|Year : 2013 | Volume
| Issue : 2 | Page : 52-56
Implant dentistry: A multidisciplinary approach
Latha S Davda1, Sanjay V Davda2
1 Dentist/Clinical Tutor and General Dental Practitioner, University of Portsmouth Dental Academy William Beatty Building, 1 Hampshire Terrace, Portsmouth PO1 QG, United Kingdom
2 Department of Oral Surgery, King's College London Dental Institute, Denmark Hill, London, United Kingdom
|Date of Web Publication||11-Feb-2014|
Latha S Davda
Dentist/Clinical Tutor and General Dental Practitioner, University of Portsmouth Dental Academy William Beatty Building, 1 Hampshire Terrace, Portsmouth PO1 QG
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Dental implants are one of the options available to replace missing teeth. The long-term success of any dental implant treatment is influenced by several factors including patient factors, preventative measures used by the patient, esthetics, surgical factors, periodontal factors, restorative factors and mechanical factors of the implant system. Dental implants are placed and restored by specialists as well as general dental practitioners with differing levels of training in dental implantology. Therefore, it becomes very important for the main clinician in charge of the implant patient to be aware of the multidisciplinary approach that is required to ensure long-term implant success. The patient factors, assessment of patient for implants, esthetic factors and prevention influencing the treatment planning of a dental implant patient are discussed in this paper. This is the first in the series of three articles that will discuss the factors listed above with relevant case studies.
Clinical relevance to interdisciplinary dentistry
- Long term success of dental implants is dependent on good case selection,detailed patient assessment and implimentation of multidisciplinary approach.
- It is in the best interest of the patient that all the specialties needed in that particular case work together under one lead clinician to achieve the best results.
Keywords: Dental implant, long-term success, multidisciplinary, patient factors
|How to cite this article:|
Davda LS, Davda SV. Implant dentistry: A multidisciplinary approach. J Interdiscip Dentistry 2013;3:52-6
| Introduction|| |
Dental implants are one of the options available to replace missing teeth.  In the recent years, dental implant design has improved to such an extent that mere integration with the bone is no longer considered as the only success criteria for the implants. It is expected that successful implant treatment restores normal function, esthetics, comfort and speech in a patient.  Albrektson et al.  have described the criteria for implant success as stability, no peri-implant radiolucency on radiography, less than 0. 2 mm of vertical bone loss annually, absence of pain, infection and nerve damage. For the patient, a pain-free procedure achieving good esthetics and function long term is a success. In order to achieve all these, meticulous treatment planning with a multidisciplinary approach is essential.
Dental implant placement and restoration was previously mainly carried out by various specialists who either worked in a team or individually. Now, with more general dental practitioners placing implants or restoring implants, it is important that they have a good knowledgebase of all the disciplines of dentistry that are required for successful implant treatment. A multidisciplinary approach would include a sound knowledge of applied anatomy, diagnosis and imaging, preventative dentistry, periodontology, orthodontics, surgical dentistry and restorative dentistry. The aspects of all these specialities and their role in successful implant treatment are discussed in this paper.
The long-term success of any dental implant treatment is influenced by several factors listed in [Table 1]. ,, Patient factors, implementation of prevention and certain aspects of esthetics are discussed in this article. The other factors will be discussed in subsequent papers along with case studies.
| Patient Factors|| |
All successful implant treatment begins with assessing the patient's expectations and understanding whether the main concern is that of appearance, function, speech or a combination of all these factors. This will also give an idea of the patient's motivation in maintaining oral health and, in the long term, the implant health. Realistic and achievable goals should be set based on a thorough oral assessment, discussion of all the other treatment options available to the patient and the clinician's competency. Patient factors that influence the long-term success of implant treatment are listed in [Table 2].
A good dental and medical history is the beginning of any dental treatment planning. The dental history will help in identifying the cause of tooth loss and the reasons why the patient is seeking replacement. If the patient has lost his teeth due to periodontal disease, there is a risk that the patient will develop peri-implantitis, unless his oral hygiene and other underlying causes for periodontal disease are not corrected. The micro-flora associated with failing implants has been found to be identical to those in chronic adult periodontitis. ,, If the tooth loss was due to caries, unless oral hygiene and diet are not improved, there is a risk of loss of additional teeth in the mouth due to caries, thereby putting more occlusal stress on the implant restorations. If the tooth loss was due to tooth wear, the risk factors causing tooth wear need to be eliminated before placing implants as it is an accepted fact that bruxism increases the possibility of implant failure.  Bruxism can cause crestal bone loss, loosening of abutments and fatigue stress fracture of implant and prosthesis.  If the tooth was lost as a result of trauma, then provisions will have to be made to replace missing bone and soft tissue to achieve good esthetics. Traumatic injuries to teeth are common in childhood and adolescence. At the age of 5 years, 31-40% of boys and 16-30% of girls, and at the age of 12 years, 12-33% of boys and 4-19% of girls will have suffered some dental trauma.  Boys are affected almost twice as often as girls. Majority of the dental injuries involve the anterior teeth, especially the maxillary central incisor. 
Medical history is important before dental treatment, and can particularly influence implant success. Majority of patients seeking dental implant treatment are older and will often have underlying medical disorders. Implant treatment should be carried out only in patients with mild to moderate systemic disease or well-controlled systemic disease. Uncontrolled diabetes mellitus, inherited bleeding disorders and acquired bleeding disorders, thrombocytopenia, bone diseases like osteoporosis, fibrous dysplasia, Paget's disease and multiple myeloma are contraindications for implant placement. Implants placed in patients taking bisphosphonates and those on long-term steroids may fail due to poor bone quality. In India, where patients are often unaware of any underlying medical problems, it may be necessary to carry out a baseline full blood count, blood glucose along with bone profile to rule out common but easily corrected diseases like anemia, diabetes mellitus and bone diseases before starting implant treatment.
Smoking is well documented as a high risk factor for implant failure. , Tobacco decreases the phagocytic activity of polymorphonuclear leukocytes by reducing their motility and chemotactic activity. This results in decreased resistance to infection, poor wound healing and loss of peri-implant gingival attachment and peri-implant bone. Chewing tobacco is linked with an increase in periodontal disease and oral cancer. A patient's desire to have implant treatment rather than denture can be used as a motivational tool to help in smoking cessation. 
Bruxism, or grinding of teeth consciously or in sleep, can overload the implants and thereby cause failure.  Habituating the patient to a night guard, occlusal rehabilitation and anxiety management therapy are recommended before treatment. 
Poor oral hygiene results in gingivitis and periodontal disease, and in patients with dental implants, it will cause peri-mucositits and peri-implantitis. ,, A 9-14-year follow-up of 999 implants showed that 48% of implants had peri-implant mucositis and peri-implantitis was seen in 6.6% of the implants.  Toljanic et al. in their prospective study of 275 hydroxyapatite-coated implants placed in the posterior region of the maxilla studied the gingival scores and plaque index scores using natural teeth in the same patient as controls and found a higher accumulation of plaque around the implant-supported restorations.  They postulated that by applying periodontal disease paradigms, one could conclude that implants in the posterior maxilla are at a higher risk of inflammation-induced connective tissue damage, including bone loss due to increased peri-implant soft tissue response to plaque. They suggested that post-implant rehabilitation should include increased frequency of recall for hygiene appointments along with stricter home care practices.
Preventative dentistry and its tools can be used to establish optimum oral health at the very beginning of the implant treatment. Oral health assessment and oral hygiene instructions act as key factors in ensuring implant success. Oral health assessment is easily carried out by finding out how the patient cleans his teeth, whether any interdental aid is used, how many times the patient brushes his teeth in a day and asking the patient to demonstrate the brushing in the dental chair. A disclosed plaque score using the Silness and Löe index is a valuable tool in patient education. In 1987, Mombelli et al. modified the original plaque index and bleeding index introduced by Silness and Löe to assess the plaque and bleeding around implants. , A disclosing solution is applied to all teeth surfaces and, after 2 min, the patient is asked to rinse the mouth gently with water. Each tooth is divided into four surfaces: Buccal, lingual, mesial and distal. All the surfaces that have plaque will stain with the dye [Figure 1], and these are counted and the area covered by plaque is calculated and given as a score to the patient.
|Figure 1: Plaque adherent on teeth visible after using a disclosing agent|
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The patient is then given oral hygiene instructions and the correct method of brushing and using interdental aids is demonstrated. The patient should be motivated to reduce the plaque score below 20% before commencing implant treatment. Regular dental hygiene visits must be built into the patient's treatment plan. Bleeding score on manual probing with a periodontal probe is used as an indication of active periodontal disease and, combined with plaque scores, can be used to improve the patient's oral hygiene.
Soft tissue examination of the patient should start with extra-oral examination of patient's lips at rest and the smile line. Patients who show the cervical area of the teeth and the adjacent gingival when they smile are considered high risk [Figure 2] as close attention needs to be given to bone and soft tissue defects, emergence profile of the implant and the material used as abutment to achieve good esthetic results. 
|Figure 2: High smile line showing the cervical margins of teeth are considered a high risk for achieving optimum esthetics|
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In some cases where the patient is a denture wearer and shows pink acrylic [Figure 3] the final implant prosthesis can be made in such a way that it improves the patients smile line [Figure 4].
|Figure 3: High smile line in a patient wearing partial denture, showing the pink acrylic|
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|Figure 4: Same patient as in Figure 3 after a full-arch implant-supported bridge|
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Intraorally, the width of the attached gingiva and its thickness will determine the extent of soft tissue correction needed. Implants placed inside the attached gingiva are easier to clean and hence less likely to accumulate plaque. If the gingiva is thin, then the metal of the abutment and implant neck may show through, giving the gingiva a bluish tinge.
A simple and quick way of conducting periodontal examination is by carrying out a basic periodontal examination and recording the score (BPE score), a system recommended by the British Society of Periodontology in the United Kingdom. The dentition is divided into sextants, as shown in [Table 3].
The World Health Organization probe has a black band that extends from 3.5 mm to 5.5 mm from the tip of the probe. This probe is used by "walking" the probe along the buccal and lingual gingival sulcus of all the teeth present, and the highest score recorded in the sextant is noted. The scores, how it is measured and their relevance are listed in [Table 4].
|Table 3: Division of dentition into sextants for measuring and recording the BPE scores as recommended by the British society of periodontology |
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|Table 4: Basic periodontal examination, how to record scores and their relevance as recommended by the British society of periodontology |
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A comprehensive periodontal examination (CPE) is then carried out in sextants with BPE score 3 and above and the treatment is planned accordingly. A CPE includes plaque and bleeding indices, measuring pocket depth, recession and attachment loss, mobility and furcation involvement of all teeth.
Hard tissue examination should include evaluation of teeth and the bone. The number of teeth decayed, missing and restored should be recorded. All conservative dentistry procedures like restoration of carious teeth and endodontic procedures should be carried out before placing implants. When teeth are lost and the edentulous space is not restored for a long time, there is a tendency of adjacent teeth to migrate into the edentulous space.  The adjacent teeth may tilt into the space or rotate [Figure 5].
|Figure 5: Study casts showing loss of edentulous space by mesial migration and tilting of the molars distal to the space|
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The degree of loss of edentulous space varies in different patients and in different areas of the mouth. In the anterior maxilla, where appearance is paramount, moving and de-rotating the adjacent teeth with orthodontics to create the optimum space before placing implants is ideal. In certain cases, it is possible to reduce the width of the adjacent teeth conservatively to increase the edentulous space available. A diagnostic wax up [Figure 6] should be performed as a part of implant planning to help both the clinician and the patient to decide the number of teeth that need replacing and the final appearance [Figure 7] that can be achieved.
|Figure 6: Diagnostic wax up on the study case shown in Figure 5 demonstrating the possibility a three-unit bridge supported by two implants, where all the widths of all units are equal|
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|Figure 7: The final result in the patient, based on diagnostic wax up shown in Figure 6|
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The bone factors and the periodontal factors listed under patient factors will be discussed in detail with the surgical and periodontal considerations for long-term implant success in subsequent papers.
| Conclusion|| |
Long-term success of dental implant treatment is dependent on good case selection, detailed patient assessment and implementation of a multidisciplinary approach. Irrespective of whether the treatment is carried out by general dental practitioners or specialists, it is in the best interest of the patient that all the specialties needed in that particular case work together under one lead clinician to achieve the best results. Dental hygienists, dental therapists and dental nurses trained in implant dentistry are invaluable members of the implant team as patient treatment coordinators, improving and maintaining periodontal health and in giving support during the treatment.  The main multidisciplinary factors influencing implant treatment are discussed in a three-part series, with patient factors highlighted in this paper.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
[Table 1], [Table 2], [Table 3], [Table 4]