular complete denture
b. maxillary complete denture
c. single unit anterior-mandible
d. single unit anterior-maxilla
e. single unit posterior-mandible
f. single unit posterior-maxilla
g. assistance for tooth support of multi-unit fixed prostheses-anterior
h. assistance for tooth support of multi-unit fixed prostheses-posterior
i. extra support &/or retention of removable partial dentures
j. provisional use while conventional-sized implants are integrating
k. other__________________________________________________________

42. I have used small diameter implants in orthodontic therapy:
a. yes b. no

43. I find chairside capture of the housing into the denture with fast-set hard
reline easy to do:
a. yes b. no

44. Cements I use are (brand name & company):
a. for temporary prosthesis: ____________________________________
b. for fixed prosthesis:________________________________________

45. Accessories I find most helpful for implant prosthodontics are:
a. __________________________________________________________
b. __________________________________________________________
c. __________________________________________________________