The Drill on Implants
Exploring implant dentistry's most controversial and confusing issues
Inside Dental Technology set out to identify and cover the hottest topics in the growing arena of implant dentistry. We started by asking eight experts from the Editorial Advisory Boards of IDT and Compendium of Continuing Education in Dentistry to suggest key areas of concern, controversy, or confusion surrounding specific aspects of implant dentistry. We then surveyed 21 members of IDT's board who specialize in implants to narrow down the suggested topics to three.
The results were clear: Our experts want to read more about the cement- vs. screw-retained options, the value of CT guided surgery, and the question of full-arch fixed restorations vs. removables.
Full-Arch Fixed vs. Removables: Are the Correct Decisions Being Made?
Treatment options must be considered carefully
By Alex Medaglia
An estimated 35 million Americans are currently edentulous, and that number is expected to grow over the next two decades as the Baby Boomer population continues to age.1 With edentulism accelerating, dentistry must quickly adapt to meet these patients’ needs. However, some questions exist regarding the most efficient and patient-centered ways to treat the problem. Approximately 3 million Americans have dental implants, and with this treatment modality gaining popularity, the number of implants being placed in the US has risen to about 500,000 per year.2 Driven in large part by patient demand, implant-supported and retained full-arch restorative treatment has been one of the fastest growing segments in dentistry with more than 12% of full denture cases now supported by implants.
In the minds of some industry experts, this development demands the question of whether full-arch implant restorations are being over-utilized when traditional dentures might be a better treatment option in some cases.
“Patient demand is driving the industry,” says Lars Hansson, CDT, head of Bay View Dental Laboratory's implant department. “Implants are a popular treatment option, and often it is assumed that this option is the patient’s preference. There is nothing wrong with implant-supported full-arch restorations, but we need to temper patient demands with clinical knowledge of the oral situation, age of the patient, and the dexterity for hygiene maintenance as well as consideration for their financial situation.”
Easy access to the Internet as well as implant-focused marketing campaigns across myriad media channels provide patients with a plethora of information on the benefits and drawbacks of different treatment options, and they often bring that information with them to the practice.
“Although an informed patient should play a significant role in the treatment planning process, promoting implants and implant-supported prosthetics as the best or only choice for restoring a partially or completely edentulous arch is not realistic or appropriate for many patients, especially in terms of affordability, available bone, and the patient’s general health conditions,” says Burney Croll, DDS, who has a private prosthodontic practice in New York City.
Affordability combined with the economy and the fact that many Baby Boomers do not have adequate retirement savings may be driving factors that will influence restorative treatment strategies in the years to come. A study by the United States Census Bureau indicated that there were just under 77 million Baby Boomers in 2011. By 2030 the youngest Baby Boomers will be 66 years of age and the oldest 84.3 In addition, only 60% of that population reports having any retirement savings.4 The immense portion of the population over the age of 65, along with the lack of savings in this age group, presents a real limitation in terms of treatment options, especially because Medicare does not provide dental coverage and private insurance covers only a small percentage of the total cost.
“While every dentist would like to prescribe an implant-supported prosthesis,” Croll says, “the financial issue is legitimate and must be taken into account.”
Gary Orentlicher, DMD, Chief of the Division of Oral and Maxillofacial Surgery at White Plains Hospital Center in upscale White Plains, New York, agrees that finances are a driving factor for treating fully and partially edentulous patients, but he points out that many patients get creative to fund the treatment they want.
“In this practice, I would say that a majority of patients pay out of pocket or have insurance that will cover the implants,” Orentlicher says. “Others will ask us for an installment payment plan or arrange payment through outside financing.”
Finances aside, other situations exist in which a removable prosthesis is a more suitable option.
“Depending upon the degree of atrophy of the jaw, a fixed restoration sometimes cannot be done,” Orentlicher says. “If there is extensive bone grafting or the patient might need a zygoma implant, or more extensive and more significant surgery, then a removable solution might be a better option.
"While there are circumstances in which a fixed restoration cannot be done, it is certainly not very often — less than 5% of patients.”
For those patients who choose a removable treatment option, bone resorption becomes an issue over time.
“Every time a patient visits the practice for a reline, more pink must be added to the prosthetic. The dentist must inform the patient that whatever pink was added represents what they have lost in bone and tissue,” Hansson says. “Implants obviously stop resorption and stabilize the bone. So it is a double-edged sword. You can place an implant that will cost more initially, but long term it will be cheaper and healthier for the patient.” Removable prosthetics can also cause simple everyday problems for patients.
“Patients with a removable solution are often self-conscious and feel old,” says Olivier Tric, MDT, owner of Olivier Tric Dental Laboratory. “Most distressing for these patients is that the plastic palate of a traditional denture inhibits their ability to taste food. But we need to weigh the pros and cons of treatment against what is best for that patient.”
Croll says the stigma surrounding removable prosthetics is increasingly being conveyed by dentists to their patients, swaying their decision on which treatment option to choose. “Unfortunately, in many cases, this is motivated by profit rather than what is the best option for the patient,” Croll says.
Another reason behind the growth in implant-supported full-arch treatment is the fact that the fit, function, and esthetics of removable prosthetics are becoming what Hansson describes as a “lost art.” Dental school curriculums have reduced training in this area, and on the laboratory side the number of knowledgeable and skilled technicians is dwindling.
“Dental students get trained less on removable prosthetics than they do on fixed today,” Hansson says. “I run the laboratory program for the Academy of Osseointegration and I’m trying to cross-train the dentists and the technicians.”
The most prominent deficiency Hansson cites is that technicians lack understanding on clinical procedures and which treatment strategies work best long term.
“In order for technicians to be part of the treatment planning process, we need to be more educated on the clinical side,” he says. “We are beginning to see this happen on the implant side with CBCT planning and virtual implant placement.”
The essential aspect of any treatment plan is, of course, the satisfaction of the patient, which is extremely integrated into Tric’s approach.
“I think we sometimes have a tendency to require the patient to fit into our technique instead of fitting our technique into what is best for the patient,” Tric says. “Our primary goal should always be to provide the best possible prosthesis and the best possible service for the patient.”
1. American College of Prosthodontics. Facts and Figures. https://www.gotoapro.org/news/facts--figures/. Accessed January 26, 2016.
2. American Academy of Implant Dentistry. Dental Implants Facts and Figures. https://www.aaid.com/about/press_room/dental_implants_faq.html. Accessed January 25, 2016.
3. Colby S, Ortman J. The Baby Boom Cohort in the United States: 2012 to 2060. United States Census Bureau. 2014. https://www.census.gov/prod/2014pubs/p25-1141.pdf. Accessed January 26, 2016.
4. Holland K. Retiring Well? Not Most Baby Boomers. CNBC. 2014. https://www.cnbc.com/2015/04/13/retiring-well-not-most-baby-boomers.html. Accessed January 25, 2016.
5. Stone J. A Look at Dentures vs. Implants. Best Dental Associates. 2014. https://drstonedds.com/dentures-vs-implants-2/. Accessed January 27, 2016.