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| REVIEW ARTICLE |
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| Year : 2015 | Volume
: 5
| Issue : 3 | Page : 150-153 |
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Dental implant for the geriatric patient
Divya Prakash, UB Gajre, Prachi Bhowmick Bhatia
Department of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Pune, Maharashtra, India
| Date of Web Publication | 28-Apr-2016 |
Correspondence Address:
Prachi Bhowmick Bhatia
Department of Prosthodontics, Bharati Vidyapeeth Dental College and Hospital, Pune, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2229-5194.181377
 Abstract | | |
Older adults are expected to account for an increasingly disproportionate number of individuals needing oral implant prostheses. However, unfavourable jawbone quantity and quality, particularly atrophy of the maxilla, impair implant success. Furthermore, placement of implants in sites that had been edentulous for shorter periods was associated with greater crestal bone loss, a finding that may have implications for younger adults undergoing such treatment. When treatment planning is done for tooth replacement, patients should be presented with all possible treatment options regardless of age. Dental implant therapy has proven to be a predictable method of permanent tooth replacement. Several studies demonstrate high implant survival rates, a relatively low need for recurrent care, and improved quality of patients lives. This modality is an accepted treatment option for all ages. Consequently, implant-.supported prosthodontic rehabilitation for function and esthetics is indicated more frequently. Authors have used MEDLINE and PUBMED search for locating, selecting, extracting and synthesising data.
CLINICAL RELEVANCE TO INTERDISCIPLINARY DENTISTRY
The rehabilitation of the geriatric patient is a herculean task for the prosthodontist. Prior to the use of dental implants for rehabilitation various factors are to be taken into account such as nutrition, lifestyle diseases etc. Which may need consultation and intervention from the medical fraternity. Management of medically compromised patients and psychological counselling plays a pivotal role in the success of prosthodontic rehabilitation. Thus an co-.ordinated inter-.disciplinary approach is the need of the hour.
Keywords: Esthetics, geriatric, implants
How to cite this article:
Prakash D, Gajre U B, Bhatia PB. Dental implant for the geriatric patient. J Interdiscip Dentistry 2015;5:150-3 |
| Introduction | |  |
India is the second largest populous country in the world and it is undergoing a demographic transition. India has been termed as an “aging” country by the WHO, as the population of the elderly accounts for 7.7% of the total population. It is estimated that the elderly population in India will reach 324 million by 2050.
People are living longer as the mortality rates have significantly dropped, thus the increased prevalence of missing teeth in commonly noted among the elderly population. When planning the treatment for tooth replacement, the older adult patients should be presented with all possible treatment options regardless of the age of the patient.[1]
Geriatric dentistry should begin with implant dentistry, so that implants are not used merely as a last resort as stated by Vorster and van Zyl.[2]
| Implants in Medically Compromised Patient | | |
Understanding bone physiology and metabolism and the fact that no single type of implant is appropriate for all geriatric patients is important because the size, shape, quality, and quantity of bone differs in each patient, which is more important for the geriatric population than in younger patients. Specific endocrine and metabolic changes are associated with aging. Decreased bone density, seen in conditions known as osteopenia and osteoporosis, are both associated with aging and also cause bone loss.
One of these processes will limit the implantologist to some extent, but the reality is that these conditions co-occur in the geriatric patient. Diabetes has also been responsible for poor wound healing (due to local microvascular changes), and Type 2 diabetes is commonly seen in an older adult. Vitamin deficiencies, especially A, B, and C, due to the changed dietary patterns and loss of teeth can cause discontinuity in the integrity of the epithelial layer of the gastrointestinal track which includes the oral mucosa and affect wound healing.
Elderly populations are also more affected by systemic diseases such as atherosclerotic heart conditions, cardiac arrhythmias, kidney disease, and peripheral vascular diseases. In studies that investigated the effect of multiple medical conditions on dental implant procedure, risks found no elevated incidence of complications in this group of patients.[3],[4]
| Osseointegration in Elderly Patients | | |
A large number of patients have difficulty in mastication and normal oral function when using a removable prosthesis (RP). Multiple studies have shown the relationship between adequate oral function, nutrition, and digestion; and when the oral function of an individual is compromised, so is the nutritional status and the systemic health. Some studies have suggested that the outcome of surgical treatments in elderly subjects was not affected by the age-dependent difference in wound healing. Toronto study from 1979 to 1992 indicated that the survival rate for implants which were placed in older adults was similar to that of implants placed in other age groups.
Brånemark and others predominantly investigated the success of bone anchored dental prosthesis in middle-aged individuals with advanced resorption of the alveolar bone.[4]
| Replacement of Missing Teeth in Elderly | | |
Single tooth replacements
As stated previously, both quality and quantity of bone are theoretically affected by aging. Bone quality is related to osseointegration, and bone quantity is related to the length of the implant used, which is important for initial stability and success. A histomorphometric and microradiographic study has clearly shown that beyond the age of fifty there is a marked increase in the cortical porosity of the mandible being greater in the alveolar bone than the mandibular basal bone. When porosity increases, bone mass decreases, which appears to be more evident in females than in males.
Morphologically, bone resorption of the labial or buccal alveolar ridge makes prosthetic treatment much more difficult. Horizontal discrepancies between the residual ridge of one jaw for implant placement and the residual teeth and ridge of the other jaw are common. Therefore, single tooth replacement is much more difficult in older adults as compared to younger adults.
Partially edentulous and completely edentulous geriatric patients
Fixed prosthesis was supported by implants: A study was conducted on partially edentulous patients in which clinical and radiologic performance of fixed implant prosthesis was assessed. The treatment results were comparable in the young patients, and the elderly but problems with adaptation were observed during the postinsertion stage of the prosthesis.[5]
Problems associated with cleaning, inflammation of the soft tissues, cheek and tongue biting were seen more commonly in the elderly population. When the length of the edentulous span is too large for resin-bonded or fixed bridgework, or the abutment teeth are unsuitable for support of the prosthesis an implant supported fixed bridge maybe the treatment of choice [Figure 1]. A success rate for partially dentate patients treated with implants was around 90% over 10–15 years. A study by Jemt [6] included a total of 391 edentulous maxillae and mandible; these patients were treated with fixed prosthesis and a 1-year follow-up was done. It was noted that the success rate was 99.5% and 98.5% for the prosthesis and implants.
| Implant Supported Overdentures | | |
In patients who have no teeth remaining the implant supported overdenture (OD) is an alternative to conventional complete dentures. The mandibular ODs supported by implants have been investigated since 1987, Van Steerbergh was one of the first to propose the placement of two implants in mandible to support an OD. Atterdet al. concluded in his study that cumulative survival rate of ODs was 100% at 15 years with the longevity of denture prosthesis being approximately 10.39 years.
OD options using implants vary in the maxilla and mandible. The mandibular ODs itself consists of OD-1 up to OD-5. The OD option is selected based on the anatomy of bone, shape of arch, patient motivation, and cost of the complete treatment.
Overdenture in edentulous maxilla
The primary advantage of using removable OD options as compared to its fixed counterpart is the reduced cost and the ability to support the upper lip by the flange of the OD. Complications such as attachment wear and prosthesis or component fracture are more common in ODs than in fixed prosthesis.
Two treatment options are available for maxillary OD.
- Option 1 – Maxillary RP-5 implant OD option
- Use of 4–6 implants, out of which, at least 3 are positioned in the premaxillary region. The implants should be well-spaced anteroposteriorly
The key positions of the implants are bilaterally in the canine region and, at least, one central incisor. The secondary implant site is being the first or second premolar region. Alternatively to the central incisor implant position, the lateral incisor and the second premolar region of the contralateral side can be used
The implants should always splinted together with a rigid bar when the force factors of the patient are high
- Option 2 – Maxillary RP-4 implant OD option
- Use of 7–10 implants which are rigid during the function. Two key positions are the bilateral canine and the distal half of the first molar positions. When force factors are greater implants maybe placed in the second molar positions also. All the implants are splinted together using a rigid bar.
Mandibular implant overdentures
- OD-1: The implants are in B and D positions, and they are independent of each other [Figure 2]
- OD-2: The implants are placed in the B and D positions, the implants are rigidly joined by a bar [Figure 3]a and [Figure 3]b
- OD-3a: Implants in the A, C, and E positions, and rigidly joined by a rigid bar if posterior ridge form is good
- OD-3b: Implants in the B, C, and D positions, joined by a rigid bar when posterior ridge form is poor
- OD-4: Implants in A, B, D, and E positions, which are rigidly joined by a bar cantilevered distally for about 10 mm
- OD-5: Implants in the A, B, C, D, and E positions, which are rigidly joined by a bar and cantilevered distally about 15 mm.[7]
 | Figure 3: (a) Bar and clip attachment over implants. (b) Bar and clip retained overdenture
Click here to view |
| Mini-Implants in the Elderly | | |
Minimal invasive surgical procedures when used in conjunction with implantology, play a pivotal role in the treatment of the elderly individuals. The use of the concept of minimal surgery can be made easier by the use of cone beam computed tomography, flapless implantology, and surgical guides. The use of mini dental implants (MDIs) is one such procedure. They can be placed without much effort and can be used to support and stabilize a variety of prosthesis. Mini implants were introduced initially to stabilize dentures; they are now being used in several other clinical applications successfully such as restoring missing teeth, splinting, and fixed-partial dentures.
Traditional implants have been the treatment of choice for patients suffering from unstable and unretentive prosthesis; however, the increased expenditure, fear of surgery, and expected healing time associated with this option may make the procedure unfavorable for many older adult patients. MDIs [Figure 4] are simple to use, easily learned, give predictable results, and are a less expensive alternative to stabilize dentures and provide the comfort, function, and confidence patients are seeking. | Figure 4: Orthopantomogram showing four mini implants placed in the mandibular region
Click here to view |
In addition, it is a minimally invasive procedure and the reduced healing time associated with this procedure appeals to those adults who fear expensive surgical procedure and surgical co-morbidities. Added advantages include ease of replacement of the implant if lost, and simple housing pickup and denture reline when needed.[8],[9]
| Summary | | |
Older adults constitute a substantial group of people needing dental implant prosthesis. The major criteria for a successful implant are osseointegration, lack of pain, absence of pathologic problems, and crestal bone loss.
Implants-supported ODs have multiple advantages over conventional complete dentures and removable partial dentures. These include reduction in bone resorption, reduced movement of the prosthesis, improved occlusal function, better esthetics and phonetics, and equal load distribution and the maintenance of occlusal vertical dimension.[10]
Age alone should not be the exclusion criteria for geriatric patients who require replacement of their missing teeth using implants. Osseointegrated dental implants can be maintained well with the removable or fixed prosthesis, despite the age factor and also keeping in mind the array of factors which are responsible for a successful prosthetic outcome. Hence, all geriatric patients must be given a treatment option involving dental implants if it is a viable and better option for the individual.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Bryant SR, Zarb GA. Outcomes of implant prosthodontic treatment in older adults. J Can Dent Assoc 2002;68:97-102.  |
| 2. | Vorster C, André W, van Zyl. Prosthodontic treatment considerations and management of a frail 87-year old patient. Int Dent S Afr 2009;11:48-50. |
| 3. | Garg A. Dental implants for the geriatric patient. Dent Implantol Update 2011;22:49-52. [ PUBMED] |
| 4. | Balshi TJ. Implants and older patients. Prosthodont Insights 1995;8:1-6. |
| 5. | Engfors I, Ortorp A, Jemt T. Fixed implant-supported prostheses in elderly patients: A 5-year retrospective study of 133 edentulous patients older than 79 years. Clin Implant Dent Relat Res 2004;6:190-8. |
| 6. | Jemt T. Failures and complications in 391 consecutively inserted fixed prostheses supported by Brånemark implants in edentulous jaws: A study of treatment from the time of prosthesis placement to the first annual checkup. Int J Oral Maxillofac Implants 1991;6:270-6. |
| 7. | Misch CE. Contemporary Implant Dentistry. 3 rd ed. New Delhi: Elsevier publication; 2008. p. 293-347. |
| 8. | Kravitz ND, Kusnoto B. Placement of mini-implants with topical anesthetic. J Clin Orthod 2006;40:602-4. |
| 9. | Patel PB, Mascolo A. Minimally invasive implant therapy in geriatric patients using small diameter implants. Implant Pract 2011;4:18-20. |
| 10. | Ikebe K, Wada M, Kagawa R, Maeda Y. Is old age a risk factor for dental implants. Jpn Dent Sci Rev 2009;45:59-64. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
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