The Complication of Removal Implants Prosthetics - Research Paper Example

Removable Implant Prosthetics Complete and partial edentulism (or the loss of teeth) affects the person with the condition in many ways. An edentulous person cannot enjoy a normal diet, because the physical act of chewing is difficult. Even the normal acts of laughing and smiling are cause for embarrassment. Self-worth and self-confidence are therefore low in edentulous patients. In such cases, it is important that the clinician and the dentist are able to present options for the patient to regain his confidence and to enjoy daily activities without the hindrance of ‘toothlessness’. Presently, several options are available to the edentulous patient. First are the conventional dentures, which are less expensive but are also less permanent. Another alternative is the use of teeth implants, which have been practiced in many advance countries, but are nevertheless costly and take more time to accomplish, compared to the application of conventional dentures. However, there are several options that a patient can consider, including both fixed and removable dental implants (Strong, 2009). Although fixed prosthesis is much more attractive because the patient can look and feel to have complete teeth, the fixed prosthesis is more expensive than the removable implants. The removable dental implant uses a metal framework that is bolted or cemented directly into the implant abutment. Construction and fitting of the framework requires technical expertise and care for successful implantation. General advantages of removal implants over fixed implant prosthesis An advantage of a removable overdenture is that the repair and replacement of the appliance is more easily accomplished compare to the fixed prosthesis. Normally, the most common repair required is the replacement of a denture tooth, which can be accomplished in a dentist’s office or a laboratory. For example, in the case of an attachment-retained implant overdenture, the existing abutments used in the original overdenture can be retained while the replacement is being fabricated. This has the added convenience of allowing the patient to continue the use of the original overdenture while the replacement is being fabricated. In On the other hand, the repair and replacement of the components of a fixed prosthesis requires more time and higher expense (Strong, 2009). Such repair requires that the original metal framework be sent to the laboratory for several days. In cases where the framework has to be completely replaced, the expense is increased. Steps in getting a removable implant prosthetic (Strong, 2009) Patients are initially referred to oral surgeons for evaluation of the bone grafting that is necessary to place the implants in suitable position. The oral surgeon will recommend the desired grafting necessary for the provision of enough bone for the implantation. This evaluation depends on the patient’s facial and jawbone structure. Discussion with the patient is necessary to decide on the number of implants required for her case. Once the choice of implant has been decided upon, a surgical bone graft will be carried out to produce enough osseous bulk to support the required implants. This bone graft is allowed to mature (the period of which depends on the patient’s specifications) before parts of the implants put in place. Surgical templates can come from existing dentures; these templates serve as guides for implantations of the overdentures. The set-up for the overdentures is completed with the attachment of the maxillary and mandibular overdentures over the healed bone graft. The patient is also given training with respect to the insertion and removal of the overdentures (Strong, 2009).Over-all, the procedure takes months to finish, but this is worth the effort since overdentures can last for many years. Complications in fixed versus removable implant prosthetics Fixed implants appear to be superior to removable implants based on the data from seventy-two studies. The studies, that have been established from either 5 years of observational trials or one-year old clinical trials, were part of a review which included the success rates and survival of dental implants, loss in bone levels, and success and maintenance between arch and prosthesis types (Bryant, McDonald-Jankowski, & Lim, 2007). The prosthesis types studied in included fixed and removable, with and without splints. The meta-analysis shows that mandibular fixed prosthesis implants had a significantly higher survival rate than the maxillary fixed prosthesis group. These results showed that fixed prosthesis survival was more affected by site of implant rather than by the design of the implant. There was also greater implant failures for removable prosthesis compared to fixed in the maxilla. This was attributed to deficient bone volume during the preparation of the maxilla for implantation. Generally, this meta-analysis showed that survival and success of implants are not affected by the difference in the prosthesis types (Bryant, McDonald-Jankowski, & Lim, 2007). However, it emphasizes that difference in the maintenance of the overdentures can spell the difference in survival and success rates. Another study evaluated the prosthetic complications that arose in patients that were treated with 528 implants in 8 years of private practice (Nedir, Bischof, Szmikler-Moncler, Belser, & Samson, 2006). During this period, the implant success rate was 99.2%. It was also shown that there more complications were observed in patients who chose to have the removable prosthesis than those with fixed type. When the prosthesis had an extension cantilever, it had more complications that those that were bar-retained. However, complications of fixed prosthesis were mainly observed only during the first two years with very low recurrence levels. Similarly, patients with overdentures that were bar-retained also experienced less complications compared to those with ball-retained prosthesis. The review showed that the different types of prosthesis led to different types of complications. However, the adjustments necessary for the removable prosthesis, although numerous and recurrent, were easy to manage (Nedir, Bischof, Szmikler-Moncler, Belser, & Samson, 2006). Reviews on prosthetic aftercare have a mean follow-up period of up to 5 years (Nedir, Bischof, Szmikler-Moncler, Belser, & Samson, 2006). These reviews show that prosthodontic and surgical problems are common for both removable and fixed implant prosthesis, without any analysis for conventional dentures. To include the comparison with conventional dentures, a ten-year randomized clinical trial was conducted to compare implants with conventional dentures. The study showed that 44% of 133 patients that wore conventional dentures decided to have implanted overdentures during the course of the trial (Visser, Meijer, Raghoebar, & Vissink, 2006). However, patients that were given implant overdentures required more treatment sessions, possibly due to complications associated with implants. Clinical complications associated with removable implants and overdentures General complications Clinical complications from implants and prosthesis showed that there are a good number of complications related to retention of the implants (33%), overdenture fractures (16%), implant loss in type IV bone (16%) and relining needs (19%) (Goodacre, Bernal, Rungcharassaeng, & Kan, 2003). Berglundh et al. (2002) analyzed reports to determine complications in implant therapy by selecting prospective studies with at least 5 years of follow-up periods. The results showed that implant loss was the top complication which was reported in over 96% of the studies. Technical complications were mentioned in 60-80% of total studies while complications that were biological in nature were mentioned in 40-60%. However, the patient profile in relation to implant losses was not enough in the studies reviewed. Implant loss was higher in patients with multiple implants for reconstruction and overdentures. Implant loss was high during overdenture therapy in a 5 year period and this loss frequently occurred in the maxilla rather than the mandible. Another main complication identified was related to soft tissue complications that required therapy. This was higher in patients that had implants for supporting and retaining overdentures. Only a few studies dealt with bone loss and peri-implantitis, but 84% of studies reported implant fracture, which was actually a rare complication that could occur during the first 5 years after treatment. Technical complications were also found to be higher in overdentures and all these were related to components and suprastructures of the implants. On a short –term basis, implant-support maxillary overdentures have been found to be successful in treating edentulism. A study conducted from 1991-1998 on patients that were given implants, that were either bar-connected or with single anchors, showed that although over-all implant survival rates was 96%, 85 complications were encountered on patients that were observed for an average of 3.2 years (Kiener, Oetterli, Mericske, & Mericske-Stern, 2001).Although the overall denture stability was 95%, most complications during this period were related to the components and anchorage devices of the implants, failures of the dentures due to mechanical and structural problems, and adjustments in the dentures. A notable problem that was encountered was the failure of the implants to integrate into the bone, and the loss of implants after loading. Although over time there were a reduced number of complications observed, the first year of the implant saw the need for the adjustment in the screws and bar retainers. Some dentures needed repair, although dentures were not fractured. Implant loss An interesting case was the loss of all implants in one patient (Kiener, Oetterli, Mericske, & Mericske-Stern, 2001). In the case of implant loss, Klemetti in 2008 made conducted a systematic review to assess the number of implants needed to retain maxillary and mandibular overdentures. The main justification for this review was to aid patients in deciding on an economical yet effective means of maintaining his overdentures. The review included articles in dental journals in a 17-year period from 1990 to 2007. It included results of clinical trials, review articles, and meta-analysis. From 1779 articles, only eleven, which met the inclusion criteria, were considered in the analysis. From these articles, it was gleaned that patient satisfaction was not dependent on the type of neither attachments nor number of implants. An overdenture in the mandible with just two implants and with bar attachments gave the least complications. Similarly, two implants for overdentures in the maxilla do not diminish the overdenture longevity or patient satisfaction. Fracture of dental implants Fracture of the dental implants is one of the rarest complications, but this could lead to severe clinical outcomes. A review of the current literature presented several factors that may cause and result in implant fracture (Tagger-Green, Horwitz, Machtei, & Peled, 2002). Failures in implants may be categorized based on the origin of the failure and the timing when the failures appeared. A biomechanical overload can result in an implant fracture, thus fractures belong to the category of late complications. The mechanical overload can be due to inappropriate positioning of the superstructure, the arrangement of the implants, leverage, occlusal forces like clenching, positioning of the implant, implant size and metal fatigue which is common in hardware when a fracture does not heal (Hak & McElvany, 2008). Metal fatigue occurs despite advances in metallurgy and the development of new metal alloys for the dental industry. It is normally difficult to deal with removal of intact or broken hardware, requiring special tools. Good clinical examinations and correct treatment plans may reduce the risk of implant fracture. Implant fractures require the surgical removal of the implant using specific treatment. One certain case of implant fracture showed that even the supporting materials, which have integrated into the bone, of a maxillary overdenture were fractured (Annibali, Sepe, Sfasciotti, & La Monaca, 2001). As stated previously, implant factures are caused by failure in implant supported overdenture, defects in the design of implant, poor material used for the implant and biomechanical overload. Options for the treatment of fractured implants include the removal the fractured implant, replacement and refabrication of the implant and prosthesis. Another option would be to modify the existing prosthesis, and to leave the fractured portion in its original position. The last option would be to modify the fracture itself and to refabricate part of the prosthesis. Surgical removal of the fracture can be performed (block-section, vestibular and occlusal approaches). In all these approaches, maximum effort must be exerted to contain the bone loss (Annibali, Sepe, Sfasciotti, & La Monaca, 2001). Bacterial infections Surface contamination in implants can lead to formation of a peri-apical lesion (IPL) which can progress to acute osteomyelitis (Rokadiya & Malden, 2008). This was observed in a case where 5 weeks after placement of mandibular implants, symptoms of pain and swelling were presented. The causative organism for the condition was found to be Staphylococcus aureus. The implant was removed but replaced a few weeks later without any recurrence of the infection. Commensal organisms may grow when post prosthesis care is neglected. Summary and conclusion The major advantage of the use of removable implant prosthetic for the edentulous patient appears to be the cost. However, the time and effort spent in constructing and attaching the implant is lengthy and arduous, which requires the expertise of an oral surgeon and an orthodontist. Construction and fabrication of the implants also require major technical skills. However, for most patients, the effort spent is well worth the return of feeling of self-worth and confidence (Strong, 2009). Several original clinical trials and meta-analysis have delved into the advantages and complications that are related to removable implant prosthetics versus the fixed types. The advantage of the removable type, aside from the cost, is the ease at which it can be sent for repair and rehabilitation, because the overdentures are just inserted into the implants. However, results from many studies, and follow-up of dental implant patients, show that there are more complications associated with removable implants. Among the top complications are implant loss, implant fracture and bacterial infections. Implant loss have been reported in many studies, and this have been related to poor design and material, and the failure of the implant to osseointegrate. Thus, it appears that preparation for implantation is a very important aspect of the process. Integration of the bone graft is a long process which apparently has to be completed; in this case patience is required. Shortening the process involve will lead to more complications in the future. Another way to avoid implant loss would be fitting the overdentures with care, and to maintain and adjust the overdentures after they have been inserted. Nevertheless, the complications reported for the removable prosthetics are easily surmountable because they can easily be removed for cleaning, repair and reconstruction. References Annibali, S., Sepe, G., Sfasciotti, G. L., & La Monaca, G. (2001). Removal of fractured cylindrical implants. Minerva Stomatologica, vol. 50, no. 3-4, pp.101-110. Berglundh, T., Persson, L., & Klinge. (2002). A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years. Journal of Clinical Periodontology, vol.9, suppl. 3, pp. 197–212. . Bryant, S., McDonald-Jankowski, D., & Lim, K. (2007). Does the type of implant prostheis affect the outcomes for the completely edentulous arch? International journal of the Oral Maxillofacial Implants, vol. 22, pp. 117-139. Goodacre, C. J., Bernal, G., Rungcharassaeng, K., & Kan, K. (2003). Clinical complications with implants and implant prosthesis. Journal of Prosthetic Dentistry, vol. 90, pp.121-132. Hak, D. J., & McElvany, M. (2008). Removal of broken hardware. Journal of the American Academy of Orthopedic Surgery, vol. 16, no. 2, pp. 113-120. . Kiener, P., Oetterli, M., Mericske, E., & Mericske-Stern, R. (2001). Effectiveness of maxillary overdentures supported by implants: maintenance and prosthetic complications. International Journal of Prosthodontics, vol. 14, pp. 133–140. Klemetti, E. (2008). Is there a certain number of implants needed to maintain an overdenture? Journal of Oral Rehabilitation, vol. 35, suppl. 1, pp. 80–84. Nedir, R., Bischof, M., Szmikler-Moncler, S., Belser, U., & Samson, J. (2006). Prosthetic complications with dental implants: from up to-8-year experience in private practice. Interantional Journal of Oral Maxillofacial Implants, vol. 21, pp. 919-928. Rokadiya, S., & Malden, N. (2008). An implant peri-apical lesion leading to acute osteomyelitis with isolation of Staphylococcus aureus . British Dental Journal, vol. 205, pp. 489 - 491. Strong, S. (2009, June 1). Removable implant-retained overdentures: a case report. Retrieved August 1, 2009, from www.dentistrytoday.com Tagger-Green, N., Horwitz, J., Machtei, E. E., & Peled, M. (2002). Implant fracture: a complication of treatment with dental implants--review of the literature . Refuat Hapeh Vehashinayim , vol. 19, no. 4, pp.19-24, 68. . Visser, A., Meijer, H. J., Raghoebar, G. M., & Vissink, A. (2006). Implant-retained mandibular overdentures versus conventional dentures: 10 years of care and aftercare. InternationalJournal of Prosthodontics, vol 19, pp. 271-278. Read More