Important Factors When Considering Implant Solutions
Various implant options are becoming more predictable
Ramzi V. Abou-Arraj, DDS, MS
Implant dentistry is one of the fastest-growing segments of the profession because patients are more aware and experienced clinicians are more capable than ever of delivering successful outcomes. Advances in digital dentistry and guided surgery have led to more general dentists, surgeons, and specialists using implant solutions to provide better patient care. Meanwhile, dental implants are no longer foreign to patients as a preferred treatment option for the replacement of missing teeth.
As clinicians embrace this option over conventional solutions, a thorough risk assessment and a proper treatment plan are crucial for successful implant outcomes. The patient’s systemic health, periodontal status, smoking status, other comorbid risk factors, and esthetic risk assessment must be considered in the treatment planning phase. In most aspects, systematic review studies favor dental implants over conventional tooth replacement options such as fixed or removable partial dentures in terms of long-term survival rates. In addition, the cost of treatment is an important consideration for patients, and is frequently accounted for in determining the treatment plan.
The All-on-4 concept remains popular, including the use of four or more implants as a platform for a fixed detachable prosthesis or a hybrid prosthesis, but it is necessary to weigh the risks and benefits for each patient. The alternative treatments that are used to provide dental implants fully supporting a full-arch prosthesis may require an extensive reconstruction of the ridge, as well as the risks associated with that. A clinical debate arises every time there is a group of remaining anterior teeth with adequate residual periodontal support and restorative condition whereas the posterior ridges are severely deficient.
The “save the tooth” strategy must always be considered first; however, the rather unpredictable vertical ridge augmentation techniques that would be necessary for implant site development must be weighed against the high likelihood of success if these residual teeth were to be “sacrificed” and replaced with four or more implants for a full-arch implant-supported prosthesis. This concept is not appropriate or applicable for all patients, but it has been a treatment option that has displayed a high degree of predictability.
Another popular new solution is the small-diameter implant (SDI), which the author uses for temporization purposes. When a clinician is going through a long-term treatment, reconstructing the ridge in different locations of the arch and replacing those teeth with implants in a sequential manner, it is sometimes necessary to support the patient’s provisional prosthesis with additional abutments. SDIs can be used as anchoring devices or simply for extra support through the temporary phase. The author does not have experience using SDIs as a definitive option, nor does the literature yet unequivocally support their use as a definitive option, except for very specific cases as a complete denture when a patient suffers from a very deficient ridge, especially the mandible, and may decline any advanced treatment to rebuild that ridge, or when the patient’s systemic health precludes invasive surgical procedures.
Immediate loading is another technique that is growing in popularity due to significant advances. There is more understanding now of when clinicians should or should not consider this option. For single teeth, immediate loading has been documented to be a predictable treatment, particularly in the anterior zone and even in the premolar area, assuming that guidelines for risk assessment, primary stability, provisional design, and occlusion are followed. Some evidence exists for the predictability of immediate loading for single implants in the posterior as well; however, in those cases it is necessary to consider whether immediate loading carries an added clinical benefit.
Overall, immediate loading of anterior implants has been shown to have no negative effects on bone loss or implant survival. However, in areas of high esthetic demand and thin tissue biotype, immediate loading should be exercised with caution and by skilled clinicians as the risk for soft tissue complications, eg, recession, is rather elevated. Immediate loading for fixed prostheses in the edentulous arch has been shown to be as predictable as conventional loading when adequate primary stability (≥30 Ncm) is achieved and after careful case selection, treatment planning and execution, and in the absence of simultaneous bone grafting.
As practitioners, we must be well informed about the advances in implant dentistry and honest with our patients. For instance, a clinician should be knowledgeable with immediate loading and prepared to deliver this option to his/her patients, while at the same time showing versatility in temporization options for improved patient acceptance and care. What if the implant does not achieve primary stability? What if the patient is a bruxer? What if he or she is a heavy smoker or has other medically compromised situations that severely compromise implant wound healing? What if bone augmentation is necessary? Several factors could complicate the treatment planning, and all must be considered when presenting options to patients. Careful case selection, proper and conscientious treatment planning, adequate training, skill and experience of the clinician(s) performing the various implant procedures are essential success factors. It is noteworthy that dental implants are not immune to inflammatory diseases affecting the natural dentition and that peri-implant diseases are on the rise. Therefore, every treatment plan for dental implants must include a dedicated section and corresponding discussion with the patient about the importance of regular implant maintenance procedures following delivery of the prosthesis.
Certainly, more implant options will become available in the future. More people are becoming interested in this treatment, from a practitioner and patient perspective. From a clinical standpoint, all leading implant systems successfully osseointegrate. That is no longer the primary challenge. The challenge is keeping the peri-implant crestal bone from resorbing after the implant is in function. The shift in focus has been to create implant designs that favor bone maintenance such as platform switching or shifting and achieve a soft-tissue seal around the implant, ideally though direct attachment onto the implant or abutment collars. As the need for dental implants and earlier restorations increases, implant manufacturers continue to develop new surface technologies that enhance bone and soft-tissue healing. Moreover, the emergence of digital dentistry has been revolutionizing implant treatment planning, surgical placement, temporization, and definitive restorations.
About the Author
Ramzi V. Abou-Arraj, DDS, MS
University of Alabama at Birmingham School of Dentistry