Implant treatment in the elderly

Implant treatment in the elderly

Gerodontology currently straddles the line between oral medicine and lifestyle. It addresses both juvenile and frail elderly patients.

The characteristics of advanced age can be summarized by the four “i’s,” grouped in order of importance: instability, incontinence, impaired intellect, and immobility, generally leading to increasing dependence and even loss of autonomy. Along with the growing deficits, there is an increase in polypharmacy.

2. Risks, indications and contraindications:

The risks involved in implant treatments are subdivided into anatomical, operative, biological and mechanical risks.

Anatomical risks include limited bone volumes as well as proximity to anatomical structures.

In the maxilla, the proximity of the nasal cavities and maxillary sinuses can limit the placement of implants.

In the mandible, the anatomical structures to avoid are the mental foramen and the mandibular canal.

However, with advances in implant surface treatments and bone grafting or sinus filling techniques, it is becoming possible to use increasingly shorter implants with limited bone volumes (Nedir, Bischof et al. 2004). Insufficient bone volume increases the risk of bone fractures, particularly in the mandible.

Regarding surgical risks, infections, hemorrhages and hypoesthesia are the main problems encountered.

The lack of osseointegration as well as fractures of implants or superstructures are respectively the obstacles linked to biological and mechanical risks.

These contraindications are:

Relative or absolute contraindications are linked to conditions for which the surgical procedure is life-threatening or interferes with tissue healing.

• Heart diseases at risk of infective endocarditis
• Congenital and acquired immune deficiencies (AIDS)
• Serious bone metabolism disorder (osteomalacia, Paget’s disease, osteogenesis imperfecta)
• Diabetes
• Anticoagulant treatments
• Conditions treated with long-term immunosuppressants or corticosteroids
• Conditions treated with IV bisphosphonates
• Heavy smoking
• Psychiatric illnesses and psychological disorders
• Cervicofacial irradiation, the main danger is osteoradionecrosis
• Periodontal diseases
• Poor or neglected oral hygiene

Advanced age is not a contraindication to dental implants

Although scientific evidence excludes age as a contraindication, the use of dental implants in the elderly, or even the very elderly, is still not widespread despite an ever-increasing need for dental replacement.

For the following assumptions:

• Knowledge of implants among older people is low.
• The attitude of older people towards implant surgery limits the use of implants.
• The degree of dependency (living situation) reduces the acceptance of implant treatments.
• Unfavorable oral health status and poor quality of life in elderly people is related to a rather negative attitude towards implant treatment.

3. Removable prosthesis (complete/partial) stabilized on implant:

It is an osteo-muco-supported or muco-implant-supported removable prosthesis, called a stabilized cover prosthesis with additional retention, of which only the retention and stability are jointly ensured by the prosthesis and the attachments buried in the anterior region of the totally edentulous maxilla or mandible (and in the partially edentulous ridges). Support is ensured by the osteo-mucosal support surface.

Fasteners : A fastener is a mechanical device that joins; with or without the possibility of movement

; a removable prosthesis with dental or implant abutments. There is a wide variety of attachment systems.

This system must ensure a retention effect through an articulated connection.

Requirements:

Simplicity. Reduced volume. Biocompatibility. Easy hygiene. Activation/deactivation possible and easy. Sufficient retentive efficiency. Simple reoperation and maintenance.

1. Axial snap-button connections:

It is a male-female attachment system. Most often the male part of the system is generally screwed onto the implant, the female part is adapted to the intrados of the prosthesis.

When positioning the prosthesis, the male part fits onto the female part which has the retention device (metal fins, elastic silicone rubber ring, nylon or Teflon capsule).

1. Mechanical axial connections:

are devices using metallic (precious or non-precious), elastic or viscoelastic (nylon, Teflon, silicone rubber) retention elements: Locator®; Dalbo® plus.

2. Magnetic axial connections:

The absence of a direct mechanical connection between the prosthesis and implants is the major characteristic of magnetic axial attachments. The direct transmission of functional stresses to the implants is limited. Two parts forming a magnetic unit.

2. The supra-implant conjunction bar:

The bar is a complementary retention system that connects the implants in place on the arch. This will help distribute the loads on the different implant abutments.

3. Number and positioning of implants:
   1. For total toothlessness:

the minimum therapeutic treatment in the maxilla is 4 implants, up to a maximum of 6 implants

2 central implants at the lateral incisor or canine level. The distal implants are placed as far back as possible.

Two parasymphyseal implants are sufficient in mandibular PACSI (according to the McGill Consensus).

Canine position is the most favorable

Outside of the McGill consensus, we can go up to 3 implants with axial attachments and 4 implants with Bar.

2. For partial edentulism:

The number and distribution according to the class of edentulism, bone quality and quantity.

Each case is treated individually, whether it is fixed or removable implants (we cannot standardize the design as for total edentulism).

Let’s take some examples: 4 implants (2 premolars and 2 molars), 2 distal implants

4. The implant-supported bridge (single/plural/complete):

* The complete bridge:

The design of an implant-supported bridge is similar to that of a tooth-supported bridge. These are prostheses without false gums on 8-10 implants placed beforehand.

The complete bridge on stilts:

A complete prosthesis reproducing teeth and gums is placed on implant pillars and away from the gum, hence its name prosthesis fixed on stilts.

It consists of a metal frame which screws onto the implant pillars (8 maxillary/6 mandibular) on which commercial resin teeth are mounted, secured using pink resin.

The ALL on Four bridge:

This technique proposed by MALO in 2003 makes it possible to carry out a

complete restoration with only four implants: two straight anteriors and two posteriors inclined at 45° .

The implants are placed in such a way as to avoid anatomical areas at risk: in the mandible, they are placed in the parasymphyseal region, in front of the mental foramina;

In the maxilla, they are placed in front of the anterolateral walls of the maxillary sinuses.

5. Therapeutic choice in elderly edentulous people:

Some particularities should be taken into consideration for this patient but are not systematically present in all patients, nor should they be grouped together in the same patient:

1. The choice between fixed unitary, plural and total (sealed/screwed) and removable (stabilized) therapy is made according to:

1. toothlessness: total, partial, remaining teeth (situation, value, prognosis), maxillary/mandibular
2. Resorption: inter-arch relationship (shift), surgery, implant choice
3. Aesthetics: smile line, false gum, implant axes, soft tissue support, visibility of hooks
4. Emergence profile
5. The available prosthetic space
6. Occlusion: chewing abilities, antagonistic arch, occlusal adjustment
7. Functional context: phonation (sounds, salivary leaks), swallowing (stability of bases, tongue)
8. Charging
9. Senescence is the element aggravating the situation . Indeed, even if he is healthy, this patient presents an involution of the oral tissues (the dental, mucosal and bone support surface). Again, if the patient presents a risky disease (syncopal, hemorrhagic, infectious) which can hinder healing or even vital prognosis. He may also present a disease or medication with prosthetic repercussions (alteration of dental and osteo-mucosal supports), This results in an accentuation of the danger already in progress. Consequently:

1. The design is analyzed at the time of pre-implant planning : the position, number, and distribution of implants must anticipate future loss of teeth or even implants, in order to be able to adapt the prosthesis in the event of future modification.
2. Precision in the work is required, and the use of three-dimensional planning, computer-aided layout, and CAD/CAM are of significant help compared to the traditional chain.

The accumulation of errors in the prosthetic chain, acceptable with young people and adults, becomes suspicious in gerodontology; they must be reduced as much as possible.

3. The implant phase:

Patients whose general condition does not allow complicated interventions may refuse the removable solution (although it remains indicated).

The flapless technique is favored in order to limit the duration of the session and avoid postoperative complications resulting from the discharge incisions, and complications due to the approximation of the edges by thread and stitches.

Bone and surgical grafts and augmentation techniques should also be avoided.

4. Conventional impression: High-viscosity silicones are preferable to plasters and polyethers for implant impressions because they have sufficient rigidity to position the implant and are non-irritating. When making impressions of the mucosal surface, fluid silicones are still preferred to polyethers and thiocols.

Very rigid materials fragment at undercuts and tear the mucous membrane, and allergenic and toxic products present in catalysts exert their toxic effect more on a fragile surface.

5. Indirect techniques for making temporary prostheses and securing attachments: avoid making the patient wait for a long time in a chair and protect them by minimizing free monomer in contact with the tissues.
6. Then, once the therapy has been established, monitoring and maintenance take on an important role: this terrain is evolving and unpredictable (compared to a young, healthy subject).

Complications and failure are expected in any patient, and even more so on such unstable ground.

Monitoring begins from the placement of the implant in order to control the state of the peri-implant tissues (periodontal treatment, management of peri-implantitis, osseointegration), and maintenance focuses more specifically on the implant-prosthetic elements (wear, fracture management, rectifications, relining with delayed resin without risk, replacement of parts).

6. Conclusion :

Implant treatment in the elderly maintains the same clinical reasoning for the choice of the ideal treatment , and the same therapeutic proposals with their indications. What differs is the prevalence compared to young and adult subjects. We find a predominance of the PACSI/PAPSI stabilized removable prosthesis for the reasons explained in the presentation. Then come the solutions fixed on implants (different types of bridges) which remain indicated as long as the clinical elements allow it.

Implant treatment in the elderly

  Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.
 

Implant treatment in the elderly