Implant treatment in the elderly
Implant treatment in the elderly
Introduction
1- Definitions.
2- Reminder on the physiology of aging.
3- Classification of elderly patients
4- Benefits of implantology in the elderly.
5- Contraindications of implant treatment.
6- Influence of aging on implantology.
6-1- Impact of aging on bone tissue .
6-2- Impact of aging on periodontal and mucosal tissues.
6-3- Impact of aging on the salivary glands .
7- Support for the elderly in implantology 8- Implant rehabilitation of the elderly:
7-1- the fixed supra-implant prosthesis.
7-2 – the complete removable prosthesis stabilized by implant.
Conclusion
Bibliography
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Introduction :
Requests for maxillary implant rehabilitation have really emerged in recent years among the elderly, motivated by the improvement of quality of life .
However, these are patients whose vulnerability is increasing due to the modification of sensory and psychological functions. The loss of a functional capacity (example of chewing due to loss of teeth ) is a destabilizing factor that can lead to a situation of rupture when the subject’s capacity to adapt is exceeded.
1- Definitions :
Dental implant : permanent invasive medical device in the form of an artificial ASMS root inserted into the bone of the mandible or maxilla and intended to create a strong and durable anchor on which an element will secondarily adapt
prosthetic .
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Osseointegration : In 1985, Brånemark defined osseointegration as a direct anatomical and functional junction between living bone remodeled at the surface
of an implant supporting a prosthetic load .
2- Reminder on the physiology of aging :
The aging process is complex and multifactorial,
Anatomical and physiological changes of old age begin several years before the appearance of external signs.
There are many theories explaining the mechanisms of aging. Two categories
emerge: Genetically programmed aging.
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Disorganization of the genetic apparatus following damage suffered during the
life : Bad and toxic eating habits, environment, ultraviolet [UV] rays, ozone , radiation.
These two theories are not mutually exclusive; they are probably intertwined.
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These two mechanisms will cause changes that occur at all levels; first at the cellular level then at the metabolic level, leading to changes in the functioning of the organism and bodily appearance.
3- Classification of elderly patients :
The elderly patient population can be divided into 3 categories:
1.1 The independent autonomous patient :
He does not have any serious pathology and is not following any restrictive treatment;
He is considered an “ordinary” patient, and should not be included in the sample of patients in geriatrics .
1.2 The motor- dependent or weakened patient :
He is generally in good health but suffers from marked osteoarthritis, severe rheumatism, etc. which make it difficult to move around , or even require him to use a wheelchair, which means he must be accompanied.
1.3 The medically dependent patient :
He suffers from illnesses requiring constant care;
It may also be a patient with dementia or Alzheimer’s disease .
He is totally dependent, treated most often in a long-stay geriatric hospital.
or at home.
These last two categories are part of geriatric care.
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4- Benefits of implantology in the elderly :
POTENTIATION OF CHEWING
Masticatory efficiency increases significantly after implant therapy. In addition, it is noted that the number of chewing cycles before swallowing is significantly reduced and the size of swallowed food particles is reduced .
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IMPROVEMENT OF PHONATION
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An improvement in phonation with implant-supported removable prostheses by an increase in retention, stability, inclination and position of the incisors as well as lip support.
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LONG – TERM BONE CAPITAL PRESERVATION
Resorption of jaw bone volume is a continuous physiological phenomenon during adult life.
Tooth loss is inevitably accompanied by the melting of the alveolar bone which forms and disappears with the teeth and in the absence of stimulation.
After dental implant placement, the stability of the bone surrounding the implant is quite remarkable.
Thus, placing a judicious number of implants in a jaw helps to preserve the existing bone capital.
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IMPROVED AESTHETICS
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The creation of an implant-supported prosthesis can allow for a more aesthetically and functionally adequate assembly than in the case of a conventional complete prosthesis.
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PRESERVATION OF HEALTHY DENTAL STRUCTURES
The conventional bridge , which for decades was the standard for the treatment of intercalated edentulism, is now becoming obsolete especially if the teeth adjacent to the edentulism are healthy because the preparation of intact teeth is considered iatrogenic.
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PSYCHOLOGICAL AND PSYCHOSOCIAL BENEFITS
The marked improvement in masticatory capacity and comfort obtained by anchoring removable prostheses on implants is accompanied by an increase in self-confidence and quality of life with a significant improvement in patient satisfaction and better psychosocial functioning.
5- Contraindications to implant treatment in geriatrics : Certain medical pathologies can also limit or contraindicate implant placement .
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The risks incurred in implant treatments are subdivided into anatomical , operative, biological and mechanical risks.
Anatomical risks include limited bone volumes and proximity to anatomical structures. In the maxilla, the proximity of the nasal fossae and maxillary sinuses may limit implant placement. In the mandible , the anatomical structures to avoid are the mental foramen and the inferior alveolar 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. Insufficient bone volume increases the risks of
bone fractures, especially in the mandible.
Regarding operative risks , infections, hemorrhages and hypoesthesia are the main problems encountered.
Lack of osseointegration as well as fractures of implants or
are respectively the obstacles linked to biological and mechanical risks .
supra structures
Relative or absolute contraindications are linked to conditions for which the surgical procedure is risky . These contraindications are: Systemic risks
Heart diseases at risk of infective endocarditis
● Congenital and acquired immune deficiencies ( AIDS )
• Serious bone metabolism disorder (osteomalacia, osteoporosis,
Paget’s, osteogenesis imperfecta )
• Diabetes
● Anticoagulant treatments
● Conditions treated with immunosuppressants or long-term corticosteroids
Conditions treated with IV bisphosphonates
Heavy smoking
Psychiatric illnesses and psychological disorders
● Cervico – facial irradiation , the main danger is osteoradionecrosis
Periodontal diseases
● Poor or neglected oral hygiene
Advanced age is not a contraindication to dental implants , however it is important to ensure the patient ‘s general condition , manual dexterity and mental fitness to receive implants .
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On the other hand, in children or adolescents, various studies show that the implant behaves like an ankylosed tooth and does not follow the vertical growth of the jaws . It is therefore imperative to wait until the end of jaw growth before considering implant therapy in adolescents.
6- Influence of aging on implantology : 6-
1- Impact of aging on bone tissue :
Aesthetic consequences of bone resorption
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Decreased facial height and loss of mentolabial angle – Further reading
vertical lines in the lips and face.ivnb
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The chin turns forward – giving a prognathous appearance.
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Decrease in the horizontal labial angle of the lip (giving the appearance of a
unhappy ) .
Loss of tone in the muscles of facial expression. ciyob suroup
Vermilion thinning of the lips.
Deepening of the nasolabial folds.
Increase in the length of the maxillary lip , so fewer teeth appear at rest and when smiling (the aged smile )
Ptosis of the mental muscles leading to a “ witch ’s chin ” appearance
Cortical resorption, both vertically and in the vestibulolingual plane, can be a source of difficulty in the choice of implant sites and implants. The reduction in bone trabeculation and mineral fraction is also a factor that reduces the potential for force absorption and must therefore be taken into account in the duration of the healing period , in the choice of the number and in the distribution of implants on the edentulous ridge.
6-2-
Impact of aging on periodontal and mucosal tissues : With age , the functional arrangement of collagen and elastic fibers present in the lamina propria and in the lamina propria changes to
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then gradually disappear and give way to diffuse fibrosis . The number and distribution of blood vessels also change , which suggests a degeneration of the surface circulatory system , more marked in very elderly subjects.
The alterations are multiple but we mainly remember the underlying dystrophic modifications and a reduction in defenses against external aggressions , whether microbiological or traumatic, exposing the patient to a risk of delayed healing or infection after dental implant placement .
6-3-
Impact of aging on the salivary glands
With age, the probability of developing one or more chronic pathologies increases. The treatment of these pathologies, which is most often based on the prescription of neuropsychotropic drugs, antihypertensive drugs , antiarrhythmic drugs , cholinergic antiulcer drugs and , in general , all sympathomimetics, atrophic drugs and antihistamines, has a high chance of inhibiting salivary secretion.
A vicious circle is therefore established with the cumulative and prolonged effect of hyposialia which
will result in:
An alteration of the mucous membranes and the periodontium.
A decrease in salivary flow has therefore
as a consequence.
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An alteration of taste perception.
Appearance of fungal infections.
This results in difficulty in prosthetic rehabilitation , particularly implant-supported.
7- Support for elderly people in implantology :
The elderly patient has a reduced capacity for adaptation , particularly in stressful conditions ( surgical intervention, for example ) . Their vulnerability being increased , this results in specific care with:
– Clear answers from the practitioner for the designated condition;
Special attention is required due to the psychological and functional impact caused by the impairment linked to the disability.
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The anamnesis does not exclude any detail of the patient’s speech and each disorder detected must be confirmed by the treating physician.
Careful assessment avoids:
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Failure to comply with an operative contraindication ;
A prescription incompatible with the prescription issued by the attending physician .
Underlying diseases (often multiple pathologies) in the elderly
amplify the operative risk.
The care of elderly people for implant rehabilitation is complex in that it must be adapted to their state of health. This is why the preoperative assessment must be individualized ; if the elderly person does not present any deterioration in their general condition, implant rehabilitations with or without bone augmentation are one of the strategies to prevent aging.
The surgical procedure has a more severe effect on the elderly and induces a response from the body with:
neuro-hormonal (bradycardia and tachycardia ) ;
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enzymatic (proteolytic enzymes); – immunological
(susceptibility to infection).
8- Implant rehabilitation in the elderly :
8-1- The fixed supra- implant prosthesis : Defined as a fixed prosthesis
covering the implants. Used mainly in an independent patient
autonomous.
8-2- Complete removable prosthesis stabilized by implant ( PACSI ) : Defined as a complete prosthesis covering the implants using them to improve retention, support , stabilization. Used especially in an elderly patient with reduced autonomy,
engine dependent or weakened
The indication of PACSI :
PACSI have their own indications compared to fixed prostheses:
When the offset of the bone bases is significant, heavy bone reconstruction work is necessary in fixed prosthesis in order to obtain implants well positioned in relation to the prosthetic corridor.
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wb-When bone resorption is advanced , and bone quality remains insufficient ,
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The same is true : heavy bone reconstruction is required with a fixed prosthesis . Choosing a PACSI offers a treatment plan that is easy and effective for both the practitioner and the patient.
PACSI has an aesthetic advantage over fixed prosthesis when the smile is gummy and lip support is not sufficient; fixed prosthesis will be contraindicated .
The inability to ensure daily maintenance of fixed prostheses due to loss of dexterity calls into question the durability of fixed treatment ; the hygiene of removable prostheses is easier.
The duration of treatment: their courage and their patience do not always correspond to the ambitions of the practitioners ; PACSI seems more indicated .
The limits of PACSI :
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The financial aspect : the cost of PACSI is higher than that of prostheses
conventional.
Failures of osseointegration.
Maintenance and reintervention required : relining , changing retention means.
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In general , the number of mandibular PACSI is much higher compared to maxillary PACSI, this observation is explained by the fact that a well -made maxillary PAC gives satisfaction due to a large support surface , in addition in the maxilla at least four implants are necessary , which increases the cost and reduces demand . It should be noted that the survival rate of mandibular implants supporting a PACSI is higher than that of implants supporting a mandibular PACSI due to the bone quality : thin maxillary cortex , little trabeculated bone type 3 or 4 .
The indication at the maxillary level arises in the case of a highly resorbed crest, this resorption results from the overload caused by the presence of longer mandibular teeth.
Patients become totally edentulous later and later, this trend is associated with advanced bone resorption , particularly at the sinus level.
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The possibility of placing four implants therefore means overcoming anatomical obstacles . In elderly patients, the solution of a maxillary or mandibular PACSI seems simpler to perform compared to fixed rehabilitations, in addition, the decrease in dexterity and the ability to ensure good oral hygiene depending on age , favors removable solutions.
Carrying out a PACSI :
At the maxillary level : The implants must be connected by a bar whose orientation must ideally be parallel to the frontal plane . Four implants take the shape of a trapezium , they are symmetrical with respect to the median sagittal plane. The minimum length must be
10mm.
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At the mandibular level : The location of the implants must be symmetrical in the parasymphyseal region, they are located between the two mental foramens. This site is very favorable due to the absence of anatomical obstacles and the frequent possibilities of supports.
bicortical.
The authors agree that two parasymphyseal implants are sufficient in mandibular PACSI if their lengths are at least 10 mm and primary stability is good.
Ideally, the implants should be positioned in place of the canines.
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Choosing the attachment system : An attachment system consists of two parts: the male or mother part , and the female or matrix part .
The attachment system provides the link between the PACSI and the intraosseous implants . It must be sufficiently effective to ensure satisfactory secondary retention , it must be sufficiently loose to facilitate the removal of the PACSI for the patient’s hygiene and rest phases.
Implants and the attachment system contribute to secondary retention . The different types of attachment systems :
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Retention bars and unit attachments are the most effective systems .
Magnet systems should be avoided, they corrode and lose their effectiveness over time.
The telescope system .
PACSI implementation : prosthetic treatment modalities :
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Cases where the patient’s prosthesis is reused :
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The prosthesis is hollowed out at the intrados level in order to accommodate the female parts.
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Protect the implant heads with paper and insulation.
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The female parts are clipped onto the implant heads.
Self-curing resin is introduced into the intrados and the prosthesis is
mouth by adjusting occlusion and positioning.
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Plan for relining to adjust the mucosal support.
Cases where the prosthesis is made in the laboratory :
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Taking impressions directly on the implant heads.
Removing the imprint.
Insertion of implant analogues into the intrados of the impression.
Casting the model.
Clipping the female parts.
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Creation of the prosthesis using resin teeth positioned in the wax
using the same process as a complete prosthesis with exclusive support
mucous.
Mounting on articulator, checking occlusion and positioning of teeth , adjustments.
Putting in mitten.
Trying on the prosthesis on a model.
Clipping the prosthesis onto implants in the mouth.
Conclusion :
Dental implantology now occupies a prominent place in our therapeutic approach to edentulism. In the field of removable prosthesis, implants can reduce discomfort and instability as well as increase functional capacity and consequently improve masticatory efficiency. At the same time, it is important to recognize the positive effects of this type of treatment on the well-being and quality of life of elderly patients as well as the favorable influence on their psycho- medical -social context.
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Bibliography :
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Mondié J.-M. Geriatric stomatology. EMC ( Elsevier SAS , Paris ) , Stomatology, 22-052-A-10, 2006.
2. Misch , Carl E. Dental implant prosthetics / Second edition. ELSEVIER 2014
M.DAVARPANAH et Al . Manual of Clinical Implantology / 3rd edition . Cdp
2014.
3. Carlsson , G. E. and L. W. Lindquist (1994) . “Ten – year longitudinal study of
masticatory function in edentulous patients treated with fixed complete dentures on osseointegrated implants.” Int J Prosthodont 7( 5 ) :448-53.
4. Heydecke , G. , D. Locker , et al . (2003 ) . “ Oral and general health- related quality of life with conventional and implant dentures.” Community Dent Oral Epidemiol 31(3): 161-8.
5. Graser , G.N. , ML Myers , et al . ( 1989 ) . “Resolving aesthetics and phonetics
problems associated with maxillary implant – supported prostheses. A clinical report.” J Prosthet Dent 62( 4 ) : 376-8.
6. Tallgren , A. ( 1972 ). “ The continuing reduction of the residual alveolar ridges in
complete denture wearers: a mixed-longitudinal study covering 25 years.” J Prosthet Dent 27(2): 120-32.
7. Bryant , S. R. and G. A. Zarb ( 2003 ) . “Crestal bone loss proximal to oral implants
in older and younger adults.” J Prosthet Dent 89 ( 6 ) : 589-97.
8. Hess , D. , D. Buser, et al . ( 1998 ) . “ Aesthetic single-tooth replacement with implants:
a team approach.” Quintessence Int 29(2): 77-86.
Wisdom teeth can be painful if they are misplaced.
Composite fillings are aesthetic and durable.
Bleeding gums can be a sign of gingivitis.
Orthodontic treatments correct misaligned teeth.
Dental implants provide a permanent solution for missing teeth.
Scaling removes tartar and prevents gum disease.
Good dental hygiene starts with brushing twice a day.