Revisiting implant controversies
The European perspective
The speaker highlighted the importance of a patient-centred perspective: adapting the technique to the patient, not vice versa. To this end, we need to know what the patient wants (Dierens et al., 2009). Patients generally want immediacy, but the practitioner wants predictability. The point is: how can we combine the two requests to achieve an ideal rehabilitation? (fig 6)
Immediate loading is highly predictable in full-arch fixed restorations
There have been a number of systematic reviews on this topic (nine since 2007, three of which were from 2019) which support the predictability of immediate loading compared to other loading options. But all studies emphasise higher risks with immediate loading.
The higher reported risk could be due to the inclusion of removable and partial prostheses in the studies. With total fixed restorations, it can be assumed that immediate loading is highly predictable (probably because the stability of the full-arch limits micromotion) (Sanz-Sánchez et al., 2015). Osseointegration does not require an absolute absence of load, but does require minimal micromotion in the bone-implant interface (Szmukler-Moncler et al., 1998).
Immediate loading is not a predictable option for every patient: there are critical factors
It has been shown that immediate loading is more predictable in the mandible than in the maxilla. Further, tobacco, periodontitis, diabetes, bruxism are all risk factors whose presence should make us reconsider the suitability of immediate loading approaches (Caramês et al., 2006). The speaker outlined some critical factors involved in the immediate loading approach which should be carefully assessed (Gapski et al., 2003):
- related to the patient: healing capacity, anatomical considerations
- related to surgery: primary stability, surgical technique
- related to occlusion: cross-arch stabilisation, force and intensity vectors, prosthesis design and material
- related to the implant: number and distribution, design and length, surface
There is no one solution that suits all patients. Different levels of atrophy require different rehabilitation approaches. Each patient is different, therefore in each case the technique must be tailored to fit the minute details of each patient.
The speaker proposed a classification system to help decision making (Caramês et al., 2017) (fig 7–8). This is based on the degree of bone atrophy both in anterior and posterior areas. Cases are classified in five categories: I, II, III, IV and V, for mandible and for maxilla. For each category, a treatment option (A) is proposed and an alternative option (B), depending on the particular preferences of each patient.
In some atrophic cases, anatomy needs to be restored before we can proceed with implant placement. Sometimes, tilted implants may provide a ‘graftless’ solution for patients who prioritise speed. An ongoing retrospective study on 3,795 implants with up to 7-year follow-up has found cumulative survival rates (CSR) of 95–99% in the maxilla, and 98–100% in the mandible (fig 9).
For definitive restorations, the speaker recommended monolithic zirconia with ceramic veneers on anterior teeth to improve aesthetic appearance (Caramês et al., 2019).