|Year : 2019 | Volume
| Issue : 1 | Page : 1-3
Success or survival: Which race to win?
Editor-in-Chief, Journal of Dental Implants, ProSmile Dental Clinic and Implant Centre, Dr. L. H. Hiranandani Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||17-Jun-2019|
Dr. Sharat Shetty
Editor-in-Chief, Journal of Dental Implants, ProSmile Dental Clinic and Implant Centre, Dr. L. H. Hiranandani Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Shetty S. Success or survival: Which race to win?. J Dent Implant 2019;9:1-3
With the increased life expectancy of an average Indian, the percentage of edentulism both partial and total has also increased. These patients are aware of the available options of replacements including implant dentistry but are not judicious enough to choose the right one since they are not appropriately informed. Today implant-based dental treatment has become more popular and acceptable as more general dentists are doing them with claimed success at least at the time of delivery of definite prosthesis and maybe a year later. The high percentage of success as reported in the literature is merely because the controlled study group consists of patients selected by inclusion/exclusion criteria. But in reality, there are all types of patients visiting clinics who will need replacements. Unfortunately, there has been no formal or sustained training amongst those who practice implant dentistry in India though there is a shift in recent times where implant training are a part of curriculum at both graduate and postgraduate program. This has led to deficient or insufficient treatment and failures (both surgical and prosthetic) over along period of appraisals (5-10 years). But the success narratives as seen on the published cases which are more of individual stand-out approaches and industry-driven, have seen a greater rise rather than academic research and reportings. This has led to misuse and/or overuse of implants in daily practice. These are evident from multiple postings on mass-media platforms. But it has been quiet on reporting of the increasing percentage of failures and failing implant treatment after 5 to 10 years for want of regular appraisals or denials of publishing such data.
So there are many implants that survive that long with deteriorating osseointegration and function. Hence, there is a need to understand the difference between survival and success. “Implant survival” implies presence of implants in the mouth at the time of evaluation irrespective of its current status of function, esthetics and comfort whereas “Implant success” means that the implants in the mouth are still acceptable for their utilities. Implant treatment is not a precision treatment but a biomechanical science that are affected with changing environment as time elapses. So it is mandatory for clinicians to understand and evaluate the risks involved and then initiate the treatment keeping the patient well-informed of the same. This good-work protocol will reduce iatrogenic errors, inadequate treatment and potential complications. This will progressively enhance the trust of patients on the integrity of the clinicians and not denude the advantages of implant treatment when used correctly.
Some recommended spectrum of risk evaluation include the following:
- Systemic contraindications: Thorough medical history recordings are essential to reduce the risks of loosing implants to those diseases or aggravating them. Those that can be regulated can be considered for implant treatment after appropriate control strategies and waiting time. Absolute contraindications include active neoplastic managements like chemotherapies and radiations, immune disorders, unstable endocrine disorders, bleeding disorders, progressive bone diseases, drug abusers, heavy smokers and non-complaint patients
- Undesirable habits like smoking and parafunction: There is increased evidence of failures of implants in patients with long duration and more frequency of smoking compared to nonsmokers due to its effect on bone health, blood flow and tissue growth. Patients need to be informed of its increased risks and encouraged for tobacco cessation. Besides brain-mediated parafunction should be identified and risks involved should be thoroughly evaluated for possible excessive overload on implants and breakages of components
- Residual infections at implant site or adjoining structures: Implants are biomaterials, which get easily infected and are difficult to treat. Bacterial contamination can occur during placement or from retrograde spread from adjoining roots of endodontically treated teeth. Strict infection controls, judicious use of shortest but effective antibiotics, delaying implant insertion in suspected infection sites and periodic clinical and radiographic checks for local oral and intra-bony infections should be carried out
- Variations in quality of bone: Bone is dynamic biologic tissues whose density affects the primary stability. Additionally, it can only tolerate certain amount, direction and timings of force. Treatment protocols should be modified based on quality of bone, which can be determined through a CBCT scan or tactile abilities during drilling
- Inadequate quantity of bone: Adequate bone volume measured in all three dimensions is necessary for implant placement. These have to be recorded accurately. Deficiency in any of the dimension will entail augmentation procedures
- Various types of neural damages to surgical interventions: Nerves likely to affected due to haphazard surgical procedures are the inferior alveolar nerve with its anterior loop, incisal nerve, mental nerve, lingual nerve and rarely the infra-orbital nerve. These can lead to transient to permanent damages. They arise due to improper radiographic interpretations and lack of knowledge of variations of these structures
- Angulation of implants: The occlusal load on the implant prosthesis will lead to undesirable tensions on the bone-implant interface and/or the screws leading to progressive loss of osseointegration and/or component failures. Use of prosthetically-driven concept to place the implants can ensure long-term viability of the implants and prosthesis over them
- Length of implants: The use of appropriate radiological images preoperatively like the CBCT and intra-operatively like the periapicals can ensure correct selection of the length of implants for optimum bone-implant-contact (BIC) and avoidance of damages to critical structures. Correct knowledge of the local anatomies and ramifications of their violations is necessary. It's equally important to know the management of complications if they arise
- Sum total numbers of implants: The nature of prosthesis whether fixed or removable will determine the minimum number of implants required for a long-term favorable distribution of forces. Any reduction in number will lead to failing implants and overuse will influence the difficulties in various prosthetic steps and oral hygiene maintenance. This will also increase the laboratory fabrication cost in turn more expensive to the patients
- Unacceptable distribution of implants: Depending on the size of the prosthesis, the location of implants need to be favourable to support them and distribute the occlusal loads. Use of digital planning and surgical stents can ensure the correct locations in the arch
- Comparable primary stability: Achieving primary stability during implant placement is the key to initiation of osseointegration and its quality. Surgical procedures are modified depending on the quality of bone to achieve good primary stability. Any disturbance due to micro-motion greater than 50 microns can lead to integration failure. Good occlusal management like passive non-loading immediate provisionals and avoiding sliding removable prosthesis, do not disturb the primary stability and subsequent healing
- Components of superstructure: The available prosthetic space and the need for retrievability determine the choice of screw-retained or cement-retained restorations. The precision used in prosthetic recordings and efficiencies of the laboratory to fabricate passive yet accurate fit of the restorations are essential for long-term survival of both the restoration and implants. Active fits lead to progressive loss of bone around implants, screw loosening or fracture and superstructure breakages
- Esthetic failures: It is essential to place the implants in the right 3D position, in relation to adjacent tooth or implants with adequate labial or buccal bone of at-least1 mm, to achieve acceptable esthetics. Concepts like immediate placements and provisionalizations in correct indications and prosthetic development of pink-white complex with adequate oral hygiene maintenance design can be instituted
- Soft tissue profiles: Healthy peri-implant tissues are essential for long-term stability of dental implants. Every effort should be made to preserve and reconstruct the keratinized tissue that includes their height and width. Innovative interventions are available to enhance the soft tissue dimensions and their maintenance
- Satisfaction of the patient: One of the most important factors influencing the success of implant treatment is the long-term psychological satisfaction of the patient with as minimal gap between the anticipatory desires and the achieved final out-comes. Patients should be adequately counseled about the possible esthetic, functional, financial and maintenance possibilities and limitations to keep high levels of contentment and comfort.
Besides regular long-term appraisals should be done every six to twelve months depending on the extent and nature of initial implant treatment and the following should be evaluated and appropriate preventive and corrective interventions carried out in case of early detection of onset of failures:
- Oral hygiene procedures at home
- Health of the peri-implant tissues
- Presence of exudates around the implants
- Tenderness or pain on touch or percussion
- Observable mobility of implant and superstructures
- Atraumatic probing depths
- Radiographic evaluation for bone loss
- Component integrity and early failures like screw-loosening, chipped materials and fractures
- Occlusal stabilities and identifications of parafunction
- Soft tissue reductions and need for augmentations.
So an individual patient-centered treatment plan should be devised based on the risk evaluation and implement surgical and prosthetic protocols accordingly. Patient education and regular follow-ups are also essential. Long-term success should be the goal and not just survival!!!
“The best part of success is that it got me past the basic survival level of existence so that I was comfortable. I didn't have to worry about stuff pertaining to survival. Once that was taken care of, I got the chance to sit down and create and work at what I do.”