By: Victor M. Sternberg, D.M.D.
December 14, 2022
I placed my first implant after training at the Toronto seminar given by Nobel Pharma 34 years ago.
At that time we had no scans. We weren't even allowed to take an x-ray during implant placement. The patient was missing all teeth distal to #6 and requested the ability to chew on that side.
Without the value of a scan I was unaware of the deep undercut on the facial. In addition, the proximity to the cuspid and the sinus on both sides of an implant placement was also not easy to access. Dental x-rays are inaccurate when you take a film of this area due to overlap.
In any event, an implant was placed. At that time it was a 10 millimeter, 3.75 millimeter Nobel implant. Somehow we managed to place it just distal to the cuspid and mesial to the sinus at about a 30 degree angle coming out the facial.
The patient, who requested more teeth, was restored with a full molar cantilevered off this first bicuspid implant that was attached to the cuspid as well.
This violates many of the things we would do today. In any event, 34 years later the implant is stable but has lost several millimeters of bone horizontally. This is due to the fact that the implant was placed very close to the buccal plate and grafting at that time was not done.
TODAY'S X-RAYS 34 YEARS PAST TREATMENT
In any event, beginner's luck sometimes has better outcomes than years and years of experience.
Here is another case that was 20 years ago with multiple implants that have stayed stable for the entire period.
However, the flip side is that more and more implants developing peri-implantitis. This may have something to do with the coatings on the surface which went from being highly polished titanium alloy to treated surfaces to increase integration. The surfaces have micro etching or other treatments to make them slightly more porous to allow tissue and bone to grow against the surface.
At a recent conference of the American Academy of Periodontology more time was spent discussing treating failing implants than actually placing them. Patients who lost teeth from periodontal disease have higher risks. It is estimated that 40% of implants develop mucositis, i.e. inflammation of the soft tissue around the implant, and over 20% develop peri-implantitis resulting in bone loss.
This first case was sent to me to treat. The 2 x-rays taken, 3 years apart, show the complete loss of bone to the apex of a second molar implant.
The next case is a case I treated 7 years ago in which 2 implants were placed. The patient had poor oral hygiene and a history of periodontitis. The anterior implant has remained stable and the distal implant has lost a great deal of bone.
Finally, a women who was a smoker and refused to quit had implants placed over 20 years ago with further fixtures placed as time went on. Integration was excellent and bone levels were maintained. However, over time progressive peri-implantitis resulted in the loss of much of the bone over 2 of the implants.
The takeaway from this experience is that the maintenance of implants is challenging. My experience, and others', have indicated that the most effective way to maintain the perio-implant soft tissue is with water irrigation under high pressure for at least 30 seconds twice a day around the implant. This has also been shown to be effective in removing a film at the time of surgery with high speed water. I currently make use of a water irrigator at a very high setting, which creates pristine surfaces around implants. Other techniques using lasers and chemical disinfection have been less effective in removing the biofilm. Many implants are placed and no one is responsible for maintaining the health of that implant. Time has proven that whoever placed the implant should be able to maintain it with regularity as well as treat it if it begins to fail.
Takeaways from all these experiences are that,
1) it is much easier to maintain teeth with periodontitis than it is failing implants;
2) once an implant fails, to replace it with another implant becomes problematic if not impossible;
3) the maintenance of the implant, seeing the patient at least once or twice a year and reviewing the use of a water irrigator is critical to the long term maintenance of the fixture;
4) attempts to treat implants that are failing is a hit and miss proposition with no predictable outcomes; and
5) it is clear that we should make all efforts to maintain natural teeth for as long as possible given the potential for implant failures.
And now a follow-up to an earlier case I've shared with you. This is a 14 year post implant case. The patient had a large periapical lesion with no buccal bone. Removing the tooth would have resulted in loss of the buccal and an irretrievably impossible cosmetic result.
In conjunction with the endodontist an apico was done in an attempt to recreate facial bone. See the photograph of the surgery.
There was no buccal bone after the apico was done and the tooth was filled from the apex and a bone graft was done.
After appropriate healing the tooth was removed because the area recurred.
At this point the socket had been repaired at least 75% allowing an implant to be placed.
And a bone graft done a second time over the implant.
Now 14 years later a fixture is free of any pathology and bone loss.
In some respects dentistry is like the ABC sports show in which the announcer talked the thrill of victory and the agony of defeat.
Let's all hope that we have much more thrills of victory and many less agonies of defeat.
But do it with your eyes open and realize all of the issues we face as dentists have a certain amount of predictability as well as unpredictably. Eliminating as many variables as possible will reduce the incidence of problems but not eliminate them completely.
As always I appreciate your feedback.
Victor M. Sternberg, D.M.D.
Dental Office of:
Victor M. Sternberg, D.M.D., PC
By Westchester Center for Periodontal & Implant Excellence
February 1, 2023