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Rationale for dental implants

Indications of replacing missing teeth:
To restore function: mastication; anterior teeth for cutting and the posterior
teeth for grinding or chewing and speech mainly the anterior teeth (upper
incisors).
The main reason for replacing anterior teeth is esthetics.
Stability of the dental arch, in a case of missing teeth there is a chance for
supra-eruption or drifting so there will be a need to replace it.
Temporomandibular Joint Dysfunction, sometimes missing teeth lead to TMD
but nothing is approved yet.
Patient psychology; feeling of completeness.


Single tooth replacement by FPD
There are many treatment options for teeth
replacement based on specific guidelines;
one of them is FPD (bridge).
The estimated mean life span of FPD is
about 50% survival reported at 10 years;
50% of the cases of FPD after 10 years
of insertion need adjustments or
treatment.




Survival rate: means that the bridge for example stills in the patient's mouth
for 10 years but it needs further treatment (adjustments) like finding recurrent
caries on cervical margins of the bridge and you need to restore it.
Success rate: it's still in the patient mouth for 10 years without any
adjustments.


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The most common cause of failure in bridges
is caries, when you prepare a tooth for a
bridge there is a high chance to have
marginal discrepancies such as gap or
overhang so it will be more susceptible to
caries.



15% of fixed partial denture abutments need endodontic treatment; when you
prepare the abutment for a bridge you may cause iatrogenic injury to the pulp or
thermal damage to the pulp then you need to do RCT, and sometimes the
chemicals you use like cement may insult the pulp and cause pulp necrosis.
So during preparation you may do four insults to the pulp; mechanical,
chemical, thermal and desiccation which lead to the need of endodontic
treatment.

Failure of abutment teeth of FPD is 8-12 % at 10 years and 30% at 15 years; the
abutment teeth may get fracture and cracks or root fractures .

80% of teeth adjacent to missing teeth (abutments) have no or minimal
restoration; when you have single missing tooth the adjacent may be almost
sound or with minimal restoration, conservatively you remove about 60-65 %
of tooth structure which is destructive , so imagine if the preparation was not
conservative the tooth will be susceptible to pulpits , fracture or at least
sensitivity for a long period of time.

Advantages of single tooth by implants over
bridge:
1- High success rate (>90% for 10 years): the
success rate depends on the SR of the implant
itself and the SR of restoration.
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- Recent studies found that a three unit bridge (if well planned) are almost
similar to implants, but in the bridge the patient has to clean under the
pontic by super floss or interdental brush otherwise the abutment will be
susceptible to caries and or periodontal disease, but in implants no need
to clean under pontics .

2- Decreased caries risk for adjacent teeth.
3- Decreased risk of endodontic problems on adjacent teeth.
4- Improved ability to clean the proximal surfaces of the adjacent teeth.
5- Improved esthetics of adjacent teeth, because it's easy to floss.
6- Improved maintenance of bone in the edentulous sites; implants used as
bone retainer.
7- Decreased cold or contact sensitivity, because there is no preparation for the
teeth.
8- Psychological advantage, because you replace one tooth by one tooth so the
morbidity on the adjacent teeth is almost zero.
9- Decreased abutment tooth loss, but in the bridge there is a chance for
abutment loss.

As a comparison between implants and bridges:


Bridges

- there is a chance for recurrent caries
- Irreversible damage to the abutments
- Tooth fracture
- Sensitivity
- Esthetic deterioration


Implants
- No caries
- No abutment's preparation
- No erosion (the erosion will be on the crown not the
implant itself).
- Only implantitis (resemble periodontitis)
- Regeneration of osteocyte (osseointegration)


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Consequences of bone loss in fully edentulous patients :

1- Decreased width of supporting bone.
2- Decreased height of supporting bone.
3- Prominent mylohyiod and internal oblique ridges
and increased sore spots (sharp bone specules).
4- Progressive decrease in keratinized mucosa
surface which is the best to tolerate the masticatory
forces .
5- Prominent superior genial tubercles with sore
spots and increased denture
movement .
6- Muscle attachment near crest of ridge due to severe resorption, the floor of
the mouth muscle will rise above the ridge reducing the retention and stability of
the denture
7- Prosthesis dislodgment due to muscular activity (soft tissues will be at the same
level of bone resorption).
8- Movement of prosthesis due to bone loss ; forward movement of prosthesis from
anatomical inclination
9- Thinning of mucosa with sensitivity to abrasion ; reduced keratinized tissues
more susceptible to trauma.
10- Loss of basal bone: especially in the posterior aspect of the mandible where
severe resorption may result in mora the 80% bone loss . this is the most serious
problem because it will not lead only to pathological fracture also it won't be
implanted unless we do bone grafting and replace all the thickness of the lost basal
bone.
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11- Parasthesia from dehiscent mandibular neurovascular canal: in some cases of
severe bone resorption mental nerve or ID nerve appear on the ridge causes
parasthesia for the patient and sometimes benign growth of nerves (tumor).

12- More active role of tongue in mastication: macroglossia is one of the
consequences of edentulism due to hyperactivity of the tongue (retention of
denture, distribution of food . Etc)
13- Effect of bone loss on esthetic appearance of lower
third of face (bone loss decreased lower facial height
and protrusion of mandible).
14- Increased risk of mandibular body fracture due to
advanced bone loss.
15- Loss of anterior Ridge and nasal spine causing
increase denture movement and sore spots during
function.



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Attwood classification of bone loss:
Class I: immediately after extraction (at the day of extraction)
Class II: two or three days after extraction
Class III: round ridge
Class IV: knife edge ridge
Class V: flat ridge
Class VI: reduced ridge (negative defect)

Soft tissue consequences of edentulism:
1- Attached, keratinized gingiva is lost as bone is lost all stress bearing area is
lost either soft tissues or compact bone.
2- Unattached mucosa for denture support causes increased sore spots: like
movable or flabby tissue.
3- Thickness of tissue decrease with age and systemic disease causes more sore
spots for dentures such as xerostomia and other systemic diseases which affect the
mouth and increase pain.
4- Tongue increase in size, which results in denture instability .
5- Decreased neuromuscular control of jaw in the elderly difficulty in
controlling the muscles.

Esthetic consequences of bone loss :
1- Decreased facial height.
2- Loss of labio-mental angle.
3- Deepening of vertical lines in lip and face (wrinkles)
4- Chin rotates forward giving a prognathic appearance (pseudo class III)
5- Decreased horizontal labial angle of lip which makes patient look unhappy.
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6- Loss of tone in muscles of facial
expression.
7- Thinning of vermillion border of the
lips results from poor lip support and
loss of muscle tone (vermillion border
: is the junction between mucosa or skin
and vermillion in the lip).
8- Deepening of naso-labial groove and
increase in columella-philtrum angle
because there is no support from upper
lip.
9- Increase length of maxillary lip and less
teeth show at rest and smile .
10- Ptosis of buccinator muscle attachment
which leads to jowls at side of face.
11-Ptosis of mentalis muscle attachment
which leads to "witch's chin "; this effect is cumulative because of the loss of
muscle tone and loss of teeth and bone in the regions where the muscles used to
attach.
Negative effects of removable prostheses :
1-Bite force is decreased from 200 to 50 psi ; The bite force of removable
prostheses is 1/10 of the natural teeth force .
2- 15-year denture wearers have reduced bite force to 6 psi.
3- Masticatory efficiency is decreased.
4- More medications to treat GI disorders ; the reduced consumption of high-
fiber foods could induce GI problems in edentulous patients with deficient
masticatory performance .
5- Food selection is limited, for ex. he can't eat hard food such as apple .
6- Healthy food intake is decreased .
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Problems with removable partial denture
1- Low survival rate 60 % at 4 years .
2- 35% survival rate at 10 years .
3- Repair of abutment teeth rate 60% at 5 years and 80% at 10 years.
4- Increased mobility, plaque, bleeding upon probing and caries of abutment
teeth.
5- 44% abutment tooth loss within 10 years specially in free-end saddle area (the
most posterior tooth) with poorly designed denture .
6- Accelerated bone loss in edentulous region if wearing RPD.


Psychological effects of tooth loss :
1- Ranges from minimal to neuroticism some patients relate their social
problems to their teeth .
2- Romantic situations affected (especially in new relationships) for example
patient has complete denture and her husband doesn't know but when he knew
that he divorced her!
3- "Oral invalids" unable to wear dentures.
4- 88% claim some difficulty with speech and 25% claim significant problems.
5- More than $200 million each year spent on denture adhesive .
6- Dissatisfaction with appearance, low self-esteem.
7- Avoidance of social contact: many people avoid contact with others to avoid
embarrassment because his/her denture is loose .


Advantages of implant supported prostheses :

1- Maintain bone.
2- Restore and maintain occlusal vertical
dimension.
3- Maintain muscle tone and facial esthetics.
4- Improve esthetics (teeth positioned for
appearance versus decreasing denture
movement).
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5- Improve phonetics.
6- Improve occlusion.
7- Improve proprioception : this is important because natural teeth have
proprioceptors in PDL but complete denture only in soft tissues below the
denture but in implants there is part of proprioceptors in bone.
8- Increase prosthesis success and survival rates because it will be more stable.
9- Improve masticatory performance, maintain muscles of mastication and
facial expression.
10- Reduce size of prosthesis.
11- Provide fixed and removable prostheses implants are flexible you can
make it on removable or fixed prostheses.
12- Improve retention and stability of removable prostheses .
13- No need to alter adjacent teeth unless it is tilted we make some adjustments
from the beginning.
14- More permanent replacement but it needs maintenance.
15- Improve psychological health ; Implants may improve the nutritional
problems in the patients and make him happier.

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Done by :
Rawan Shatnawi & Rasha Al-Shboul