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Augmentation procedures for geriatric patients

01.02.2018
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Old age is not a contraindication for bone augmentation and implant placement, but patient and technique factors have to be considered.

Prof. Zhuofan Chen | China, Dr. Zhipeng Li | China

Since 2010 global demographics have revealed an ever-increasing elderly population.

Aged patients, who tend to present with partial or total tooth loss, inevitably need more complex and higher quality dental rehabilitation, including dental implant therapy.

Nevertheless, a recent systematic review provides evidence that aged patients receiving dental implants have excellent implant survival rates, clinically acceptable marginal bone loss changes and minimal complications.1

Therefore, it seems that advanced age alone should not be a contraindication for dental implant therapy, and implants can be a recommended treatment option in the rehabilitation of elderly, edentulous patients who are in reasonably good health and want to improve their oral function and quality of life.2

Systemic conditions

However, aged patients frequently suffer from one or more systemic diseases, especially diabetes and bone-related disorders, most of which not only restrict the surgical procedures that can be performed but also compromise implant success.

Before choosing an appropriate therapy, it is extremely important to obtain a thorough medical history and a detailed report of systemic conditions. Also, a comprehensive risk assessment should be conducted on a case-by-case basis. Safe surgical procedures and implant success can be expected only if the overall conditions of aged patients are considered.

Bone substitute to minimize surgical trauma

When bone augmentation is unavoidable, instead of autologous bone, xenogenic or alloplastic bone substitutes with comparable clinical outcomes like Geistlich Bio‑Oss® can be recommended. Donor site morbidity is avoided, and surgery time is reduced.3 Collagen membranes such as Geistlich Bio‑Gide®, with its biocompatibility and ease of use, are also effective in dealing with surgical complications like Schneiderian membrane perforations.


The Clinical tips: flap technique

The coronally advanced flap is preferred when dealing with thin mucosal tissue (thin biotype), since the preparation of a tunnel is likely to cause perforations or tearing of the gingiva. The coronally advanced flap is also recommended when a greater amount of coronal advancement is planned and if the scalloped nature of the free gingiva is absent – flatly contoured gingival zenith, such as in the lower anterior region.
The tunneling technique is ideal when working with a thick biotype, highly scalloped free gingiva and suitable keratinized tissue. The tunneling technique should also be considered if esthetics are critical and a mild to moderate coronal advancement is anticipated. One of the key factors for success is the proficiency of the periodontal surgeon.


Connective tissue graft vs. biomaterial

Connective tissue grafts help create keratinized gingiva, based on a study of tissue specificity by Karring and co-workers.3 In this epithelial differentiation study, Karring was able to demonstrate that free grafts harvested from the palate produced keratinized gingiva, whereas grafts transplanted from the non-keratinized alveolar mucosa produced alveolar mucosa.4

Advantages of connective tissue grafts include plasmatic circulation (capillary beds within the grafts) that help with high graft survival, outstanding color match after healing and dimensional stability. Disadvantages include patient morbidity, e.g. bleeding, delayed healing and pain, along with the secondary graft harvest sites. (Figs. 1, 2)

Accordingly, clinicians have been interested in developing a graft substitute. Such biomaterials not only avoid connective tissue graft harvest and associated morbidity but also provide unlimited supply with consistent quality. Working with such biomaterials, complete primary closure with a tension-free flap is recommended. Ideal biomaterials should act as scaffolding to promote ingrowth and regeneration by host cells, while remaining dimensionally stable. (Fig. 3)

Prof. Zhuofan Chen

Prof. Zhuofan Chen | China

Department of Oral Implantology
Guanghua School and Hospital of Stomatology
Sun Yat-sen University, Guangzhou

Dr. Zhipeng Li

Dr. Zhipeng Li | China

Department of Oral Implantology
Guanghua School and Hospital of Stomatology
Sun Yat-sen University, Guangzhou

References
  1. Srinivasan M, et al.: Clin Oral Implants Res 2017;28(8):920-930.
  2. Liu JY, et al.: J Oral Rehabil 2012; 39(8): 591–99.
  3. Chen ZF, et al.: Chinese J Oral Maxill Surg 2016, 26(1): 1–12.
  4. Erdoğan O, et al.: Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007; 104(6): 738.e1–13.
  5. Giovannacci I, et al.: J Craniofac Surg 2016; 27(3): 697–701.
  6. Chen ZF: Research and clinical application of dental implant therapy.[Book], 2010, Beijing, China.
  7. NIH Consensus Development Panel on Osteoporosis Prevention, Diagnosis, and Therapy: JAMA 2001; 285(6): 785–95.

Clinical case pictures: Zhuofan Chen, Zhipeng Li, Guanghua. SYSU

Illustration Header: Quaint

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