Surgical Strategies in Elderly Implant Patients

Article

Feature Article

Nov 13, 2018 // 22 min read

DOI: 10.3290/iti.fi.45660

Abstract

The mean age of candidates for implant surgery as well as dental patients is generally increasing due to the growing life expectancy worldwide. While being older per se is no contraindication for implant therapy, it often implies medical conditions and more medication (polypharmacy). These aspects often reduce the resilience of patients and lead to increased risk of complications after implant surgery.

The present review first describes typical dental and medical conditions of the elderly and their relevance to implant surgery. The main focus is subsequently set on surgical strategies in elderly patients to minimize the related morbidity without compromising the treatment outcome. Whenever possible, a standard implant placement without simultaneous bone grafting is preferred to offer a low-morbidity procedure. The use of short implants as well as narrow diameter implants is important to avoid bone grafting procedures. In addition, the frequency of flapless implant placement using computer-assisted implant surgery (CAIS) has increased considerably over the past 5 years and has become a highly attractive surgical approach in terms of minimal invasiveness.

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Introduction

Implant surgery in elderly patients has become a topic of growing interest in first and second world countries, primarily driven by the demographics of the population, since life expectancy has shown global and continuous growth over past decades (World Health Organization 2016). As at 2015, the mean life expectancy for a new-born was 76.9 years in the Americas and 76.8 in Europe. Mean life expectancy for an individual aged 60 reached 82 years. Coupled with a constant reduction in birth rates (World Health Organization 2016), this trend is leading to an unavoidable and constant increase in the mean age of patients in the dental office. The analysis of the implant patient pool treated in the Department of Oral Surgery and Stomatology at the University of Bern at three defined timeframes between 2002 and 2016 is in line with this general evolution (Fig. 1; Bornstein et al. 2008, Brügger et al. 2015, Ducommun et al. 2018). In this timeframe, the percentage of implant patients aged >70 has increased from 7.7% to 19.5% (Table 1). This shift is even more pronounced in the group of very old patients (age >80) with an increase from 1.0% to 4.0%.

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Fig. 1: Age distribution of the implant patient population treated in the Department of Oral Surgery and Stomatology of the University of Bern between 2002 and 2016

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Table 1: Distribution of elderly implant patients treated in the Department of Oral Surgery and Stomatology of the University of Bern between 2002 and 2016

Few studies focus on the dental status of very old patients, i. e. above age 80. However, some clinical surveys show a significant decrease in the prevalence of edentulism in older age cohorts. It is already a rare condition in high-income households in the US today (Slade et al. 2014). Edentulism is projected to fall to 2.6% by 2050 and will probably be seen mostly in the older, economically deprived population. There is no doubt that this trend can be observed in most of the western world. In Germany and Switzerland, the preventive measures that were launched in the early 1960s are now paying off in the elderly generation. The rate of edentulism in the 65 to 74 age cohort dropped from 24.9% in 1997/2000 to 12.4% in 2014. In this cohort in Germany, the mean number of teeth was 19.9 and 83.8% of the missing teeth were replaced, either with removable partial dental prostheses (RPDP: 33%), fixed partial dental prostheses (FPDP: 36.6%), or a combination (14.1%). The prevalence of dental implants increased from 2.6% in 1997/2000 to 8.1% in 2014. However, this representative study (Deutsche Mundgesundheitsstudie) still found 32.8% edentulous patients in the oldest age cohort of 75-to-100-year-olds (Micheelis & Schiffner 2006, Jordan & Micheelis 2016). In Switzerland, oral health showed an even greater improvement over time. In the last representative survey, edentulism affected only 6.5% of the 65-to-74-year-old cohort and 15.1% of the >85 cohort. However, almost 100% of those in the latter age group had some kind of fixed or removable dental prosthesis (Schneider et al. 2017). Finally, prevalence of edentulism ranged 0-54.7% in the 65-74 cohort globally and 2.7-27.6% in Europe and Israel (Stock et al. 2016).

It can thus be observed that edentulous patients are becoming older and hence more complex to manage. The overwhelming indications for dental implants, however, are nowadays single tooth replacements with implant-supported single crowns (SC), or extended edentulous spaces with implant-supported FPDPs, even in the oldest patients (Schimmel et al. 2017a). Today, there is consensus that age is no contraindication for implant therapy, as shown in a recent systematic review demonstrating very high survival rates in patients above the age of 75 years that were similar to those of younger patients (Schimmel et al. 2018).

Fig. 1: Age distribution of the implant patient population treated in the Department of Oral Surgery and Stomatology of the University of Bern between 2002 and 2016

Table 1: Distribution of elderly implant patients treated in the Department of Oral Surgery and Stomatology of the University of Bern between 2002 and 2016

Fig. 2: Pronounced intraoral (A) and extraoral (B) hematoma one week after staged sinus floor elevation and GBR in a patient with antithrombotic medication (acetylsalicilic acid 100 mg/d) and suspected hemostatic disorder

Fig. 3: 78-year-old man on medication with a vitamin K antagonist. Good communication with the physician enables measurement of the INR value (INR: 2.3) on the afternoon prior to surgery and to leave the anticoagulation unmodified. The terminally decayed abutment teeth (A) are removed and two interforaminal implants placed immediately, after a substantial ridge reduction until an adequate crestal width is reached (B). Primary wound closure and subperiosteal application of fibrin sealant (C). Healing after 1 week is uneventful, without formation of hematoma intraorally (D) and extraorally

Fig. 4: Implant placement in a 89-year-old woman. An implant with 3.3 mm diameter is inserted into the healed bone of the previous pontic area after the failure of a FPDP (A). The vertical ridge reduction (B) coupled with the reduced implant diameter leads to standard implant placement without bone grafting (C). An adjacent regular diameter implant enables a mesial cantilever unit with successful clinical (D) and radiological (E) findings after 4 years in function

Fig. 5: Pronounced horizontal atrophy after failure of an implant in area 45 after 30 years in function and loss of the implant restoration in a 80-year-old woman (A). A 2.9 mm implant (B) is inserted in the failed site without need for bone grafting (C, D) and heals transmucosally (E). Splinting to the surviving implant in area 47 allows for full fixed rehabilitation of the area. Clinical (F) and radiological (G) findings after 1 year in function

Fig. 6: The first 6-mm short implant placed in the Department

Fig. 7: Splinted, cantilever implant restoration on a 6-mm short implant (4.8-mm diameter) and an 8-mm long (4.1-mm diameter) implant after 10 years in function (A, B)

Fig. 8: 85-year-old patient with a single-tooth gap in close proximity of the maxillary sinus floor (A, B). Sufficient crest width allows for flapless placement of a 6-mm short implant (C, D, E). The peri-implant tissue around the single tooth restoration with a moderate crown-to-implant ratio show healthy conditions after 4 years in function (F, G)

Fig. 9: 6-mm and 4-mm (extra-) short implants placed in an upper posterior 2-tooth gap in close proximity of the maxillary sinus floor without need for bone grafting (A). The 74-year-old patient suffers from chronic polyarthritis and is medicated with immunosuppressants. The peri-implant findings are satisfactory after insertion of the splinted implant crowns (B) as well as 4 years later (C, D)

Fig. 10: 77-year-old woman medicated with acetylsalycilic acid requiring additional chewing units after an implant failure and subsequent vertical atrophy in the right lower premolar area (A). A 4-mm extra-short implant can be placed in area 45, distally of the pre-existing implant and splinted to the latter (C, D). Courtesy: Dr. M. Fonseca, ZT A. Bassermann

Fig. 11: Clinical (A) and radiological (B) findings of 66-year-old edentulous patient treated with an upper overdenture and a lower FPDP on 4 splinted implants, the posterior implants being 4-mm long (ongoing clinical study, courtesy of PD Dr. J. Wittneben)

Fig. 12: A cantilever restoration allowed to avoid maxillary sinus grafting procedures. Clinical (A) and radiological (B) findings after 10 years in function

Fig. 13: This cantilever restoration in the atrophic mandible allowed to avoid complex bone grafting procedures. Preoperative horizontal CBCT view of the horizontal atrophy (A), clinical (B) and periapical/cross-sectional findings (C) after 10 years in function

Fig. 14: Clinical (A) and radiological (B) view of a 68-year-old patient’s lower jaw. Two short (6-mm) implants support the distal aspect of a RPDP (C) by means of dome-shaped attachments

Fig. 15: The section shape of the interforaminal area can be assessed pre-operatively with palpation or CBCT. In crests with a triangular section type (A), the initially insufficient crestal width (B) can be increased by occlusal reduction (C). Such ostectomy is contraindicated in sandglass (D, E) or thin, parallel-shaped (F, G) anterior mandibles because it extends beyond the floor of the mouth. The latter cases may only be eligible for diameter-reduced or small-diameter implants. Clinical (H, I) and radiological (J) picture of 2.1-mm narrow implants after 3 years in function in the 97-year-old man

Fig. 16: Cross-sectional CBCT image of a canine area of an edentulous lower jaw with a thin crest (A). The planned implant type has to be placed deep subcrestally in spite of the reduced endosseous diameter (buccal view, B) in order for the microrough surface (green line) to be surrounded by a ≥ 1-mm thick bone. The peri-implant tissue surrounding such a deeply placed implant shoulder can remain biologically healthy only if the crest is accordingly reduced using an open flap procedure. Lower edentulous jaw with predominantly reduced keratinized mucosal width (C). Circles with a 4.8-mm diameter simulating the tissue to be removed for a flapless surgery are superimposed and show the invasion of the mobile mucosa