October 13, 2025 • 23 mins
A comprehensive overview of evidence-based implant dentistry, drawing upon the expertise of multiple dental professors. The content focuses heavily on clinical protocols and challenges associated with implant treatment, particularly addressing peri-implant diseases such as mucositis and peri-implantitis, emphasizing that cement-retained restorations pose a higher risk. Several chapters also discuss surgical considerations, including the use of CBCT and guided surgery, and the management of systemic and local risk factors like diabetes, smoking, and anticoagulation. Finally, the source evaluates various prosthetic designs and materials, including screw-retained versus cement-retained restorations, and the technical aspects of digital workflow and maintenance for edentulous patients.
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Episode Transcript
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Speaker 1 (00:00):
Welcome to the deep dive. Today, we're tackling something really substantial,
a core text on evidence based implant treatment. And our
goal here isn't just a quick overview, Oh definitely not.
We're aiming for a very detailed, comprehensive summary. I think
risk assessment, surgical techniques, materials all geared towards dental students,
(00:20):
younger professionals, or anyone really committed to self learning in
this field.
Speaker 2 (00:24):
Exactly. We're translating some pretty dense research into practical clinical insight,
and the whole philosophy we're exploring today really hangs on
one key idea ossio sufficiency.
Speaker 1 (00:35):
Okay, ossio sufficiency. That sounds like it might just mean
enough bone, but I get the feeling it's broader than that.
Speaker 2 (00:41):
Oh much broader. It's about the total state needed for
successful long term ossio integration. It's actually a triad, the patient,
the clinician, and the implant itself all working together.
Speaker 1 (00:54):
A triad.
Speaker 2 (00:54):
Yeah, and if one part isn't sufficient, you get what
the authors call ossio separation. And here's a really challenging point.
Right off the bat, they argue against the term implant failure.
Speaker 1 (01:05):
Really, what are they propose.
Speaker 2 (01:07):
Instead, they say, implants don't fail on their own, they're retrieved,
and that retrieval is usually down to issues with the
patient or the clinician much more than the implant device.
Speaker 1 (01:17):
Wow, okay, so the implant itself is maybe the least
critical factor in its own success. Right. That really puts
the focus back on us, the.
Speaker 2 (01:25):
Clinicians, precisely the burden of managing risk.
Speaker 1 (01:29):
Right. But before we even get to the patient or
the procedure, we have to talk about the foundation evidence
based dentistry EBED. How do we sort the good research
from well the noise in implantology.
Speaker 2 (01:43):
Well, the hierarchy is pretty clear. You've got your meta analysis,
systematic reviews, RCTs, randomized control trials. Those are the gold
standards at the top. Okay, animal studies, lab studies, case reports.
They provide information, sure that they shouldn't be driving our
clinical decisions directly.
Speaker 1 (01:59):
But even RCTs the gold standard, they have issues, right,
especially in a field like implants, where there's a lot
of commercial interest time cost.
Speaker 2 (02:06):
Exactly, and ethical constraints too sometimes. But beyond that, we
really need to watch out for bias too. Big ones
stand out first, allocation bias This is when the group's
being compared aren't truly similar from the start, like comparing
implants put in with high torque maybe for immediate loading
versus low torque implants needing a two stage approach.
Speaker 1 (02:27):
Ah, so you're not really comparing the loading protocols. Then
you're comparing different patient situations.
Speaker 2 (02:32):
You got it, You're comparing apples and oranges. Essentially. The
second big one is conflict of interest or COI bias.
Let's be honest, a lot of implant research is funded
by the industry, and studies show that research involving author
COI is just statistically more likely to report results favoring
the product or intervention being tested. We have to be
(02:53):
aware of that.
Speaker 1 (02:54):
And what about the studies that don't show positive results?
The issue of publication bias.
Speaker 2 (02:59):
That's a huge problem. Negative findings often just vanish journals funders,
they tend to prefer positive, exciting results. Yeah, but think
about it. Study showing a technique doesn't work, that's incredibly
valuable clinically, it stops us from going down dead ends.
Speaker 1 (03:13):
That makes perfect sense, which leads to another critical point
you mentioned statistical versus clinical significance.
Speaker 2 (03:20):
Oh, absolutely crucial. You might see a study showing a
statistically significant difference in say, bone loss, between two techniques.
Speaker 1 (03:28):
Right p value less two point zero five. Everyone gets excited, exactly.
Speaker 2 (03:31):
But then you look closer and the actual difference is
measured in nanometers. Nanometers, yeah, and as clinicians we work
in millimeters. A difference that small is clinically meaningless. Even
if it's statistically real. You always have to ask, does
this actually change my patient's outcome in a noticeable way?
Speaker 1 (03:51):
Good rule of thumb, and the sample size issue the end.
Speaker 2 (03:54):
Right, you see these big studies hundreds, maybe thousands of patients,
looks impressive, but then you realize that looking at so
many variables implant type, location, smoking status, bone density, length width, Ah, so.
Speaker 1 (04:06):
The actual number of patients relevant to one specific protocol
might be tiny.
Speaker 2 (04:11):
Precisely, every variable you add effectively slices the sample size.
Many studies are actually underpowered to draw the conclusions they
claim for specific scenarios.
Speaker 1 (04:19):
Okay, that's a really solid grounding in how to approach
the evidence. Let's apply that rigor now to the first
part of that triad, the patient factor. How do we
decide who's a suitable candidate?
Speaker 2 (04:31):
It starts with risk stratification. Generally, elective implant treatment is
for patients who are ASA classification I two or maybe
a stable three.
Speaker 1 (04:39):
Okay, what about higher risk groups like immunocompromise patients.
Speaker 2 (04:43):
The evidence there is pretty low level, mostly case reports,
case series, so the advice is extreme caution. Interestingly, some
reports show fairly normal outcomes even with long term cyclosporin
a use. But prudence is definitely the keyword.
Speaker 1 (04:59):
The diabetes up constantly.
Speaker 2 (05:00):
It does, and the guidance is clear. Uncontrolled diabetes is
a definite contraindication for elective implant surgery.
Speaker 1 (05:06):
We'll have about controlled or maybe borderline hyperglycemic patients.
Speaker 2 (05:09):
There's a specific protocol. First, confirm good glycemic control before
and after surgery. Second, allow a longer healing time minimum
four months. Third, use prophylactic antibiotics and ze point one
two percent core exitting rents. And fourth surgically aim for
longer and wider implants were possible, just to maximize that
(05:29):
bone to implant contact.
Speaker 1 (05:31):
That's quite a detailed plant shows how the patient's condition
directly shapes the clinical approach. How about anticoagulants warfarin heppron.
Speaker 2 (05:39):
For warfare and patients minor surgery, so not involving big
grass or flaps is generally okay. If the ion r's
two point five or less. If they're on heppern, you
need to check the PTT. If it's elevated, say one
point five times normal, you have to postpone.
Speaker 1 (05:51):
The surgery and recent heart attacker stroke. I know the
recurrence risk is high soon after, very high.
Speaker 2 (05:57):
Initially it's around thirty percent risk of another event if
you do elective surgery within three months, but that drops
significantly down to about five percent after a year. So
definitely delay elective procedures accordingly makes sense.
Speaker 1 (06:07):
Now the big lifestyle factors smoking and alcohol.
Speaker 2 (06:12):
Yeah, the destructive habits. Smoking is clearly linked to higher
failure ras almost double actually a relative risk of one
point nine to two wow, and it complicates things like
sinus lifts and only graphs too. Alcoholism is associated with
peri implantitis and a higher risk of infection, partly because
it can suppress the immune system, specifically T helper cells.
Speaker 1 (06:34):
Is there any good news there?
Speaker 2 (06:35):
Well? Yes, Stopping alcohol consumption before surgery can significantly lower
the risk of post operative complications, so cessation helps.
Speaker 1 (06:43):
Okay, And is there a contraindication that's less about physical
health and more about the patient's mindset.
Speaker 2 (06:50):
Absolutely unrealistic expectations. That's considered an absolute contraindication. You just
can't proceed if the patient doesn't understand the limitations or
potential outcomes.
Speaker 1 (06:59):
And for pas, maybe with neuropsychiatric conditions or issues with compliance.
Speaker 2 (07:03):
You have to think about long term maintenance. Prosthetic design
becomes key. Often removable options like overdentures are preferable because
they might be easier for the patient or even a
caregiver to manage. Flexibility is crucial.
Speaker 1 (07:15):
Got it. So we've assessed the patient thoroughly. Let's move
to the other two parts of the triad, the clinician
and the implant. Starting with surgical complications, Nerve injury is
obviously a major concern.
Speaker 2 (07:27):
It is for everyone involved. We use the Sunderlin or
set in classification I to V. Class I neuropraxia is
the mildest temporary numbness, usually recovers in under three months. Okay.
Class V neurotmesis is the most severe. The nerve is
actually severed and needs surgical repair.
Speaker 1 (07:45):
How do we assess that quickly if a patient reports numbness.
Speaker 2 (07:49):
Every clinician should have a simple kit ready, a cotton
tip for light touch, something sharp and dull for discrimination,
and something cold like ethyl chloride spray test immediately if
there's any report of altered sensation.
Speaker 1 (08:01):
Right. What about implants getting lost implant displacement.
Speaker 2 (08:05):
In the upper jaw of the maxilla. The most commonplace
for a displaced implant is the maxillary sinus. This usually
happens if initial stability wasn't achieved and the mandible the
bones dens are there, so it's less common, but if
stability is really poor, they can sometimes shift down into
the cancel's bone space below the intended site.
Speaker 1 (08:22):
Okay, let's tuck site development building bone maxillary sinus grafts
the lateral window approach. Those are pretty reliable, right.
Speaker 2 (08:32):
Generally, Yes, success rates are high, often quoted around ninety
ninety six percent, especially when using rough surfaced implants and
often zenogeneic graft. Materials and techniques have improved definitely. Things
like pisoelectric surgery or specialized kits like the desk system
have really helped reduce the risk of carrying that sinus
membrane during the procedure, which used to be a common complication.
Speaker 1 (08:53):
But what if you need vertical height vertical ridge augmentation.
Speaker 2 (08:57):
That sounds trickier, much trickier, and much The complication rates
jump significantly, somewhere between twenty and sixty percent.
Speaker 1 (09:04):
Wow, that's high.
Speaker 2 (09:05):
Why it's almost always due to the barrier membrane getting
exposed leading to infection. Astead distraction can sometimes be an
alternative for vertical gain, but it doesn't work well if
the ridge is also very thin. So yeah, vertical augmentation
needs a very careful risk benefit discussion with the patient understood.
Speaker 1 (09:22):
How about immediate implant placement IPP, especially in the front
the esthetic zone. It's popular, but the criteria must.
Speaker 2 (09:30):
Be strict, incredibly strict, non negotiable.
Speaker 1 (09:32):
Really.
Speaker 2 (09:33):
You need five things. First, intact socket walls all around. Second,
the facial bone wall must be at least one millimeter thick,
and you need to maintain about a two millimeter gap
between the implant and that facial bone.
Speaker 1 (09:45):
Okay, that gap is for grafting.
Speaker 2 (09:46):
Exactly, usually filled with the slow resorting graft. Third, you
need a thick soft tissue biotype. Fourth, no active infection
in the socket. And fifth you absolutely must achieve good
primary stability, usually engaging bone beyond on the socket apex
or on the palatal side. Miss any of those and
the risk goes way up.
Speaker 1 (10:05):
And managing the soft tissue, especially the papilla between implants, yeah,
that's notoriously difficult. It is.
Speaker 2 (10:10):
The papilla height between two implants just doesn't reach the
same level as between an implant and a tooth, or
an implant and a pontic. You get maybe three point
four or three point five millimeters between implant.
Speaker 1 (10:19):
Compared to maybe five point five next to a pontic.
Speaker 2 (10:22):
Right, So, to preserve the bone peak that supports that papilla,
you need a minimum of three millimeters of bone between
the implants themselves edge to edge. Using narrower implants can
sometimes help achieve that space.
Speaker 1 (10:35):
Good point. Lastly, under surgical protocols, loading times immediate early conventional,
Do we always need to wait months?
Speaker 2 (10:46):
Well? The evidence, particularly for healed posterior sites, is interesting.
Five year survival rates seem pretty similar whether you load
immediately within a wind early one week to two months,
or conventionally after two months.
Speaker 1 (10:58):
Really similar survival.
Speaker 2 (10:59):
Yes, But and this is a big but, only if
you achieve excellent initial stability. That means high insertion torque
typically quoted above twenty to forty five Newton centimeters or
an ISQ reading over sixty or sixty five. Without that stability,
immediate or early loading is much riskier.
Speaker 1 (11:15):
Okay, that stability is the key prerequisite. Now let's shift
gear slightly. This is where I think things get really
fascinating and maybe a bit counterintuitive. The main cause of
long term biological problems materials technical issues.
Speaker 2 (11:26):
Right, let's talk pery implant diseases. We've got pery implant
mucositis PIM. That's inflammation, reversible, no bone loss yet, and
very common, maybe around fifty percent prevalence. Okay, Then you
have peri implant titis PI. Then volves progressive bone loss
also worryingly common. Figures range from twelve percent up to
(11:46):
forty percent of sites, depending on the study and definition.
And PI is generally seen as a progression from PM.
Speaker 1 (11:52):
So what drives that progression? Poor hygiene plaque.
Speaker 2 (11:55):
That's part of it, Yes, like periodontitis. But the source
material we're reviewing is very clear on this. The single
most likely factor initiating or exacerbating PI leading to eventual
implant loss is residual cement.
Speaker 1 (12:08):
Residual cement really more so than plaque. That kind of
goes against some traditional teaching.
Speaker 2 (12:12):
It does challenge it. But the thinking is this. Cements
designed for teeth often have properties like fluoride release or
antimicrobial agents. These can actually be irritants or toxic to
the very delicate biological seal around the implant abutment connection.
Speaker 1 (12:26):
So what's good for a tooth isn't necessarily good for
an implant interface exactly.
Speaker 2 (12:31):
And once that cement gets extruded into the sulcus, it's
a foreign body, a plaque trap, and a source of
chronic inflammation. So minimizing extrusion is paramount. The safest way
to do that from a margin perspective, keep them super
genable clearly above the gum line.
Speaker 1 (12:46):
But sometimes you need subjugable margins for esthetics. So if
you have to use cement, how do you stop it
squeezing out?
Speaker 2 (12:52):
There are techniques. One is the copy abutment technique, basically
making a little jig to squeeze out excess cement outside
the mouth before you seat the crown. But more effectively,
you can modify the abutment itself how So, two main
ways described are the open abutment or OA, which leaves
the space, or the internal vented abutment IVA. The IVA
(13:13):
involves drilling small vent holes inside the abutment bent holes. Yeah,
so when you seat the crown, the excess cement flows
into these internal vents instead of out into the sulcus.
It's shown to dramatically reduce extrusion and interestingly, can sometimes
even increase the crown's retention force.
Speaker 1 (13:29):
That's clever. This whole cement issue feeds directly into the
big debate screw retain versus cement retained restorations. What's the
overall risk profile?
Speaker 2 (13:39):
Well, based on the cement risk, cement retained crowns tend
to have higher rates of biological complications meaning PM and PI.
Screw retain restorations, on the other hand, tend to have
more technical complications, things like the access screw loosening or
maybe the porcelain chipping around the access hole.
Speaker 1 (13:56):
So which way do clinicians lean?
Speaker 2 (13:58):
Because dealing with biological complications like PI is often much
harder and less predictable than fixing a technical issue, and
because retrievability is so important for cleaning or repairs, Screw
retention is often favored, especially for more complex cases or
posterior teeth makes sense.
Speaker 1 (14:14):
Let's talk biomechanics. We often hear about aiming for axial
loading straight down the implant, but you mentioned earlier human
chewing forces aren't purely axial.
Speaker 2 (14:23):
They're really not, and successful concepts like all on four,
which rely heavily on tilted, non actually loaded implants, kind
of prove that non axial loading is okay, provided the
forces don't exceed the fatigue limits of the components or
the bones capacity.
Speaker 1 (14:38):
Does the type of implant connection matter much here? External
hex versus internal.
Speaker 2 (14:43):
It does have implications. External hex connections, especially on single crowns,
are notoriously more prone to screw loosening. Internal connections are
generally better for stability, but can be subject to different
stresses like hoop stress, outward forces on the implant wall.
Speaker 1 (14:58):
What about patients who grow heavily bruxism That must be
a major risk.
Speaker 2 (15:02):
Factor, huge risk for mechanical complications. Screw loosening, component fracture,
porcelain chipping management involves several strategies. Is using really strong
monolithic materials thinks solid zirconia or maybe gold avoiding or
minimizing cantilevers on the prosthesis, ensuring the restoration is easily
retrievable for repair, and recommending night guards or occlusal splints,
(15:26):
although the hard evidence supporting their effectiveness and preventing implant
complications is actually somewhat limited.
Speaker 1 (15:32):
Interesting and passive fit How critical is that?
Speaker 2 (15:35):
Absolutely critical for the long term health of all the components.
Misfit creates stress. The exact tolerance level is hard to define,
but we know cad CAM fabrication and techniques like laser
welding have helped improve fit significantly compared to older casting methods.
Speaker 1 (15:51):
Does cement help compensate for minor misfit.
Speaker 2 (15:53):
It can yes. In cement retain restorations, the cement layer
can act as a bit of a slop factor, potentially
reduce using stress from minor inaccuracies. That's one small argument
sometimes made in its favor despite the biological risks.
Speaker 1 (16:06):
Let's touch on the digital workflow, CBCT scans and guided surgery.
What's the evidence say?
Speaker 2 (16:11):
CBCT is strongly supported, fantastic tool for diagnosis, planning and
patient communication, no question there, and surgical guides guided surgery
generally reduces inaccuracy compared to placing implants freehand. That's documented. However,
it's not perfectly accurate because errors can creep in at
multiple stages the scan, the planning software, the guide fabrication,
(16:34):
the fit of the guide in the mouth, the drills.
It's a cumulative error chain, so not fool proof. Definitely
not and fully guided flapless surgery, especially in completely identialist
jaws where you have no teeth for stable support. That
requires extreme caution and experience. You can't see the bone directly.
Tooth supported guides generally offer better accuracy than guides resting
(16:56):
only on soft tissue or bone.
Speaker 1 (16:57):
Good to know. Yeah. Finally, on materials mentioned monolithic zirconia
alpha materials evolved overall well.
Speaker 2 (17:04):
Older ceramics like lusite reinforced or aluminum based ones have
kind of plateaued in development. The big shift has been
towards higher strength materials. Lithium disilicate like IPS max is
widely used strong.
Speaker 1 (17:15):
Aesthetic around four hundred MPa for press.
Speaker 2 (17:18):
Yeah, about four hundred pressed, maybe three sixty for the
cadcam blocks. And then zirconia, which is even stronger, especially
the monolithic solid forms which are great for bruxers because
you avoid the risk of the layering porcelain chipping off
out of buttments.
Speaker 1 (17:32):
Are stock A buttments still common, less.
Speaker 2 (17:34):
So for final restorations, especially in the esthetic zone. Custom
Cadcama buttonmons either titanium or zirconia are becoming standard, and
we're seeing more of the hybrid abutment concept. That's a
titanium base for the connection strength bonded to a zirconia
upper structure for tissue response and esthetics. Best of both
worlds potentially.
Speaker 1 (17:53):
Okay, comprehensive overview of the technical side. For our last segment,
let's tackle the really complex scenario, the fully identialist patient
and maxilla facial reconstruction.
Speaker 2 (18:04):
Right, And the first point the sources make here is
actually a critique of dental education. Yeah, lamenting that traditional
complete denture prosidontics is sometimes marginalized. This means clinicians might
jump to implants without first truly maximizing what a conventional
denture can achieve, really nailing down things like border molding,
poster palatal seal, checking the vibrating line properly. You have
(18:27):
to master the basics first.
Speaker 1 (18:28):
That's a fair point. So assuming conventional options are exhausted
or insufficient for the identialist maxilla upper jaw. When is
an implant over denture an IOD preferred over a fixed bridge.
Speaker 2 (18:42):
An IOD is often the better choice when there's significant
bone or soft tissue loss that requires support for the
lips and face, something a fixed bridge can't provide, or
when hygiene access is a major concern, which is often
the case for elderly patients or those with dexterity issues.
Speaker 1 (18:55):
How many implants typically for a maxillary IOD, four to.
Speaker 2 (18:59):
Six implants generally provide successful stable.
Speaker 1 (19:02):
Retention and the manible the lower jaw.
Speaker 2 (19:04):
For the manible the implant retained overdensure, usually on two implants.
IROD is considered almost a standard of care now. It
offers a massive improvement in stability, chewing function, and overall
quality of life compared to a conventional lower denture, which
notoriously floats around.
Speaker 1 (19:21):
Huge difference for patients. What about the absolute highest risk
cases patients have had radiation therapy to the head and neck.
Speaker 2 (19:28):
Those are incredibly challenging. Irradiated bone, especially in areas like
the frontal bone, has a very high implant failure rate
due to poor healing potential osteo radiantcrosis risk. Is there
anything that helps, Yes, Hyperbaric oxygen therapy HBO. The data
is quite striking. One review showed failure rates dropping from
around forty percent without HBO down to about eight point
(19:50):
five percent with the HBO protocol before and after surgery.
Speaker 1 (19:53):
That's a dramatic improvement, it really is.
Speaker 2 (19:55):
But success still depends heavily on the radiation dose received
and the implant specifics. Shorter implants in heavily irradiated bone
have the lowest survival rates. Meticulous planning is essential.
Speaker 1 (20:06):
And finally, using implants after major surgery for oral cancer, macalectomies,
and bulectomies.
Speaker 2 (20:11):
Implants become absolutely critical.
Speaker 1 (20:13):
In these cases.
Speaker 2 (20:14):
For patients who've lost part of their jaw, implants might
be the only way to adequately retain and stabilize an
opperator or an overlay prosthesis, especially if they've had reconstruction
with say a fibula free flap.
Speaker 1 (20:27):
So implants enable function again.
Speaker 2 (20:28):
They enable function stability chewing, but it's not straightforward. Often
you need secondary surgeries around the implants to thin bulky
soft tissue flaps or graft attached gum tissue palad all
graphs are often preferred to create a healthy, stable, cleansible
tissue interface around the implant posts.
Speaker 1 (20:46):
Wow, okay, we have really covered a massive amount of
ground here, from the foundations of EBD, through patient risks,
surgical details, materials, complications, and these very complex reconstructions. It
feels like it all comes back to that first concept
you introduced.
Speaker 2 (21:01):
It absolutely does. If we loop back to that ossio
sufficiency triad, patient clinician implant. The core message from this
deep dive echoing the source material is pretty humbling. The
implant itself is the least influential factor. Success or failure
or rather, retrieval hinges primarily on the patient factors and
the clinician's skill, judgment and management.
Speaker 1 (21:23):
Which brings us to the application. How do we put
all this detailed knowledge together in practice time for that
synthesis challenge?
Speaker 2 (21:29):
All right, let's test that synthesis. Imagine the scenario. You
have a patient presenting they're a heavy smoker, they have
controlled type two diabetes, and they need an immediate implant
placed in the esthetic zone, say replacing an upper incisor.
Based on everything we've discussed today, all the risks, the protocols,
the evidence. What three specific key risk mitigation strategies must
you prioritize in your treatment plan and in that crucial
(21:52):
informed consent discussion.
Speaker 1 (21:53):
Okay, pulling it all together, that requires integrating points from
across our whole discussion based on the evidence reviewed, I'd
say the absolute priorities have to be first, addressing the smoking,
a serious conversation about cessation or at least reduction, plus
emphasizing impeccable oral hygiene commitment. That's non negotiable good number one. Second,
(22:15):
managing the diabetes very carefully confirming that strict glycemic control
before and after surgery, and definitely implementing those prophylactic measures
the chlorhexidine rents the antibiotics.
Speaker 2 (22:27):
Right, managing the systemic factor and number three.
Speaker 1 (22:30):
Number three has to be about the surgical and restorative execution,
especially for IAPP and the esthetic zone. That means rigorously
confirming you meet the criteria thick tissue biotype, ensuring you
have or can graft to get at least that one
point five to two millimeter buckle bone gap, and critically
planning the final restoration with supergingual margins if at all possible,
(22:50):
or using those vented abutment techniques to drastically minimize the
risk of cement extrusion.
Speaker 2 (22:55):
Excellent. That's that integrated thinking, combining patient management systemics, surgical
site prerequisites, and restorative design based on known risks. That
is the essence of applying evidence based principles. It's moving
beyond just knowing the facts to achieving clinical mastery.
Speaker 1 (23:12):
Keep synthesizing that knowledge, keep questioning the evidence, and keep
focusing on how you can master that assio sufficiency triad
for every patient you treat. Thanks for joining us for
this deep dive
Welcome to the deep dive. Today, we're tackling something really substantial,
a core text on evidence based implant treatment. And our
goal here isn't just a quick overview, Oh definitely not.
We're aiming for a very detailed, comprehensive summary. I think
risk assessment, surgical techniques, materials all geared towards dental students,
(00:20):
younger professionals, or anyone really committed to self learning in
this field.
Speaker 2 (00:24):
Exactly. We're translating some pretty dense research into practical clinical insight,
and the whole philosophy we're exploring today really hangs on
one key idea ossio sufficiency.
Speaker 1 (00:35):
Okay, ossio sufficiency. That sounds like it might just mean
enough bone, but I get the feeling it's broader than that.
Speaker 2 (00:41):
Oh much broader. It's about the total state needed for
successful long term ossio integration. It's actually a triad, the patient,
the clinician, and the implant itself all working together.
Speaker 1 (00:54):
A triad.
Speaker 2 (00:54):
Yeah, and if one part isn't sufficient, you get what
the authors call ossio separation. And here's a really challenging point.
Right off the bat, they argue against the term implant failure.
Speaker 1 (01:05):
Really, what are they propose.
Speaker 2 (01:07):
Instead, they say, implants don't fail on their own, they're retrieved,
and that retrieval is usually down to issues with the
patient or the clinician much more than the implant device.
Speaker 1 (01:17):
Wow, okay, so the implant itself is maybe the least
critical factor in its own success. Right. That really puts
the focus back on us, the.
Speaker 2 (01:25):
Clinicians, precisely the burden of managing risk.
Speaker 1 (01:29):
Right. But before we even get to the patient or
the procedure, we have to talk about the foundation evidence
based dentistry EBED. How do we sort the good research
from well the noise in implantology.
Speaker 2 (01:43):
Well, the hierarchy is pretty clear. You've got your meta analysis,
systematic reviews, RCTs, randomized control trials. Those are the gold
standards at the top. Okay, animal studies, lab studies, case reports.
They provide information, sure that they shouldn't be driving our
clinical decisions directly.
Speaker 1 (01:59):
But even RCTs the gold standard, they have issues, right,
especially in a field like implants, where there's a lot
of commercial interest time cost.
Speaker 2 (02:06):
Exactly, and ethical constraints too sometimes. But beyond that, we
really need to watch out for bias too. Big ones
stand out first, allocation bias This is when the group's
being compared aren't truly similar from the start, like comparing
implants put in with high torque maybe for immediate loading
versus low torque implants needing a two stage approach.
Speaker 1 (02:27):
Ah, so you're not really comparing the loading protocols. Then
you're comparing different patient situations.
Speaker 2 (02:32):
You got it, You're comparing apples and oranges. Essentially. The
second big one is conflict of interest or COI bias.
Let's be honest, a lot of implant research is funded
by the industry, and studies show that research involving author
COI is just statistically more likely to report results favoring
the product or intervention being tested. We have to be
(02:53):
aware of that.
Speaker 1 (02:54):
And what about the studies that don't show positive results?
The issue of publication bias.
Speaker 2 (02:59):
That's a huge problem. Negative findings often just vanish journals funders,
they tend to prefer positive, exciting results. Yeah, but think
about it. Study showing a technique doesn't work, that's incredibly
valuable clinically, it stops us from going down dead ends.
Speaker 1 (03:13):
That makes perfect sense, which leads to another critical point
you mentioned statistical versus clinical significance.
Speaker 2 (03:20):
Oh, absolutely crucial. You might see a study showing a
statistically significant difference in say, bone loss, between two techniques.
Speaker 1 (03:28):
Right p value less two point zero five. Everyone gets excited, exactly.
Speaker 2 (03:31):
But then you look closer and the actual difference is
measured in nanometers. Nanometers, yeah, and as clinicians we work
in millimeters. A difference that small is clinically meaningless. Even
if it's statistically real. You always have to ask, does
this actually change my patient's outcome in a noticeable way?
Speaker 1 (03:51):
Good rule of thumb, and the sample size issue the end.
Speaker 2 (03:54):
Right, you see these big studies hundreds, maybe thousands of patients,
looks impressive, but then you realize that looking at so
many variables implant type, location, smoking status, bone density, length width, Ah, so.
Speaker 1 (04:06):
The actual number of patients relevant to one specific protocol
might be tiny.
Speaker 2 (04:11):
Precisely, every variable you add effectively slices the sample size.
Many studies are actually underpowered to draw the conclusions they
claim for specific scenarios.
Speaker 1 (04:19):
Okay, that's a really solid grounding in how to approach
the evidence. Let's apply that rigor now to the first
part of that triad, the patient factor. How do we
decide who's a suitable candidate?
Speaker 2 (04:31):
It starts with risk stratification. Generally, elective implant treatment is
for patients who are ASA classification I two or maybe
a stable three.
Speaker 1 (04:39):
Okay, what about higher risk groups like immunocompromise patients.
Speaker 2 (04:43):
The evidence there is pretty low level, mostly case reports,
case series, so the advice is extreme caution. Interestingly, some
reports show fairly normal outcomes even with long term cyclosporin
a use. But prudence is definitely the keyword.
Speaker 1 (04:59):
The diabetes up constantly.
Speaker 2 (05:00):
It does, and the guidance is clear. Uncontrolled diabetes is
a definite contraindication for elective implant surgery.
Speaker 1 (05:06):
We'll have about controlled or maybe borderline hyperglycemic patients.
Speaker 2 (05:09):
There's a specific protocol. First, confirm good glycemic control before
and after surgery. Second, allow a longer healing time minimum
four months. Third, use prophylactic antibiotics and ze point one
two percent core exitting rents. And fourth surgically aim for
longer and wider implants were possible, just to maximize that
(05:29):
bone to implant contact.
Speaker 1 (05:31):
That's quite a detailed plant shows how the patient's condition
directly shapes the clinical approach. How about anticoagulants warfarin heppron.
Speaker 2 (05:39):
For warfare and patients minor surgery, so not involving big
grass or flaps is generally okay. If the ion r's
two point five or less. If they're on heppern, you
need to check the PTT. If it's elevated, say one
point five times normal, you have to postpone.
Speaker 1 (05:51):
The surgery and recent heart attacker stroke. I know the
recurrence risk is high soon after, very high.
Speaker 2 (05:57):
Initially it's around thirty percent risk of another event if
you do elective surgery within three months, but that drops
significantly down to about five percent after a year. So
definitely delay elective procedures accordingly makes sense.
Speaker 1 (06:07):
Now the big lifestyle factors smoking and alcohol.
Speaker 2 (06:12):
Yeah, the destructive habits. Smoking is clearly linked to higher
failure ras almost double actually a relative risk of one
point nine to two wow, and it complicates things like
sinus lifts and only graphs too. Alcoholism is associated with
peri implantitis and a higher risk of infection, partly because
it can suppress the immune system, specifically T helper cells.
Speaker 1 (06:34):
Is there any good news there?
Speaker 2 (06:35):
Well? Yes, Stopping alcohol consumption before surgery can significantly lower
the risk of post operative complications, so cessation helps.
Speaker 1 (06:43):
Okay, And is there a contraindication that's less about physical
health and more about the patient's mindset.
Speaker 2 (06:50):
Absolutely unrealistic expectations. That's considered an absolute contraindication. You just
can't proceed if the patient doesn't understand the limitations or
potential outcomes.
Speaker 1 (06:59):
And for pas, maybe with neuropsychiatric conditions or issues with compliance.
Speaker 2 (07:03):
You have to think about long term maintenance. Prosthetic design
becomes key. Often removable options like overdentures are preferable because
they might be easier for the patient or even a
caregiver to manage. Flexibility is crucial.
Speaker 1 (07:15):
Got it. So we've assessed the patient thoroughly. Let's move
to the other two parts of the triad, the clinician
and the implant. Starting with surgical complications, Nerve injury is
obviously a major concern.
Speaker 2 (07:27):
It is for everyone involved. We use the Sunderlin or
set in classification I to V. Class I neuropraxia is
the mildest temporary numbness, usually recovers in under three months. Okay.
Class V neurotmesis is the most severe. The nerve is
actually severed and needs surgical repair.
Speaker 1 (07:45):
How do we assess that quickly if a patient reports numbness.
Speaker 2 (07:49):
Every clinician should have a simple kit ready, a cotton
tip for light touch, something sharp and dull for discrimination,
and something cold like ethyl chloride spray test immediately if
there's any report of altered sensation.
Speaker 1 (08:01):
Right. What about implants getting lost implant displacement.
Speaker 2 (08:05):
In the upper jaw of the maxilla. The most commonplace
for a displaced implant is the maxillary sinus. This usually
happens if initial stability wasn't achieved and the mandible the
bones dens are there, so it's less common, but if
stability is really poor, they can sometimes shift down into
the cancel's bone space below the intended site.
Speaker 1 (08:22):
Okay, let's tuck site development building bone maxillary sinus grafts
the lateral window approach. Those are pretty reliable, right.
Speaker 2 (08:32):
Generally, Yes, success rates are high, often quoted around ninety
ninety six percent, especially when using rough surfaced implants and
often zenogeneic graft. Materials and techniques have improved definitely. Things
like pisoelectric surgery or specialized kits like the desk system
have really helped reduce the risk of carrying that sinus
membrane during the procedure, which used to be a common complication.
Speaker 1 (08:53):
But what if you need vertical height vertical ridge augmentation.
Speaker 2 (08:57):
That sounds trickier, much trickier, and much The complication rates
jump significantly, somewhere between twenty and sixty percent.
Speaker 1 (09:04):
Wow, that's high.
Speaker 2 (09:05):
Why it's almost always due to the barrier membrane getting
exposed leading to infection. Astead distraction can sometimes be an
alternative for vertical gain, but it doesn't work well if
the ridge is also very thin. So yeah, vertical augmentation
needs a very careful risk benefit discussion with the patient understood.
Speaker 1 (09:22):
How about immediate implant placement IPP, especially in the front
the esthetic zone. It's popular, but the criteria must.
Speaker 2 (09:30):
Be strict, incredibly strict, non negotiable.
Speaker 1 (09:32):
Really.
Speaker 2 (09:33):
You need five things. First, intact socket walls all around. Second,
the facial bone wall must be at least one millimeter thick,
and you need to maintain about a two millimeter gap
between the implant and that facial bone.
Speaker 1 (09:45):
Okay, that gap is for grafting.
Speaker 2 (09:46):
Exactly, usually filled with the slow resorting graft. Third, you
need a thick soft tissue biotype. Fourth, no active infection
in the socket. And fifth you absolutely must achieve good
primary stability, usually engaging bone beyond on the socket apex
or on the palatal side. Miss any of those and
the risk goes way up.
Speaker 1 (10:05):
And managing the soft tissue, especially the papilla between implants, yeah,
that's notoriously difficult. It is.
Speaker 2 (10:10):
The papilla height between two implants just doesn't reach the
same level as between an implant and a tooth, or
an implant and a pontic. You get maybe three point
four or three point five millimeters between implant.
Speaker 1 (10:19):
Compared to maybe five point five next to a pontic.
Speaker 2 (10:22):
Right, So, to preserve the bone peak that supports that papilla,
you need a minimum of three millimeters of bone between
the implants themselves edge to edge. Using narrower implants can
sometimes help achieve that space.
Speaker 1 (10:35):
Good point. Lastly, under surgical protocols, loading times immediate early conventional,
Do we always need to wait months?
Speaker 2 (10:46):
Well? The evidence, particularly for healed posterior sites, is interesting.
Five year survival rates seem pretty similar whether you load
immediately within a wind early one week to two months,
or conventionally after two months.
Speaker 1 (10:58):
Really similar survival.
Speaker 2 (10:59):
Yes, But and this is a big but, only if
you achieve excellent initial stability. That means high insertion torque
typically quoted above twenty to forty five Newton centimeters or
an ISQ reading over sixty or sixty five. Without that stability,
immediate or early loading is much riskier.
Speaker 1 (11:15):
Okay, that stability is the key prerequisite. Now let's shift
gear slightly. This is where I think things get really
fascinating and maybe a bit counterintuitive. The main cause of
long term biological problems materials technical issues.
Speaker 2 (11:26):
Right, let's talk pery implant diseases. We've got pery implant
mucositis PIM. That's inflammation, reversible, no bone loss yet, and
very common, maybe around fifty percent prevalence. Okay, Then you
have peri implant titis PI. Then volves progressive bone loss
also worryingly common. Figures range from twelve percent up to
(11:46):
forty percent of sites, depending on the study and definition.
And PI is generally seen as a progression from PM.
Speaker 1 (11:52):
So what drives that progression? Poor hygiene plaque.
Speaker 2 (11:55):
That's part of it, Yes, like periodontitis. But the source
material we're reviewing is very clear on this. The single
most likely factor initiating or exacerbating PI leading to eventual
implant loss is residual cement.
Speaker 1 (12:08):
Residual cement really more so than plaque. That kind of
goes against some traditional teaching.
Speaker 2 (12:12):
It does challenge it. But the thinking is this. Cements
designed for teeth often have properties like fluoride release or
antimicrobial agents. These can actually be irritants or toxic to
the very delicate biological seal around the implant abutment connection.
Speaker 1 (12:26):
So what's good for a tooth isn't necessarily good for
an implant interface exactly.
Speaker 2 (12:31):
And once that cement gets extruded into the sulcus, it's
a foreign body, a plaque trap, and a source of
chronic inflammation. So minimizing extrusion is paramount. The safest way
to do that from a margin perspective, keep them super
genable clearly above the gum line.
Speaker 1 (12:46):
But sometimes you need subjugable margins for esthetics. So if
you have to use cement, how do you stop it
squeezing out?
Speaker 2 (12:52):
There are techniques. One is the copy abutment technique, basically
making a little jig to squeeze out excess cement outside
the mouth before you seat the crown. But more effectively,
you can modify the abutment itself how So, two main
ways described are the open abutment or OA, which leaves
the space, or the internal vented abutment IVA. The IVA
(13:13):
involves drilling small vent holes inside the abutment bent holes. Yeah,
so when you seat the crown, the excess cement flows
into these internal vents instead of out into the sulcus.
It's shown to dramatically reduce extrusion and interestingly, can sometimes
even increase the crown's retention force.
Speaker 1 (13:29):
That's clever. This whole cement issue feeds directly into the
big debate screw retain versus cement retained restorations. What's the
overall risk profile?
Speaker 2 (13:39):
Well, based on the cement risk, cement retained crowns tend
to have higher rates of biological complications meaning PM and PI.
Screw retain restorations, on the other hand, tend to have
more technical complications, things like the access screw loosening or
maybe the porcelain chipping around the access hole.
Speaker 1 (13:56):
So which way do clinicians lean?
Speaker 2 (13:58):
Because dealing with biological complications like PI is often much
harder and less predictable than fixing a technical issue, and
because retrievability is so important for cleaning or repairs, Screw
retention is often favored, especially for more complex cases or
posterior teeth makes sense.
Speaker 1 (14:14):
Let's talk biomechanics. We often hear about aiming for axial
loading straight down the implant, but you mentioned earlier human
chewing forces aren't purely axial.
Speaker 2 (14:23):
They're really not, and successful concepts like all on four,
which rely heavily on tilted, non actually loaded implants, kind
of prove that non axial loading is okay, provided the
forces don't exceed the fatigue limits of the components or
the bones capacity.
Speaker 1 (14:38):
Does the type of implant connection matter much here? External
hex versus internal.
Speaker 2 (14:43):
It does have implications. External hex connections, especially on single crowns,
are notoriously more prone to screw loosening. Internal connections are
generally better for stability, but can be subject to different
stresses like hoop stress, outward forces on the implant wall.
Speaker 1 (14:58):
What about patients who grow heavily bruxism That must be
a major risk.
Speaker 2 (15:02):
Factor, huge risk for mechanical complications. Screw loosening, component fracture,
porcelain chipping management involves several strategies. Is using really strong
monolithic materials thinks solid zirconia or maybe gold avoiding or
minimizing cantilevers on the prosthesis, ensuring the restoration is easily
retrievable for repair, and recommending night guards or occlusal splints,
(15:26):
although the hard evidence supporting their effectiveness and preventing implant
complications is actually somewhat limited.
Speaker 1 (15:32):
Interesting and passive fit How critical is that?
Speaker 2 (15:35):
Absolutely critical for the long term health of all the components.
Misfit creates stress. The exact tolerance level is hard to define,
but we know cad CAM fabrication and techniques like laser
welding have helped improve fit significantly compared to older casting methods.
Speaker 1 (15:51):
Does cement help compensate for minor misfit.
Speaker 2 (15:53):
It can yes. In cement retain restorations, the cement layer
can act as a bit of a slop factor, potentially
reduce using stress from minor inaccuracies. That's one small argument
sometimes made in its favor despite the biological risks.
Speaker 1 (16:06):
Let's touch on the digital workflow, CBCT scans and guided surgery.
What's the evidence say?
Speaker 2 (16:11):
CBCT is strongly supported, fantastic tool for diagnosis, planning and
patient communication, no question there, and surgical guides guided surgery
generally reduces inaccuracy compared to placing implants freehand. That's documented. However,
it's not perfectly accurate because errors can creep in at
multiple stages the scan, the planning software, the guide fabrication,
(16:34):
the fit of the guide in the mouth, the drills.
It's a cumulative error chain, so not fool proof. Definitely
not and fully guided flapless surgery, especially in completely identialist
jaws where you have no teeth for stable support. That
requires extreme caution and experience. You can't see the bone directly.
Tooth supported guides generally offer better accuracy than guides resting
(16:56):
only on soft tissue or bone.
Speaker 1 (16:57):
Good to know. Yeah. Finally, on materials mentioned monolithic zirconia
alpha materials evolved overall well.
Speaker 2 (17:04):
Older ceramics like lusite reinforced or aluminum based ones have
kind of plateaued in development. The big shift has been
towards higher strength materials. Lithium disilicate like IPS max is
widely used strong.
Speaker 1 (17:15):
Aesthetic around four hundred MPa for press.
Speaker 2 (17:18):
Yeah, about four hundred pressed, maybe three sixty for the
cadcam blocks. And then zirconia, which is even stronger, especially
the monolithic solid forms which are great for bruxers because
you avoid the risk of the layering porcelain chipping off
out of buttments.
Speaker 1 (17:32):
Are stock A buttments still common, less.
Speaker 2 (17:34):
So for final restorations, especially in the esthetic zone. Custom
Cadcama buttonmons either titanium or zirconia are becoming standard, and
we're seeing more of the hybrid abutment concept. That's a
titanium base for the connection strength bonded to a zirconia
upper structure for tissue response and esthetics. Best of both
worlds potentially.
Speaker 1 (17:53):
Okay, comprehensive overview of the technical side. For our last segment,
let's tackle the really complex scenario, the fully identialist patient
and maxilla facial reconstruction.
Speaker 2 (18:04):
Right, And the first point the sources make here is
actually a critique of dental education. Yeah, lamenting that traditional
complete denture prosidontics is sometimes marginalized. This means clinicians might
jump to implants without first truly maximizing what a conventional
denture can achieve, really nailing down things like border molding,
poster palatal seal, checking the vibrating line properly. You have
(18:27):
to master the basics first.
Speaker 1 (18:28):
That's a fair point. So assuming conventional options are exhausted
or insufficient for the identialist maxilla upper jaw. When is
an implant over denture an IOD preferred over a fixed bridge.
Speaker 2 (18:42):
An IOD is often the better choice when there's significant
bone or soft tissue loss that requires support for the
lips and face, something a fixed bridge can't provide, or
when hygiene access is a major concern, which is often
the case for elderly patients or those with dexterity issues.
Speaker 1 (18:55):
How many implants typically for a maxillary IOD, four to.
Speaker 2 (18:59):
Six implants generally provide successful stable.
Speaker 1 (19:02):
Retention and the manible the lower jaw.
Speaker 2 (19:04):
For the manible the implant retained overdensure, usually on two implants.
IROD is considered almost a standard of care now. It
offers a massive improvement in stability, chewing function, and overall
quality of life compared to a conventional lower denture, which
notoriously floats around.
Speaker 1 (19:21):
Huge difference for patients. What about the absolute highest risk
cases patients have had radiation therapy to the head and neck.
Speaker 2 (19:28):
Those are incredibly challenging. Irradiated bone, especially in areas like
the frontal bone, has a very high implant failure rate
due to poor healing potential osteo radiantcrosis risk. Is there
anything that helps, Yes, Hyperbaric oxygen therapy HBO. The data
is quite striking. One review showed failure rates dropping from
around forty percent without HBO down to about eight point
(19:50):
five percent with the HBO protocol before and after surgery.
Speaker 1 (19:53):
That's a dramatic improvement, it really is.
Speaker 2 (19:55):
But success still depends heavily on the radiation dose received
and the implant specifics. Shorter implants in heavily irradiated bone
have the lowest survival rates. Meticulous planning is essential.
Speaker 1 (20:06):
And finally, using implants after major surgery for oral cancer, macalectomies,
and bulectomies.
Speaker 2 (20:11):
Implants become absolutely critical.
Speaker 1 (20:13):
In these cases.
Speaker 2 (20:14):
For patients who've lost part of their jaw, implants might
be the only way to adequately retain and stabilize an
opperator or an overlay prosthesis, especially if they've had reconstruction
with say a fibula free flap.
Speaker 1 (20:27):
So implants enable function again.
Speaker 2 (20:28):
They enable function stability chewing, but it's not straightforward. Often
you need secondary surgeries around the implants to thin bulky
soft tissue flaps or graft attached gum tissue palad all
graphs are often preferred to create a healthy, stable, cleansible
tissue interface around the implant posts.
Speaker 1 (20:46):
Wow, okay, we have really covered a massive amount of
ground here, from the foundations of EBD, through patient risks,
surgical details, materials, complications, and these very complex reconstructions. It
feels like it all comes back to that first concept
you introduced.
Speaker 2 (21:01):
It absolutely does. If we loop back to that ossio
sufficiency triad, patient clinician implant. The core message from this
deep dive echoing the source material is pretty humbling. The
implant itself is the least influential factor. Success or failure
or rather, retrieval hinges primarily on the patient factors and
the clinician's skill, judgment and management.
Speaker 1 (21:23):
Which brings us to the application. How do we put
all this detailed knowledge together in practice time for that
synthesis challenge?
Speaker 2 (21:29):
All right, let's test that synthesis. Imagine the scenario. You
have a patient presenting they're a heavy smoker, they have
controlled type two diabetes, and they need an immediate implant
placed in the esthetic zone, say replacing an upper incisor.
Based on everything we've discussed today, all the risks, the protocols,
the evidence. What three specific key risk mitigation strategies must
you prioritize in your treatment plan and in that crucial
(21:52):
informed consent discussion.
Speaker 1 (21:53):
Okay, pulling it all together, that requires integrating points from
across our whole discussion based on the evidence reviewed, I'd
say the absolute priorities have to be first, addressing the smoking,
a serious conversation about cessation or at least reduction, plus
emphasizing impeccable oral hygiene commitment. That's non negotiable good number one. Second,
(22:15):
managing the diabetes very carefully confirming that strict glycemic control
before and after surgery, and definitely implementing those prophylactic measures
the chlorhexidine rents the antibiotics.
Speaker 2 (22:27):
Right, managing the systemic factor and number three.
Speaker 1 (22:30):
Number three has to be about the surgical and restorative execution,
especially for IAPP and the esthetic zone. That means rigorously
confirming you meet the criteria thick tissue biotype, ensuring you
have or can graft to get at least that one
point five to two millimeter buckle bone gap, and critically
planning the final restoration with supergingual margins if at all possible,
(22:50):
or using those vented abutment techniques to drastically minimize the
risk of cement extrusion.
Speaker 2 (22:55):
Excellent. That's that integrated thinking, combining patient management systemics, surgical
site prerequisites, and restorative design based on known risks. That
is the essence of applying evidence based principles. It's moving
beyond just knowing the facts to achieving clinical mastery.
Speaker 1 (23:12):
Keep synthesizing that knowledge, keep questioning the evidence, and keep
focusing on how you can master that assio sufficiency triad
for every patient you treat. Thanks for joining us for
this deep dive
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