l ecia Implants and Older Patients Sp ue ss Due to advances in modern medicine, there is predictable method of permanent tooth I an ever increasing demographic trend towards replacement. Preliminary results of a a larger number of older patients. Many of these retrospective study of over 200 patients over patients are missing teeth for various reasons. 65 years of age, conducted at Conventional replacement of missing teeth, Intermedica, Fort Washington, PA are such as crown and bridge therapy and consistent with the results of previous studies removable , may not be the preferred indicating that age is not a factor in the success method of tooth replacement for many of these of dental implants. patients. The following are two brief clinical reports When treatment planning for tooth representative of the 200+ older patients replacement, patients should be presented with treated with Branemark osseointegrated all possible treatment options regardless of age. dental reconstructions at Prosthodontics Thomas J. Balshi, therapy has proven to be a Intermedica over the past five years. D.D.S., F.A.C.P. Implant Reconstruction At Age 90

Balshi T

This 90 year old "Great- Three months following implant grandmother" (Fig 1) presented with a placement, Stage II surgery was chief complaint of compromised completed, including the construction of function due to missing mandibular a fixed acrylic prosthesis. A traditional teeth and an unstable partial type IV gold framework was used as the overdenture prosthesis (Fig 2). Her supporting structure for the final medical history was significant only mandibular fixed prosthesis (Fig 4 with regard to controlled a,b,c). and a history of a spontaneous femur fracture two years prior. This patient enjoyed the last four years of life with complete oral function. The It was determined that optimal bone ability to dine with her nursing home was available for the placement of colleagues and masticate food efficiently Branemark implants in the mandible to gave her enormous pleasure (Fig 1). It construct a fixed prosthesis instead of a was an honor and a pleasure to know this complete removable denture (Fig 3). "Great" woman over my entire lifetime. The remaining teeth were extracted She was called "Great" by my children, a Figure 1 with concomitant placement of seven Patient demonstrates "Great" ability to name affectionately bestowed on my function with the bone anchored bridge. Branemark implants into the wonderful grandmother (Fig 5). mandible. The patient healed Photos continued on Page 2 uneventfully with little swelling or ecchymosis. Acknowledgements: Fort Washington Dental Lab, Inc. 1 outcome of surgery in elderly subjects. for And although a large percentage of post menopausal women may have or are Elderly Patients developing , a recent study Zarb G, Schmitt A concluded that osteoporosis is not a contraindication for prescribing Evidence has shown that conventional osseointegration. removable dentures are poor substitutes for missing natural teeth. Essentially a The present study involved the overall conventional removable denture becomes results on Branemark implants placed quite a compromise of quantitative and Fig 2 during the Toronto Study from 1979 to Few remaining teeth are qualitative support. Studies have shown a 1992 and compared those results to that periodontally compromised. significant number of patients in all age of the subgroup of patients whose ages groups experience difficulty in obtaining ranged from 60 to 81 years. Surgically comfortable and efficient oral function with related problems and complications a removable prosthesis. Several studies encountered with the elderly patients in have shown the relationship between this study were similar to those reported adequate oral function and proper digestion in other studies and were not frequent in and nutrition; and where oral function is the elderly patient group. Data gathered compromised, so too is nutritional status. from previous articles indicated that the survival rate for implants placed in Because the life expectancy of edentulous elderly patients was similar to that of patients will increase, the risk of denture implants placed in other age groups. dissatisfaction and its functional implications can only be prolonged. To date this clinical study from Toronto Published clinical data for osseointegrated supports the conclusion that neither Fig 3 dental implant treatment of maladaptive advanced age itself, nor the diminished Panradiograph showing ample patients has led to the clinical impression levels of that often quantity of bone throughout the that a stable prosthesis could preclude most accompany it, are alone contraindications mandibular arch. of the problems associated with complete to the prescription for treatment with denture wearing. The original studies on osseointegration. Until recently being osseointegrated dental implants were done elderly and edentulous has undermined on maladaptive edentulous patients. Age the quality of life for the patient. However did not enter into either the inclusion or patients who were elderly at the time their exclusion criteria. Any geriatric patient implants were placed, and patients who whose systemic health did not preclude a have grown elderly since implant minor oral surgical procedure was insertion, have functioned successfully considered a candidate for with implant supported prostheses of osseointegration. Previous studies have various designs throughout the years. proven that age dependent differences in Fig 4a wound healing do not appear to effect the J Prosthet Dent, 1994; 72:559-568. Panradiograph showing mandibular bone anchored bridge supported by seven Branemark implants.

Fig 4b Fig 4c Fig 5 Bone anchored mandibular prosthesis, Occlusal view of implant supported Full facial esthetics with centric relation. prosthesis. completed mandibular implant supported restoration Acknowledgement: Fort Washington Dental Lab, Inc. 2 Torus Necessitates Maxillary Implant Rehabilitation Balshi T

Treatment of older patients presents distinct challenges in prosthodontic rehabilitation. One such example is a 90 Fig 1 Fig 5 year old female patient who was referred to Panradiograph showing severe periodontal Postop panradiograph of the final Prosthodontics Intermedica for the deterioration of the two remaining maxillary prosthesis supported by seven treatment of a failing maxillary fixed maxillary molars and the anterior teeth. implants. Note the three remaining teeth prosthesis. Due to her inability to wear a (#'s 7,10, 15) have been removed. removable denture, it was a challenge to provide her with continued fixed prostheses throughout the implant treatment reconstruction.

The patient's medical history revealed rheumatism, arthritis and recent frequent occurrences of pneumonia. She was sensitive to Penicillin and was medicated with Prednisone every other day. Fig 2 The patient's dental history included Panradiograph following selective fixed prostheses restoring both mandibular extractions and placement of eight posterior quadrants and a failing, mobile Branemark implants. Wire reinforced fixed prosthesis and multiple missing teeth provisional restoration is supported by in the maxilla. three remaining natural teeth. Fig 6 Postoperative full face view with the The maxillary left molars were final prosthesis fastened to 7 Branemark periodontally and restoratively hopeless. implants. Radiographic examination of the maxillary teeth could only be anterior implants and a standard abutment on accomplished with panradiographic (Fig the pterygomaxillary implant on the left side. 1) due to the enormous torus palatinus Its counterpart on the right side was not which totally obliterated the palate. This osseointegrated and was therefore removed. extosis extended beyond the occlusal A porcelain fused to gold fixed prosthesis surface and incisal edges of the maxillary (Fig 3 & 4) was constructed using the seven dentition. The patient was reluctant to Branemark implants. A short cantilever consider surgical intervention to remove Fig 3 provided additional function and esthetics this overgrowth of bone. Porcelain fused to gold maxillary implant for the right side (Fig 5 & 6). supported prosthesis in centric relation. The treatment plan prescribed the The patient is able to perform adequate oral Branemark method of osseointegration hygiene and has excellent masticatory (Class III modification). Three of the function. She reports delight in chewing food remaining natural teeth (#'s 7, 10, and 15) without discomfort or fear of loosing her were selected to serve as temporary maxillary teeth. abutments to support a fixed prosthesis (Fig 2). A wire reinforced heat processed Patients in later years are indeed good acrylic provisional restoration was candidates for osseointegrated implants ad prepared in advance. modem Branemark. This 90+ year old patient had excellent bone growth response Using local anesthesia, teeth #'s 6,8,9,11 to the titanium implants permitting a solid and 16 were removed. Branemark implants fixed restoration. This certainly is a were placed in the pterygomaxillary region significant contribution to maintaining her bilaterally and six additional implants were quality of life and the ability to function inserted in the anterior region. Following Fig 4 orally. implant placement and full flap closure the Frontal view of maxillary fixed prosthesis provisional fixed prosthesis was cemented. and extensive torus. Acknowledgement: Fort Washington Dental The patient was comfortable Lab, Inc. for construction of the porcelain postoperatively with little swelling or Following a five month healing period, fused to gold tissue integrated prosthesis. ecchymosis. angulated abutments were placed on the six

3 Titanium Implants in investigate the possible influence of prosthetic loading. patient age on successful rehabilitation the Treatment of with the Branemark implant system by Although the number of subjects in Edentulousness comparing the outcome of treatment in the study was small and the group a group of elderly patients with a group distribution somewhat uneven, the Influence of Patient's of younger patients, 65 to 85 years and findings indicate that the Age on Prognosis 36 younger patients, 18 to 54 years, chronological age of the patient alone treated for edentulousness with tissue does not seem to be a determining integrated implants were recalled factor in the prognosis for Kondel PA, Nordenram A regularly after treatment. The osseointegration. Landt H observation periods ranged from 1 to 6 Gerodontics 1988:4:280-284. years. The elderly group received a There is a demographic trend total of 284 Branemark titanium towards populations with Educational Opportunities Sponsored implants and the younger group 183 By The Institute for Facial Esthetics increasing proportions of elderly implants. patients. The dental profession will Presented at Prosthodontics soon be faced with a generation of A very high success rate was noted in Intermedica very elderly patients who expect to both age groups with respect to A Branemark System Implant maintain high standards of oral Treatment Center continuing function and stability of the A Unique Training Opportunity: function, even in . Many original implants. The criteria for elderly people experience evaluation of dental implant success • Live surgeries, lectures and hands-on considerable difficulty obtaining proposed by Albrektsson et al 1986 is Training adequate oral function with so stringent that a high success rate • Patient interaction removable dentures. Edentulous • The conversion prosthesis: based on this criteria would clearly Converting a full denture or RPD elderly patients have experienced indicate that the therapy is appropriate. To a provisional osseointegrated greater difficulty adapting to full The elderly group showed a 90% Prosthesis at stage II surgery. dentures than younger patients, and success rate in the maxilla and 99.5% • Oral hygiene for implants those who eventually adapt take a in the mandible; the younger group • Laboratory procedures considerably longer amount of • Tips on monetary arrangements experienced 88% success rate in the • Implant rehabilitation from time. Recent articles have shown maxilla and 98% in the mandible. It treatment planning to completed the significance of adequate oral was also of interest to note that where osseointegrated prostheses. function for proper digestion and osseointegration of implants failed, • Class size limited to 6. nutrition. 76% of the failures occurred within The purpose of this study was to For information, log onto: one year of installation and before Http://www.dentalimplants-usa.com

Implant Treatment in problems adapting to the prosthesis. This is not surprising, as previous Elderly Patients studies indicated that the muscular Jemt T learning process is prolonged in elderly patients. In spite of this, all With the increasing number of The results of this treatment indicated patients adapted to their implant elderly persons in the population, that healthy vital elderly patients who supported prosthesis within one year we will be seeing more older were provided with dental implants and no major maintenance problems patients seeking dental treatment in can have the same prognosis as were encountered during the the future. A retrospective study younger patients. Marginal bone following years. Thus the selection was conducted on 48 elderly response around the neck of the criteria for implant treatment should patients, 30 women and 18 men, implants showed a pattern of modeling be the same for all patients who were treated at the Branemark and remodeling which was similar to regardless of age and no patients Clinic in Sweden. The mean age at that found in younger age groups. Most should be refused implant treatment implant placement was 82.7 years patients experienced minimal post- because of advanced age. with an age range of 80-89 years. A placement problems, but the study also total of 254 implants were placed. indicated that some patients had Int J Prosthodont 1993;6:456-461.

4 Care for a Lifetime become involved in promoting dental care for are subjected to different biomechanical seniors, such as: stress is known to influence remodeling of Dental Care for • Volunteer at local and state dental bone tissue. societies, and oral health programs Ambulatory Sponsored by these organizations. The literature clearly indicates that osteoporosis increases with age and is more Senior Citizens: • Promote oral health in a newsletter or prevalent in women than in men. The Special letter to older patients. prevalence of osteoporosis in asymptomatic Getting the women has be reported to be as high as 25% Word Out • Hold an open house for older patients and for those 45 to 54 years and 39.2% for the present a brief talk on dentures. range 50 to 54 years. If there were a direct Stapleton M, Watson MT correlation between osteoporosis and • Offer to make presentations to groups at predictability for osseointegration, we would local senior's centers. expect to find the rate of implant loss caused Preventative oral health initiatives have by failure of osseointegration to increase traditionally focused on young patients. Oral health-care providers, and corresponding to age and gender. However researchers and dental health their staffs are the most logical instigators of experts are also directing attention to the the educational process. However, the The results of this study indicate that the oral health needs of the rapidly expanding educational efforts must move from the rate of implant failure is not related with age elderly population. As a result of these dental office to the general community. and sex, thus subjects at risk for osteoporosis efforts, over 60% of our senior citizens Dental Products Report, April 1995 are not at risk for implant failure. A review of retain some or all of their natural dentition, the literature and the results of a series of compared to 45% in 1990. patients treated does not provide a compelling theoretic or practical basis to Older patients are at risk for oral health Osteoporosis: A Risk expect osteoporosis to be a risk factor for problems, resulting from declining osseointegrated dental implants. physical and/or mental status, Factor for medications, and reluctance or failure to Therefore, denying implant treatment to a seek routine dental care. The elderly Osseointegration of patient whose diagnosis of osteoporosis is population must recognize that based on a decrease in bone mass, or on the is preventable. They need to understand Dental Implant presence of a traumatic fracture in a site other the risks associated with untreated dental than the jaw itself cannot be supported at this disease, the signals indicating that dental time. It is important that treatment planning care is required, the importance and value Dao TT, Anderson JD, Zarb GA for dental implant therapy be based on a local of thorough daily oral hygiene practices, assessment of the potential surgical site. as well as regular professional cleanings The success of osseointegration depends in and examinations. part on the state of the bone, the host site, and Int J & Maxillof Impl 1993;8:137-144. its healing capacity. Concerns have therefore Through educational efforts, optimal been raised about the treatment of osteoporotic oral health for the life of the individual patients with osseointegrated dental implants. or "Dry may be ultimately attainable. Education of Osteoporosis is a condition believed to be the patient can begin in the dental office, associated with a decrease in bone quality and Mouth" with brochures, audio and video tapes, and bone quantity. Whether osteoporosis effects Ebwab R even high tech options such as interactive bone quality, bone quantity, or both, remains a CD's. matter of controversy. Thus a diagnosis of osteoporosis made solely on the basis of bone Xerostomia or "dry mouth" can result mass remains empirical and arbitrary. from the congenital non-development of The American Society for Geriatric one or more of the salivary glands. It is (ASGD) is a professional usually a manifestation of a clinical organization devoted to creating However, the orthopedic literature indicates that osteoporotic fractures heal readily, and the disorder. Most often, xerostomia is a awareness of the oral health problems of decrease in salivary flow due to many the elderly. The Society's membership level of bone mass and estimates of the parameters associated with bone remodeling possible conditions, including medications consists of dentists, hygienists, such as diuretics, antihistimine, auxiliaries, dental researchers, dental present considerable overlap between patients with osteoporosis and control subjects. The antihypertensives, , narcotic school faculty members, and other oral analgesics, or aging. health professionals. ASGD works to concern that osteoporosis effects the mandible or the maxilla in the same manner as other parts ensure that seniors receive quality and There are many degrees of xerostomia appropriate dental care by providing of the skeleton that serve as diagnostic markers for the disease; and the impaired bone with symptoms ranging from dry mouth or continuing education programs, burning sensation with normal mucosa to promoting access to geriatric oral health- metabolism in osteoporotic bone may reduce the healing capacity around implants. severe alterations in the mucous care, encouraging dental schools to membranes. The mucosa can appear dry, provide didactic and clinical training in It appears that osteoporosis diagnosed at one atrophic, inflamed, pale and translucent. geriatric dentistry, and advocating The tongue can appear dry, atrophic with expanded dental benefits for the elderly. particular site of the skeleton is not necessarily seen at another distant site. This is not loss of papillae, inflamed, fissured, cracked surprising because bones in different locations and in severe cases denuded. There are a variety of ways doctors can Continued next page... 5 Implant Therapy For to dental implants as a treatment option. The Dietary The lack of implants used in older patient the Older Edentulous populations can be attributed to two Adequacy of possible causes: misconceptions arising Patient from negative stereotypes regarding Edentulous Older Myers G older adults, and misconceptions Patients regarding the feasibility of implants in Greksa et al The population of older adults has older adults. increased dramatically in recent Tooth loss, even with denture decades and will continue to grow in Studies have shown that dentists often replacement, tends to result in a reduced the future. These people will make different treatment decisions for masticatory functional capacity and anticipate a greater life expectancy significant alterations of dietary patterns. older adults, based on stereotype views Edentulous patients consume fewer tough accompanied by a higher quality of of the elderly, such as life expectancy, life. Their expectations, like those of but nutritious foods, such as meat, fruits, dexterity, motivation, and economic and raw vegetables, and increase their all patients, include a functional standing. These stereotypes tend to be consumption of softer foods such as dentition that is esthetically attractive. negative and can lead to reduced options processed foods, refined carbohydrates, Many of these older patients are fully and quality of care for the elder patient. and soft drinks. The latter group of foods edentulous and are often given has a lower content of many essential nutrients and a high content of salt, sugar, dentures as the only restorative Studies attest that age has no bearing on option. cholesterol and fat. This dietary the success of osseointegrated dental inadequacy leads to further deterioration implants. Reports also indicate the long- of oral health and increased risk for About one-fourth of denture term reliability of osseointegrated dental various chronic diseases. wearers report disatisfaction with implants even in situations with less than removable prostheses. Studies have optimal oral hygiene. These reports do This study compares the dietary patterns shown that older patients have more not support the exclusion of patients due and adequacies of 34 edentulous subjects difficulty in adapting to a removable (16 men, 18 women) who regularly wore to lack of manual dexterity or dentures with 38 dentate subjects (15 denture. In addition, the added life motivation. The author states that expenctancy will lead to further men, 23 women). The subjects were "...regardless of economic status, it is the between the ages of 51 and 83 years. increased risk of dissatisfaction patient's ethical right to make decisions because long term denture use regarding the economic feasibility of The results of this study suggest that promotes increased bone loss. implants and it is the 's tooth loss does not result in a modification responsibility to offer them as a of eating habits. However, they do indicate that tooth loss and denture Due to these problems with treatment option." removable dentures, there is a need wearing is associated with a decrease in for an alternative dental treatment for dietary adequacy. In particular, the diet of Dentists need to be better informed of the dentate subjects tended to be superior older edentulous patients. Previous the realities of the aging process as it to that of the edentulous subjects, as studies indicate that patients who relates to the success of implant indicated by lower fat and cholesterol have had dentures replaced with a placement, and to the need and desires of %RDAs and by higher %RDAs for fixed implant retained prosthesis older patients. The dental community protein and all of the vitamins and reported an improvement in the minerals. Contrary to the findings of would then be more likely to offer a wide previous studies, the results of this study quality of their lives. Other studies range of available therapies to indicate improved chewing ability as indicate that tooth loss and denture edentulous older patients, including wearing are not associated with a change a result of implant therapy. implant supported reconstructions. in dietary patterns but are associated with a decrease in dietary adequacy. Universally, the older population First place. Fourteenth Annual Arthur has not experienced the same access Elfenbaum Essay Award Contest, 1995: These findings can be used in dental Sponsored by the American Society of Geriatric Dentistry office education programs to encourage patients to maintain their teeth throughout life. Secondly, once tooth loss and denture Xerostomia... replacement has occurred, this data (Continued from page 5.) suggests that patients should be directed to a registered dietician who can assist Is published by Prosthodontics Intermedica The dentition may show rampant caries And distributed without charge to qualified them in monitoring their diets more with accompanying . Individuals. Please request a subscription on closely to ensure that there is not a Your organizations’s letterhead. decrease in dietary adequacy, resulting in Treatment of the primary disease, using decreases in their overall and dental salivary substitutes, can improve the oral Fixed, Removable, Maxillofacial and Implant Prosthodontics health. Prosthodontics Intermedica condition and relieve many of the 467 Pennsylvania Avenue, Suite 201 J Prosthet Dent 1995; 73: 142-5. accompanying symptoms. Fort Washington, PA 19034 USA Tel: 215-646-6334 Fax: 215-643-1149

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