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Dental Tribune Middle East & Africa Edition | 3/2017 IMPLANT TRIBUNE D3 Considerations for Long Term Success Implants are Never Forever! By Dr. Shankar Iyer, USA This article will emphasize the im- portance of factors to consider be- fore treatment planning for full arches with implants. It is not un- common to make misleading prom- ises to patients when presenting im- plants as an option with unfounded claims of 98% success rates. Most of the survival statistics have evaluated implants for full mouth reconstruc- tions through profuse citations of the original Branemark’s work pub- lished in 1981. Repeated citations of this article and the subsequent fol- low up articles have made claims of a high percentage of success with im- plants. While this is partially true, the circumstances under which these implants survived has been incor- rectly extrapolated to other clinical situations. The original Branemark research was done on edentulous arches with hybrid prosthesis op- posing either complete dentures or prosthesis of similar construction. Patients are now wondering with these highly overstated survival rates, why their implants are ail- ing and need maintenance within a short span. The answer lies in the lack of understanding of biomechan- ics. The connotation that anything works has led to confusion in the field. The diametrically opposite views of short vs long implants, axial vs angled implants, graft vs graftless solutions, regular vs minis, delayed vs immediate, one piece vs two piec- es, guided vs free hand placements and platform switiching concepts have only caused anarchy in the discipline of implant dentistry. Po- dium concepts have gained popular- ity through corporate support and we see opinion leaders vociferously making unsubstantiated claims through limited clinical evidence. A novice finds it very difficult to get in- volved in implant dentistry because the education is being blessed by companies and not through univer- sities or institutions. After being involved in implants for over 20 years, I find it to be an hum- bling experience with cases that I treatment planned two decades ago returning to me for maintenance. Seeing these cases today, I wish I had this experience at that time so I could have served my patients bet- ter. Today it has taught me a lot in treatment planning. I am able to prognosticate the outcome and its management in the event of an un- toward incident. The lessons in bio- mechanics has complemented the initial biologic responses that can be predicted initially so that the surviv- al of implant therapy is prolonged. I am a firm believer of long term data and I fear the rapid evolution of products and techniques that claim to be faster and easier. If only I could train my patients osteoblasts to work harder and faster so their bones can heal rapidly, all of the problems can be eliminated and failures can be a thing of the past. The life cycles of cells have been a constant over a mil- lion years and now we are told that implants are appoved for immedi- ate load and the cells can adhere to inanimate objects through unique surfaces. My understanding of cell biology may be limited but it is com- mon knowledge that behavior of cells cannot be hastened because the mitotic cycle for the DNA takes the programmed time period for turn over. Only in disease this rapid un- controlled proliferation takes place. If this normal cycle is upset then we are look at metaplastic or anaplastic changes according to the turnover rate. Claims made by certain compa- nies that, bone heals faster with their implants is presumptuous. Bone levels are magically maintained with their unique surface modification is also far from the truth. I have used over 16 different implant systems in my practice over the years and in my training programs and I have found that the osteoclasts are notoriously unbiased. There is bone loss with every system and modifying the sur- face or creating morphological shifts does not predictably deter bone loss. In the courses I teach, I recommend waiting for a period of three years after any new feature or biologic product is introduced into implant dentistry. There is no room for lat- est or newest in clinical practice. If a company is constantly introduc- ing new product lines and changing their designs, there is only one con- clusion – They are having trouble and hence they have to change. A robust system that works seldom needs modification for getting pre- dictable results. Aspirin can never be debunked for its efficacy, be- ing so old and dated. The original Branemark external hex (now made out of type 4 Titanium but designed in 1965) is still very functional and a work horse for hybrid prosthesis. The surfaces have improved much but its basic design and biomechani- cal considerations will be valid for another 50 years. Premature adop- tion of technology or materials is fraught with shortcomings and unknown consequences. Classical examples of potential catastrophic failures include the TPS coatings, HA surface modifications, sintered surfaces, flapless surgeries, guided surgeries, immediate loading, costly BMPs and the list goes on. The message is very simple – one crawls before they walk and you must learn to walk before you can run. The same is true for implant dentistry. The novice today has a wide choice – you can become a com- plete arch implant specialist with 4 implants and guided surgery over a weekend or spend a year learning the basics and judiciously treatment plan cases with customized solu- tions. Half of the participants of our Maxicourses that we run in the U.S. and overseas have practitioners who have placed hundreds of implants and got their training through cor- porate education. One does not be- come a musician by buying a piano or a musical instrument, nor can you become a pilot by buying a plane. Training in implant dentistry has be- come a fad. Most courses are offered through companies and the com- pany’s sole interest is to sell their sys- tem. There is a whole world of treat- ment plan that is out there before the system can be utilized. Lets not place the cart before the horse. The void is very apparent the time is now for implementing judicious treat- ment plans. Lets serve our patients with what they need and not what we want them to have. Iyer’s Top 10 Guidelines for Predict- able Implantolgy 1. Diagnose the problem first and don’t treat because you have a tool that you can use. 2. Measure the disease and provide the therapy, don’t sell concepts. 3. Leave what’s new and latest to the risk takers, stick with proven and tried systems. 4. Implants are the last resort in treat- ment planning – exhaust all conserv- ative, conventional modalities 5. Implants should replace missing teeth not replace teeth. 6. Expensive implants don’t mean success rates are better, cheaper does not mean everything works – you get what you pay for. There is no substi- tute for evidence based practice 7. Consider every implant as a failing ÿPage D4 Fig 1 Fig 2 Fig 3 Fig 4 Fig 5 Fig 6 Fig 7 Fig 8 Fig 9 Fig 10