Restoring the Edentulous Mandible with Implants for a Smoker: Any Ideas?

There are so many options here. What is your patient's preference? Finances? Fixed vs. Removable? If she wants fixed you can place five intraforaminal implants for a hybrid prosthesis. If she doesn't mind a removable you can place four intraforaminal implants for an overdenture and precision attachments or a bar. Another option is all on four. Nice case, good luck.

In my opinion, two implants at lower jaw for removable denture,and then we should do more effect step by step if she wants to get more comfortable.At the same time,the complication can be observed. Thanks

For some reason the moderators at osseonews.com have edited my original post. I find that quite strange. Anyway, the patient wants a better solution than a unusable mandibular complete denture and a fixed prosthesis is too expensive for her. The question actually comes down to whether to install two or four intraforaminal implants?

You can consider 2 implants with "O" Rings or locators. You can consider 4 implants intraforaminal with a bar and any assortment of attachments for the OD. You can take care of many problems and avoid many problems this way. Of course try to get her to cut back------fat chance!

The decision about number of intraforaminal implants (2 to 4 ) indirectly depends on posterior alveolar ridge support...2 implants only when res alveolar ridges are prominent.

I agree with Dr. Andy, 2 implant retaine lower denture.

Place 4 MDI implants. Trust me you and patient will be happy. I am telling you from my esperience. Never had problems with them for 7 years. Patient happy, I am happy, quike surgery, excellent retention, no flap needed, same day loading, no 3 to 4 month wait time.

My understanding of the smoking risk is that it mainly manifests itself in the soft tissues,so gentle management and planning for good closure on that front is a big concern. Of course, and any break in smoking prior to placement and during healing will increase the peripheral circulation. The x-ray is too small for me to see if it is possible, but many of these cases can have short implants placed above or to the lingual of the inferior alveolar nerve using ridge split techniques. If a couple of posterior implants were possible, it could reduce the complexity and cost of a fully supported denture. For us, two anterior implants is a predictable situation which, as mentioned, could be enhanced later. John

Conventional 4 implants of 3.7 to 4.1 mm diameter in the interforaminal zone: and a denture on locators or on a bar

looks like a perfect 4 implant stabilization case. there are 3 options in my mid depending on a few factors, age, anatomy, finance and opposing dentition being the major ones. 1, mini implants, I tend to only use these in "geriatric" cases. 2, a single piece ball attachment (the biohorisons implant is a good one for this). I like to use this if the patient is more cost conscious the only problem is you many not be able to "upgrade" later. 3, conventional implants with locators. similar to above but with greater flexibility. Possibility of submerged healing which may be important in some cases. 4, syncone case my preferred choice as you can make a much more minimal fianl prosthesis. leaves the option to place a couple more and do bridges if the patient is younger. 5, all on 4 I don't have much experience with this, but can be a good option if the patient wants fixed, but alot more effort if the denture breaks, however I am not so sure about fixed acrylic hybrid dentures from a hygiene standpoint. There are many ways to approach this case finding out what the patient wants now is very important but it is worth finding out what the patient would ideally want you never know, kids may have finished collage in 5 years time... hope this helps, all the best, mike

I think Dr. Ainsworth has provided a well thought out and comprehensive set of options, nice work :-) Just a note that Biohorizons has created a 3.0 mm two piece implant that will allow the patient to "upgrade later" or repair a damged ball (it does happen, just not always sure how). Since your question relates to the patients smoking addiction, you may be consoled by the fact that in some European countries, where they still smoke like it is a cure for cancer, the success rates are not that much worse. Having said that I do believe these patients are at greater risk and you can do some risk management such as, smoking cessation or reduction for 2 weeks prior to surgery, flapless surgery (not recommended for inexperienced operators), closing the soft tissue with PRP of PRGF, Increased hydration, nutrition and vitamin therapy,strict post op protocols including chlorhexidine rinses and more frequent post operative visits

Thanks for all the advices and alternatives! It's interesting to hear the thoughts of other colleagues. The prosthodontist and the patient agreed on 2 implants in the intraforaminal region and a locator retained overdenture. Because the patient is a heavy smoker and poor bone quality I went for a 2-stage procedure and a prolonged healing period. Unfortunately we were not able to get the patient to cut back on her smoking. Good guessed, dr. Hughes!

on the smoking point, I work in spain and people tend to come attached with chimneys here and smoking in my experience is less important than other factors in initial success. Later on (10-15 yrs) I am not so sure I am not sure if many long term papers have ben done on this.....If anyone of you literature literate chaps knows.... My feeling however is that Patient factors (hygiene, systemic disease) keratanised tissue and occlusal scheme (load) come in as more important factors to determine long term success.

It is time that implantologists start to ,Think Outside The Box,after 20 yrs of experience there is only one way I would treat this patient today.BASAL IMPLANTS.No grafting!Immediate loading!!!.Yes fixed prosthesis on immediate load protocol.I have been doing this since the last 6 yrs which has convinced me that it is the best option to all the conventional options we have today.

I think Overdenture with four implants will do the job perfectly. You can select KOS ONE PIECE Implant, and do Flapless procedure and place four implants at lateral incisor and first premolar sites bilaterally maintaing parellelism . You can reline the denture with soft reliner for three months followed by copings in the dentures.

Are BASAL implants available for sale in the US? If so what company?

This is a perfect case for an All on 4. Because of the smoking issue I would use either a Nobel Guide or a Simplant Guided Stent made from a CT scan with a flapless surgery. I have had great success with this technique and the patients are very happy with the results. Other option if cost is a factor is the new Inclusive Mini's from Glidewell and an overdenture.

Please contact manufacturer Dr Ihde Dental. www.boi.ch for more information.

Dear resident, if you are getting ready for your boards , good luck! The number one contraindication for implants , the number two contraindication is smoking. The physiologic mechanism for failure if impants, bone grafts , soft tissue reconstruction and cosmetic surgery is something you should appreciated better than anyone. If you must place implants in a smoker that will not quit, you have to consider the simplest most time tested option. She has proven she can't keep her teeth clean , so what makes you think she's going to take care of her implants. The only people that place mini-implants in my part of the country are those that don't know any better. In 20 years I've never seen a single indication for a mini-implant, but have removed at least 25 that have failed . I have had 7 implant failures since I finished my residency at parkland, why, because I don't place implants where they don't belong. If I were to scan this lady in my facility I promise you she could accommodate two standard impants. Place two standard implants in front of each nerve and have them restored with a simple to clean overdenture. Considering anything more( ridge splitting, nerve lat., fixed restorations) or anything complicated is ill-advised . This is when you divorce yourself from dollar signs or MRB. B. Vinci. Omfs

Addendum; the number one contraindication for implant placement is periodontal disease . She doesn't have any active dz now because she is edentulous . Obviously the sentence should read you should appreciate the physiology associated with the I'll effects of smoking better than anyone. Smoker failure occurs at the bone level as much or more than at the soft tissue level. Even considering immediate loading on this patient is reckless at best. Best of luck . B. Vinci

Dear Dr. Vinci, Thank you for the good advice! I'm still in training and not getting ready for my boards just yet. As I commented earlier I placed two standard implants (2 x Straumann RC Bone Level SLActive 4,1 x 12 mm) in the intraforaminal region and they're getting restored with an overdenture after healing. Regarding mini-implants I share your thoughts on the subject.

Consider giving patient hybrid bridge on 6 implants. I have done a lot of such cases with 4 interforaminal implants and 2 basal implants on either side at lower 2nd molar area. You load them in 3 days.need not bother about periimplantitis and smoking as the implants engage basal bone.

Dear resident, you handled the case just as you should. Most of my responses were directed at the answers you received prior to my own. The response after yours and mine , is possibly the most insane. People rarely change their habits regardless of wether they just won the lottery or some large settlement. Please excuse my sarcasm , but as a twenty year vet , that still takes head and neck call like a resident, it's hard not to take a few jabs at gross negligence . The best surgeons, in my opinion, are the ones that no when not to operate. There will be plenty of work out there ! DO THE RIGHT THING. Respectfully B. Vinci

Correction; know when not to operate. B. Vinci

I read through all the post. Basically the type of treatment selected is pretty much based on the price. Should have indicated the patient's price range in the topic. Pretty much comes down to only 2 implants overdenture option. Much less confusion/debate if that was mentioned in the beginning

I have yet to see any smoking patients where the smoking affects the integration/bone quality. I think smoking-bone quality is a big load of hogwash. Smoking affects mostly the soft tissue healing and that's about it.

Blah, if you actually read all the posts, you'll see that the economic aspect has been mentioned earlier. Read my post from June 25th. By the way, are your thoughts on smoking and osseointegration/bone quality backed up by any litterature?

My experiences doing implants on smokers is what backs me up. After few decades of doing this, I feel the literature is just wrong, or at the very least not a good representation of the real world. I have done some academic researches before, and to be honest, one can often 'skew' the numbers to get the results you want.

Blah, while at first I thought you had some grasp of what you were doing , but to suggest that smoking has no effect on integration is absurd. Do you read any scientific journals?Do you do soft and hard tissue reconstructive surgery? Do you know anyone that does? It is a well known fact that smoking is deleterious to the vessels , mostly the ones at the microscopic level , that we rely on , for fine healing. Have you ever looked at the skin of a smoker? Come on, if you are going to engage in intellectual debate, at least keep it in " the park". Bv

Smoking affects soft tissue yes, healing yes. Bone quality no, integration itself no. I find no difference in the distribution and bone quality (type 1-4) in a smoker compared to non smoker. Poster max bone is shit in smoker and non somker. Md anterior bone is hard in smoker and non smoker. Quoting dental literature is a joke in itself. Most are sponsored by implant companies and reads like High school science projects. I don't see dental journals having any "science" in them anyway. More like "check out what I'm doing" by the author

Blah, "conversing" with you Is like debating a high school kid. To suggest our scienctific journals are useless is again absurd. I wouldn't let you place an implant in a balsa model. This mentality is why surgeons and well trained perio guys argue as to who should be doing these cases. The majority of gp's that place implants live and die by science . It is the researchers writing these articles that have gotten dentistry to where it is today. SHAME ON YOUR THANKLESS MENTALITY! Bv

oh dear

Dear Doctors, I want to know about the implant quality and long term success rate of adin implants. How is response in immediate loading cases.

Dr. Ag , in my experience, loading implants in a smoker that lost all of her teeth, makes little or no sense, even though there are some questionable studies that do support this practice . Remember this is an "imperfect world", so I suggest you do everything you can to improve your success. I have seen this done in my part of the country with success rates significantly lower than tx as per branemark studies. Why can't this pt wait three months? Bv

Dr. Ag , in my experience, loading implants in a smoker that lost all of her teeth, makes little or no sense, even though there are some questionable studies that do support this practice . Remember this is an "imperfect world", so I suggest you do everything you can do to improve your success. I have seen this done in my part of the country with success rates significantly lower than tx as per more traditional long term studies. Why can't this pt wait three months? Bv

I heard a well experienced OMS say that, if we did not place implants in smokers, we'd lose a large portion of the implant patient pool. My experience is to tread carefully with knowledgeable planning: double check the patient cooperation level, double check the soft tissue quality, double check the bone quality, allow extra clearance, plan smaller thinner grafts, allow controlled loading, longer healing both soft and hard tissues. Try to work under complete tissue coverage. AND to refer to a specialist if any of these factors is "iffy". John