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12 (cid:9)DENTAL TRIBUNE(cid:9) Pakistan Edition(cid:9)May 2017 CLINICAL IMPLANTOLOGY Considerations for Long Term Success By Dr Shankar Iyer, USA Implants are Never Forever! T his 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 promises to patients when presenting implants 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 implants. 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.(cid:9) Patients are now wondering with these highly overstated survival rates, why their implants are ailing 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. Podium 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 involved in implant dentistry because the education is being blessed by companies and not through universities or institutions.(cid:9) 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 better. 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 survival of implant therapy is prolonged.(cid:9) 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 million years and now we are told that implants are appoved for immediate load and the cells can adhere to inanimate objects through unique surfaces. My understanding of cell biology may be limited but it is common 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 Pre-op Patient Presentation Radiographs of the Failing Maxillary Implant Reconstruction Fig 1 Fig 2 Removal of Implant FPD Tissue Remnants After Removal of Prosthesis and Implants Fig 3 Fig 4 4 week post op - after tissue conditioning Stereolithographic Models after Scan Fig 5 Fig 6 Bilateral Sinus Lifts and Implant Placement Stage II impression for Abutment selection Fig 7 Fig 8 Universal Modified abutments for tissue level connection Vertification Jigs Fig 9 Fig 10 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 surface or creating morphological shifts does not predictably deter bone loss.(cid:9) 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 latest or newest in clinical practice. If a company is constantly introducing new product lines and changing their designs, there is only one conclusion - They are having trouble and hence they have to change. A robust system that works seldom needs modification for getting predictable results. Aspirin can never be debunked for its efficacy, being so old and dated. The original Branemark external hex (now made out of type 4 Continued on Page 14