A place at the table

January 2010 | Dental Products Report
Clinical 360° : Dental Implants

The take-aways

• The number of dentists involved in placing dental implants continues to grow.
• While not the go-to solution for every case, implants are increasingly becoming the standard of care.

A place at the table

Making the case for regular dental implant coverage in DPR and the integration of dental implants in the general practice.

by Dr. Brien Harvey

The set-up

“Welcome to the Dental Products Report Clinical 360° Dental Implants column! My teammates, Drs. Lee Gause, Michael Tischler, and Joyce Warwick, and I are excited to be able to provide you with timely, state-of-the-art information about topics of critical importance to dentists and their teams. All four of us are in full-time clinical practice, with an emphasis on implants and implant continuing education. I am confident that you will find our collective perspective to be real-world and in the trenches with you.”-Dr. Brien Harvey. Team Lead

The question arises, though, why implants? Why has Dental Products Report added a team on dental implants?

Well, the numbers are compelling. The American Dental Association, in its 2007 Survey of Current Issues in Dentistry, found that 16% of all practicing dentists had surgically placed an implant in 2006, and the number of practitioners doing so was increasing steadily. Given this finding and trend, coupled with the United States Department of Labor Bureau of Labor Statistics projection that there will be 176,000 practicing dentists in 2016, it is easy to anticipate that there will be as many as 40,000 dentists placing implants in the next 5 years, and it goes without saying that essentially all restorative dentists will be involved with implant-supported prostheses.

The emergence, development and refinement of osseointegrated dental implants over the last three decades, particularly in terms of simplified, ‘tooth-like’ prosthodontic treatment options, leaves the practicing dentist with no option but to consider dental implants when tooth replacement is necessary. In fact, the situations during which implants can and should be considered the treatment of choice for tooth replacement are becoming the rule rather than the exception.

Better dentistry, happier patients

Not too many years ago, it seemed that having virgin adjacent, potential abutment teeth, along with lacking abutments posterior to the edentulous sites, were the only clear indications for implants in partially edentulous patients. And patients completely edentulous in one or both arches might have a recommendation for implants only if they complained of severely compromised function.

Now, though, the perspective on the role of dental implants in fixed and removable prosthodontics has changed, and I suspect we can all agree this perspective has changed dramatically. There is compelling evidence that using implants in edentulous arches both slows the rates of alveolar ridge shrinkage and improves patient perceptions concerning comfort and function, leading to an improved quality of life. In fact, using implants to support a complete mandibular prosthesis imparts such a positive effect that offering a minimum of two implants to a patient who is (or is soon to be) edentulous in the mandibular arch is considered the standard of care.

For those of us doing implants over a long period of time, the improved quality of life attributable to implants that is routinely experienced by our edentulous patients comes as no surprise. For our partially edentulous patients, the benefits of using implants rather than conventional tooth-supported partial prostheses might be seen as less life-changing, and yet the arguments in favor of considering and offering implants are nonetheless compelling. Who amongst us would still consider a conventional 3-unit fixed partial prosthesis (FPP) to be a reasonable treatment option in an otherwise esthetically pleasing and functionally intact segment when using an implant would allow replacement of the missing tooth without adversely affecting unrestored adjacent teeth?

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Digging a little deeper into the available data, the argument can be made that a single implant-supported crown is the treatment of choice for the pontic site when an existing FPP requires replacement, along with one or two new single crowns as needed for the teeth that had been serving as abutments. This argument seems justified because the long-term prognosis for single implant- and tooth-supported crowns is better than that for FPPs, with lower complication and failure rates.

In situations where an existing FPP has failed and one or more of the supporting abutment teeth are lost in conjunction with this failure, it behooves the practitioner to take a long, hard look at using implants rather than just making a longer, more complicated bridge. Clearly, the risk factors that led to loss of the FPP and abutment teeth are still at work long-term in the patient’s mouth even if the dentist seems to have gained improved patient oral health and stability short-term.

• Refer to slideshow for figures

Case in point

The images included in this article are of a patient I treated in 2004. She had a conventional tooth-supported 6-unit FPP replacing her mandibular incisors for many years. The combination of longstanding periodontitis, even though relatively well-controlled, and secondary occlusal trauma left this FPP mobile, and it ultimately failed with loss of the two abutment teeth. DEXIS digital radiographs (Figs. 1A and 1B) revealed favorable residual ridge height in the mandibular anterior segment and also revealed the mandibular premolars had some bone loss and less-than-ideal root morphology. I cannot imagine placing implants without digital radiographs. Even if the only thing I used my DEXIS sensors for was intraoperative orientation images, and clearly it is not as I have not had a film processor in my office since 1998, digital radiography would remain the best investment I have made in technology. Isn’t it nice, knowing whether or not you need a retake before the sensor is out of the mouth? 

Would it have been possible to restore this patient with a 10-unit tooth-supported FPP (using all four mandibular premolars as abutments)? Sure. Would I have been nervous about these teeth holding up as bridge abutments? Absolutely.

Implants for this patient were placed in the position of her mandibular canines, and her existing temporary removable partial was modified to serve as an immediate-load minimally functional screw-retained provisional FPP (Figs. 2A and 2B). When making an immediate fixed provisional, I generally use flowable composite intraorally to lute the crown or bridge to the temporary abutments. Healing in this case was uneventful, with favorable tissue and bone health at four months (Figs. 3A, 3B, and 3C). The definitive implant-supported FPP was then fabricated and cemented (Fig. 4), satisfying both the patient and the restorative dentist. Almost six years later, she continues to comment on how nice it is to be able to enjoy her favorite fruit: Granny Smith apples.

Are implants a cure-all?

So, am I implying that dental implants are the treatment of choice for every edentulous or partially edentulous patient? The one-word answer remains, “No.” Current research and my clinical experience leave me with a few one-word alternative answers, though: “Almost” or “Perhaps.”

Every time we see a patient with a missing tooth or missing teeth, we should consider dental implants as a treatment planning option (commonly the treatment of choice), and we should help each patient make an informed decision consistent with his or her values and priorities.

During my years as editor of Inscriptions, the Journal of the Arizona Dental Association, our tagline was ‘Essential Reading for Arizona Dentists.’ My goal, our goal as your Clinical 360° Dental Implants Team, is to make this column equally compelling. Essential reading for America’s implant dentists. Let us know how we are doing.

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