Revisiting implant controversies
No implants in the aesthetic zone
The use of dental implants in the aesthetic zone is one of the most important challenges of dentistry. To deal with this challenging area, we should keep an open mind, and consider possible alternatives to implants and think about other possibilities that we have perhaps forgotten.
Are the beautiful cases usually presented representative of real life?
The clinical reality seems to be different to what is presented in professional meetings. The speaker gave examples of several problematic cases which he had encountered in practice involving poor implant placement in the aesthetic area. These cases were a nightmare for the patient and required a great deal of therapeutic effort to correct. He cautioned the audience that the ‘beautiful’ cases that are sometimes presented may not always show the true extent of work required for the case (fig 5).
Unanswerable problems with implants
It is well known from the late sixties that implant placement in very young patients leads to disastrous results. This is because the jaws continue to grow, but peri-implant tissues do not. Even between the ages of 30 and 40, the alveolar process is still growing. Placing implants in the upper incisor area can therefore have a high aesthetic impact, due to the continued eruption of adjacent teeth (Huanca et al., 2017). Another study on implants placed in the premaxilla observed infra-occlusion in 73% of patients, and found it was more pronounced in women than men (Cocchetto et al., 2019).
We are still a long way away from our goal that implants could match the evolution of oral tissues over time. The speaker therefore outlined a number of potential alternative solutions for young and middle-age patients (fig 6).
1. Palatal implants
Palatal implants may be a good solution in young patients, despite the long lever arm (Wehrbein et al., 1996).
2. Resin bonded bridge
These are a very good alternative, especially for lateral incisors, and have a success rate of 92% (Kern et al., 2017).
3. Surgical extrusion
This is a solution that was proposed in the late seventies (Tegsjö et al., 1978). It consists of: root canal treatment; then extrusion; followed by stabilising for two weeks; a two-month healing period; and finally, preparations for receiving a crown (Kahnberg et al., 1988).
4. Orthodontic extrusion
Orthodontic extrusion is particularly indicated for bone fractures. It requires root canal treatment; and it is a good alternative to maintain dental structure.
5. Orthodontic space closing
In cases involving missing lateral teeth, the canines can be moved to the position of the missing laterals; implants are then placed in the premolar positions, which is easier to manage.
6. Sophisticated endo
In some cases, appropriate endodontic treatment can solve the problem without extracting the teeth.
In a case involving infrabony fracture, a central incisor needed to be extracted. An included mesiodens was extracted and transplanted to the extraction socket. The crucial factor was maintaining the integrity of periodontal ligament. Reported success rates for this technique are in the range of 75.3–91% (Machado et al., 2016).
8. External cervical root resorption
The management of external cervical resorption through endodontic treatment and composite reconstruction is another successful alternative (Patel et al., 2018).
9. Periodontal treatment
Periodontal treatment of hopeless teeth in the anterior area is a valid treatment option, to avoid extractions and complex and expensive regenerative treatments. A study by Cortellini and colleagues (not yet published) has found that after 10 years, the majority of observed hopeless teeth can remain in the patient’s mouth in a safe and healthy way with the appropriate periodontal treatment.
The speaker concluded by presenting his own daughter’s case, which involved external cervical resorption. He said that the best treatment option did not involve implant therapy, but in fact root canal treatment and restoration with a composite of resorption.