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J Am Dent Assoc, Vol 138, No suppl_1, 34S-40S.
© 2007 American Dental Association
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ARTICLES

Dental Implants

A Role in Geriatric Dentistry for the General Practice?



Clark M. Stanford, DDS, PhD


   ABSTRACT
TOP
 ABSTRACT
DENTAL IMPLANT THERAPY
 TREATMENT PLANNING FOR THE...
 CONCLUSION
 REFERENCES
 
Background. In the general population, the use of dental implants has become a management strategy for replacing missing teeth. As part of the treatment plan for the aging population, general dentists should consider this treatment modality in their practices.

Overview. This study reviews specific issues concerning the aging population and tooth replacement therapies. Older people often desire to replace missing teeth, but they have complex medical, social, economic and resource issues that must be accounted for in their treatment plan. Dentists need to give careful attention to the patient-based assessment, diagnostic criteria and diagnostic steps to help the patient and family understand the strengths and challenges of each type of tooth replacement therapy. The author emphasizes the importance of careful evaluation and assessment of fixed versus removable implant–retained prostheses in the aging population.

Conclusions and Clinical Implications. For many general dentists, dental implants have become an increasingly common treatment option for missing dentition. With the population becoming increasingly older worldwide, the general dentist will be confronted with patients who have complex medical and social histories who desire tooth replacement therapy. The rational delivery of this oral health care will assist in providing a high quality of life for these patients.

Key Words: Dentures; diabetes mellitus; aging; decision making; health care delivery; dental care for elderly patients; dental care for people with disabilities; dental implants; medical history taking; risk assessment

Abbreviations: FCD: Fixed complete denture • FPD: Fixed partial denture

Older patients visiting a dental office often have a constellation of medical, dental, social and patient-specific issues that can challenge the diagnostic and therapeutic capabilities of the dental clinician. When patients need and desire tooth replacement therapy, this can vary from conventional removable or fixed prostheses to a combination of fixed and removable implant-supported forms of tooth replacement.


   DENTAL IMPLANT THERAPY
TOP
 ABSTRACT
 DENTAL IMPLANT THERAPY
TREATMENT PLANNING FOR THE...
 CONCLUSION
 REFERENCES
 
For the majority of the population, the clinical success of dental implant therapy has improved such that some clinicians consider it to be a form of standard of care.1 However provocative this assessment may be, clinicians should not ignore the role of implant therapy to support the oral rehabilitation of the elderly population and of other medically compromised patients. The patient, caregiver, family and clinical team need to weigh the inherent advantages and costs of implant therapy. Tooth replacement therapy can vary from single-tooth replacement with conventional or implant-supported restorations to full-arch replacement with individual implants/tooth-to-implant–supported overdentures. Each of these options (including no tooth replacement) has advantages and costs that must be weighted in a multifactorial consideration of patients’ desires, understanding, resources and perspectives.2–4 The predictable esthetic and functional outcomes of care depend on a comprehensive diagnostic evaluation and treatment planning.5

Patients who undergo implant therapy face medical and surgical risks that are similar to those of outpatient oral surgical intraosseous procedures. The surgical team should evaluate the patient for systemic conditions that may compromise healing (for example, immunocompromised states, uncontrolled diabetes) and the systemic effects of medications. In general, the survival rates of dental implants in older patients can be affected by certain systemic conditions associated with aging, including long-term smoking, diabetes and postmenopausal estrogen therapy.6 In addition, the use of multiple medications influencing bone metabolism (for example, steroids, bisphosphonates) has the potential to alter the outcomes of implant therapy.7,8 For instance, investigators recently have become concerned about surgical interventions in patients with osteoporosis who receive long-term oral bisphosphonate therapy.9–11 As part of a careful informed consent process, the dentist needs to provide the patient and his or her family with an accurate assessment of the procedures, the length of treatment time, risks and alternatives to implant treatment (including no tooth replacement and conventional fixed or removable prostheses).

Investigators often point to the ability of bone to heal in the older patient as a concern with regard to implant outcomes. Researchers have addressed this question through the clinical assessment of implants placed in the anterior mandible, a region of the oral cavity that does not experience significant age-associated osteopenia.12–14 Implants placed, restored and functioning in areas of predominantly trabecular bone (for example, atrophic maxilla) are at a higher risk of experiencing complications.Implant interfaces are maintained through dynamic modeling and remodeling processes within the bone of these regions. ("Modeling" refers to any net change in bone shape, whereas "remodeling" refers to the continuous turnover of bone without a net change in shape or size.) These processes (referred to as "the adaptive capacity" by Stanford and Brand15), in turn, allow bone to respond to the clinical procedures and occlusion over long periods.

Patient assessment. The predictable esthetic and functional outcomes of implant treatment for geriatric patients require comprehensive diagnosis and treatment planning.5 The clinician should assess the patient’s medical and dental history for bruxism, periodontal disease, tobacco use, uncontrolled diabetes mellitus and metabolic diseases of bone.7 Some investigators have reported elevated complications related to smoking after controlling for age and other medical conditions.6,16 Diabetes, especially type 2, is a disease of increasing concern in which control (as measured by hemoglobin A1C levels < 7.0 percent) is considered important for successful long-term outcomes of implant therapy.8,17 Throughout the surgical and prosthetic phases of implant reconstruction, the general dentist should review the treatment with the patient and any key significant others and obtain comprehensive written and oral informed consent from the patient.6,18 It may be helpful to have a private discussion with the patient to assess his or her specific needs and desires and balance them with those of the caregiver.

To improve treatment outcomes, the dentist should design and compose the proposed prosthesis during the diagnostic phase. Planning will include issues such as the type of prosthesis (removable, fixed or a combination). Clinicians should consider the use of implants in combination with removable partial dentures in a compromised dentition to provide greater support, esthetics and potential function for the partial denture.19 On the basis of the acquired diagnostic information, the dentist can use a surgical guide or denture to indicate the desired implant position, angulation and need for hard- and/or soft-tissue augmentation before or during implant placement. The clinician should carefully evaluate the patient’s soft- and hard-tissue changes to encourage realistic patient expectations.

For geriatric patients who have a single edentulous arch or a partially edentulous arch, there is a balancing of treatment options that include fixed partial dentures (FPDs), adhesive resin restorations and single or short-span implant restorations, as well as no tooth replacement. The final decision is made after considering the patient’s desires, treatment objectives, clinical capability of the clinician, dentist’s expertise and training, treatment costs, treatment time and potential morbidity. Occasionally, given a stable occlusion, the dentist might consider a rigid tooth-to-implant fixed prosthesis (a design that does not allow any movement between the two retainers)20,21 (Figure 1Go). Preoperative planning helps to achieve rational, functional and esthetic goals by ensuring that the final restorative therapy is in the patient’s best interests.22 As part of the informed consent process, the clinician should discuss with the patient treatment plan alternatives with regard to the ability to control esthetics and function with the various methods of tooth replacement.


Figure 1
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  		Figure 1. An 85-year-old frail woman visited her dentist (C.M.S.) with extensive caries under the anterior retainer for a fixed partial denture (FPD). Caries extended under the anterior retainer with loss of the coronal tooth structure (A) and extended to the radiographic alveolar crest (B), creating a challenge to conventional approaches. After a careful assessment and discussion of the risks and benefits, the patient chose a treatment plan that involved an FPD from an implant placed in the canine to the endodontically treated molar. Extraction of the canine and immediate implant placement allowed fabrication and placement of a titanium scalloped abutment (C) restored with a new FPD (D).

 
Diagnostic phase. During the diagnostic phase, the dentist should assess the number of missing teeth the patient desires to be replaced for a functional and esthetic dentition. The clinician also should consider a shortened dental arch with restoration though the second premolars.23–25 When replacing multiple adjacent teeth with dental implants, clinicians often find it clinically useful to replace three teeth with a short-span FPD on two implants, using the pontic to adjust for contours and the final implant position (Figure 2Go). This approach is especially useful in the anterior maxilla in cases involving multiple teeth in which the smallest tooth to be replaced is planned as a pontic with implants placed in the canine and central incisor region.


Figure 2
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  		Figure 2. An 83-year-old man visited his dentist (C.M.S.) with a fractured first premolar though the first molar. The clinician placed two implants (A), one in the first molar and one in the first premolar region, and fabricated a three-unit fixed partial denture to restore posterior occlusion on the patient’s right side, thus providing enhanced function and occlusal stability (B).

 
The clinician should consider and plan for site development. The dentition tends to be positioned more facially or buccally relative to the central axis of the alveolar ridge, resulting in a thin facial plate of bone over the teeth.5 In the mandible, the resorption pattern can occur at an uneven rate, leading to increased bone loss on the thin superior regions and producing a wider ridge with elevated muscle attachments, making denture stability potentially difficult.

The optimal tooth position for a functional and esthetic prosthesis starts with a mounted diagnostic setup consisting of denture teeth on a trial base, with soft- and hard-tissue contours waxed to full contour. Low cusp-angle denture teeth are useful for this purpose, because their reduced occlusal table size potentially limits excessive mechanical load.26 A vacuum-formed matrix of this diagnostic setup assists the surgeon in determining the position, placement and volume of the site (that is, hard- and soft-tissue grafting) needed before implant placement. Because implant position in the partially edentulous or single-tooth situation is critical to achieving a predictable esthetic outcome, the dentist should discuss these risk factors with the patient and members of the implant team. He or she should evaluate osseous contours through palpation, sounding with anesthesia (that is, inserting a needle through the gingiva to the bone to measure mucosal thickness) coupled with two- and three-dimensional radiographic imaging studies.

Depending on the patient’s esthetic expectations, the dentist should evaluate the periodontal tissues carefully to assess their biotype. This assessment can be of particular significance in older patients who have a history of recession. Thick periodontal tissue typically has thick, flattened osseous plates and offers a higher resistance to recession than does thin periodontal tissue. In contrast, patients with a thin periodontal tissue biotype have a thin erythematous periodontium covering a thin or nonexistent facial alveolar bone, which can be associated with soft-tissue recession.27,28 For patients with a thin periodontal tissue biotype, the clinician may need to consider connective-tissue grafting.


   TREATMENT PLANNING FOR THE OLDER PATIENT
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 ABSTRACT
 DENTAL IMPLANT THERAPY
 TREATMENT PLANNING FOR THE...
CONCLUSION
 REFERENCES
 
The edentulous arch presents unique challenges, especially when it is in a state of advanced atrophy. The mandibular arch can be restored by using a fixed complete denture (FCD), an FPD or an overdenture. The FCD typically is a prosthesis designed with acrylic resin teeth bonded to a casting or a titanium framework milled via computer-aided design/computer-aided manufacturing. These prostheses are designed to replace as many teeth as possible by using four to five interforaminal implants.29

If the clinician anticipates a fixed approach for the edentulous arch, the diagnostic workup should include impressions, jaw relationship records and an esthetic try-in involving the use of prosthetic teeth on a mounted trial denture base. He or she should evaluate lip support with the smile line (that is, the anterior and posterior occlusal planes) of the diagnostic denture setup in the mouth. The dentist should assess the patient’s lip support with and without the anterior facial denture flange being present. The anterior smile line (relaxed and exaggerated) not only demonstrates the degree of tooth exposure, but also provides clues about the expected crown length, gingival display and potential need to use gingival tone porcelain for appropriate tooth length and esthetics.

The incidences of esthetic, phonetic and oral hygiene problems are higher with a fixed maxillary prosthesis compared with an overdenture prosthesis; this is, in part, associated with excessively long anterior teeth, excessive facial cantilever pontics and mesiodistal complications with embrasure forms.27 During the diagnostic phases, the dentist should discuss with the patient the advantages and disadvantages of the FCD compared with those of an overdenture. When using a ceramometal full-arch fixed reconstruction, the dentist should consider replacing every three teeth with a three-unit FPD on two implants.5 Because of the clinical and laboratory complexity and costs associated with these types of prostheses, a maxillary overdenture on four to six implants, typically connected with a rigid bar-and-clip attachment system, may be an alternative solution.28,30,31

Overdenture. An overdenture may be the treatment of choice for patients with moderate-to-severe resorption and problems with dexterity and management of phonetic palatal contours.32 On the other hand, overdenture therapy has been associated with more postinsertion complications and higher maintenance costs, which should be discussed with the patient and family.1,2,33–36 An overdenture designed to attach to the implants via a bar-and-clip assembly or free-standing attachments (for example, ball attachments, Locator attachments [Zest Anchors, Escondido, Calif.]) is useful, especially as a means to provide function and lip and esthetic support in a reduced amount of time and with less morbidity relative to the restoration of implants with conventional crowns or FPDs37–40 (Figure 3Go).


Figure 3
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  		Figure 3. A 78-year-old man with long-standing Parkinson disease visited his dentist (C.M.S.) with the inability to wear his lower denture even though he had adequate anatomy (A). Provision of a two-implant free-standing ball attachment overdenture (B) enabled the patient to insert the denture (shown) and provided for function, stability and access for oral hygiene (C).

 
An overdenture should use a sufficient number of implants for long-term stability, typically four in the maxilla (canine and second premolar region) and two in the lower canine or first premolar region.41 Using the denture setup, the clinician fabricates a radiographic guide with radiopaque markers (for example, gutta percha, bur shanks or prosthetic teeth containing barium sulfate) at the sites of interest within the surgical guide.

In the mandible, the trial setup is useful to evaluate the height and position of the prosthetic teeth relative to the symphyseal cross-sectional anatomy.42 Radiographic information and the diagnostic setup will help determine the type of definitive prosthetic design. On the basis of the skeletal classification, the biomechanics of implant loading can influence the type of prosthesis selected. Skeletal class I and II relationships with minimal resorption may allow normal contours and lip support with an FCD, while a prognathic class III relationship can increase prosthetic problems, especially if implants cannot be placed distal to the mental foramens. In such cases, an overdenture approach yields a more predictable result.

The overdenture approach in older patients provides significant treatment flexibility. In a recent consensus conference report, the consensus panel recommended treatment of the edentulous lower jaw with two implants and an overdenture.43 This approach results in significant improvement in a patient’s physiological bone mass, quality of life and, possibly, nutritional status.43–45 Two implants spaced between 12 millimeters and 16 mm apart (edge to edge) in the mandibular canine region can be restored with free-standing attachments such as ball attachments, Locator attachments (Zest Anchors) or ERA attachments (Sterngold Dental, Attleboro, Mass.) or with an overdenture bar system (for example, Hader bar, Sterngold Dental) and a plastic clip attachment in the denture. Bar reconstructions are appropriate for nonparallel implants in which the connecting bar is designed to be parallel to the retromolar pads (fulcrum of rotation), allowing the overdenture to gain retention from the bar and support from the mucosal tissue.

The method of overdenture rehabilitation has been controversial, but recent long-term studies have documented little difference in outcomes between bar-and-clip–retained and free-standing overdenture abutments.37,38 In patients with advanced mandibular resorption, an implant-supported bar on three or four interforaminal implants can provide support for the implant over-denture while avoiding pressure on the supracrestal mental nerve and thin mucosal tissues.

Implant complications. Implant therapy, while highly effective, does have the potential for both technical and biological complications, as well as the potential for psychological complications if the patient’s expectations are not met or are impossible to satisfy with this approach. Loss of an implant may be a catastrophic complication—or a simple inconvenience, especially if the clinician can retrofit or modify the existing prosthesis to allow it to continue to function. The patient also should be aware that implant parts, especially overdenture attachments, are designed to wear out and that ongoing maintenance will be needed.

Clinicians should inform patients that they will need to return for annual recall visits so that the prosthesis can be checked and adjusted. These types of recall schedules can create challenges with regard to travel and costs and pose an additional burden on family members. Thus, before starting implant therapy, the clinician should discuss these issues with the patient and his or her family members. It is important to provide clear information to the patient, caregiver and family members to ensure that their expectations can be met by the surgical and restorative team and to ensure informed consent.


   CONCLUSION
TOP
 ABSTRACT
 DENTAL IMPLANT THERAPY
 TREATMENT PLANNING FOR THE...
 CONCLUSION
REFERENCES
 
Dental implant therapy can significantly improve the lives of older people. Through discussions with the patient, his or her caregiver and, possibly, other family members, the clinician needs to assess the patient’s expectations and desires carefully and balance them with the time and resources needed to accomplish acceptable outcomes. The provision of care should be patient-centered. It should best address the rational needs of the patient while offering an improved quality of life. This can range from complete implant rehabilitation to no treatment at all.

In the end, clinicians need to be sure that, regardless of the treatment strategy proposed, the patient must understand and desire it, and it must be in concert with what we as a profession can provide.


   FOOTNOTES
 

Dr. Stanford is Centennial Fund Professor for Clinical Research, Dows Institute for Dental Research and Department of Prosthodontics, University of Iowa, N447 Dental Science Building, University of Iowa, Iowa City, Iowa 52242, e-mail "Clark-Stanford{at}uiowa.edu". Address reprint requests to Dr. Stanford.


   REFERENCES
TOP
 ABSTRACT
 DENTAL IMPLANT THERAPY
 TREATMENT PLANNING FOR THE...
 CONCLUSION
 REFERENCES
 

  1. The McGill consensus statement on overdentures. Quintessence Int 2003;34(1):78–9.[Medline]

  2. Zitzmann NU, Sendi P, Marinello CP. An economic evaluation of implant treatment in edentulous patients: preliminary results. Int J Prosthodont 2005;18(1):20–7.[Medline]

  3. Bragger U, Krenander P, Lang NP. Economic aspects of single-tooth replacement. Clin Oral Implants Res 2005;16(3):335–41.[Medline]

  4. Kronstrom M, Palmqvist S, Soderfeldt B, Vigild M. Subjective need for implant treatment among middle-aged people in Sweden and Denmark. Clin Implant Dent Relat Res 2002;4(1):11–5.[Medline]

  5. Stanford CM. Application of oral implants to the general dental practice [published correction appears in JADA 2005;136(10):1372]. JADA 2005;136(8):1092–100.

  6. Moy PK, Medina D, Shetty V, Aghaloo TL. Dental implant failure rates and associated risk factors. Int J Oral Maxillofac Implants 2005;20(4):569–77.[Medline]

  7. Beikler T, Flemmig TF. Implants in the medically compromised patient. Crit Rev Oral Biol Med 2003;14(4):305–16.[Abstract/Free Full Text]

  8. Hwang D, Wang HL. Medical contraindications to implant therapy, part II: relative contraindications. Implant Dent 2007;16(1):13–23.[Medline]

  9. Wang HL, Weber D, McCauley LK. Effect of long-term oral bisphosphonates on implant wound healing: literature review and a case report. J Periodontol 2007;78(3):584–94.[Medline]

  10. Mavrokokki T, Cheng A, Stein B, Goss A. Nature and frequency of bisphosphonate-associated osteonecrosis of the jaws in Australia. J Oral Maxillofac Surg 2007;65(3):415–23.[Medline]

  11. Mortensen M, Lawson W, Montazem A. Osteonecrosis of the jaw associated with bisphosphonate use: presentation of seven cases and literature review. Laryngoscope 2007;117(1):30–4.[Medline]

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  16. Sanchez-Perez A, Moya-Villaescusa MJ, Caffesse RG. Tobacco as a risk factor for survival of dental implants. J Periodontol 2007;78(2): 351–9.[Medline]

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  20. Lang NP, Pjetursson BE, Tan K, Bragger U, Egger M, Zwahlen M. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years, II: combined tooth—implant-supported FPDs. Clin Oral Implants Res 2004;15(6):643–53.[Medline]

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