stomaeduj-2-2020-article-3

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                    ORAL IMPLANTOLOGY
                    IS THERE AN AGE LIMIT FOR IMPLANT DENTISTRY?
Original Articles
                    Daya Masri1,5a* , Liat Chaushu2b , Joseph Nissan3c , Sarit Adriana Naishlos4d , Gavriel Chaushu1,5e
                    1
                     Department of Oral and Maxillofacial Surgery, Rabin Medical Center, Petah Tiqwa, Israel
                    2
                     Department of Periodontology and Implant Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
                    3
                     Department of Oral Rehabilitation, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
                    4
                     Department of Pediatric Dentistry, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel-Aviv University, Tel-Aviv, Israel
                    5
                     Department of Oral and Maxillofacial Surgery, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel

                    a
                      DMD; e-mail: dr.dayamasri@gmail.com; ORCIDiD: https://orcid.org/0000-0002-3808-8664
                    b
                      DMD, MSc; e-mail: liat.natanel@gmail.com; ORCIDiD: https://orcid.org/0000-0002-5755-7526
                    c
                     DMD, MSc; e-mail: nissandr@gmail.com; ORCIDiD: https://orcid.org/0000-0001-7290-4357
                    d
                      DMD; e-mail: river554@gmail.com; ORCIDiD: https://orcid.org/0000-0002-2920-7000
                    e
                      DMD; e-mail: gabi.chaushu@gmail.com; ORCIDiD: https://orcid.org/0000-0001-9176-4978

                    ABSTRACT                                                                                https://doi.org/10.25241/stomaeduj.2020.7(2).art.3

                    Introduction Aging may impede implant survival due to compromised wound healing. The present study
                    assessed, retrospectively, whether there is an age limit for implant dentistry.
                    Methodology All patients treated with a single implant brand in a single medical center were included. Early
                    implant failure (EIF) was recorded. The cohort was divided to a younger (20 to 65) and an older (≥65) group.
                    The comparison between groups was based on: (1) gender (2) physical status (3) implant location (4) implant
                    dimensions (5) number of implants placed per patient and (6) bone grafting.
                    Results Out of 121 patients, the younger group comprised 57 and the older 64. The younger cohort received
                    192 implants (mean: 3.25±3.68, range: 1 to 16 implants per patient) vs. 171 (mean 2.78±1.91, range: 1 to 11
                    implants per patient) in the older group. The older did not differ significantly (p > 0.05) from the younger
                    in any of the parameters evaluated. EIF on implant and patient level was 1.0 and 3.5%, respectively in the
                    younger vs. 1.1 and 3.1%, respectively in the older. Seven patients were ≥80 years. EIF at implant and patient
                    level was 8.3 %and 14.3% respectively.
                    Conclusions Elderly patients ≥65 years old presented a similarly low EIF rate as younger patients 20 to 65
                    years old, while patients ≥80 years old may have a slight tendency for a higher EIF rate. Hence, there seems
                    to be no age limit for implant dentistry.
                    KEYWORDS
                    Early Implant Failure; Osseointegration; Older Population; Dental Implant; Aging.

                    1. INTRODUCTION                                                                  suggested that age may be associated with a higher
                                                                                                     implant failure rate [8,9]. Bone quality and quantity
                    The growing numbers of population ≥ 65 years [1]                                 are related to initial stability and longitudinal
                    offer an important challenge for the dental profes-                              success [10,11]. Both are theoretically compromised
                    sion. Implant dentistry has a major contribution to                              by aging. After the age of 50 a marked increase in
                    improving life quality [2-4]. Aging may compromise                               bone porosity and decrease in bone mass, were
                    implant survival due to compromised wound healing                                demonstrated [12]. Implant success can thus be
                    [5,6]. The proliferative phase of healing is prolonged                           compromised [10]. Bone volume may be reduced
                    due to reduced numbers of stem cells [6]. A study in                             requiring grafting before or with implant placement.
                    a rat model demonstrated that the younger group                                  Bone augmentation success is age-related [13]. The
                    achieved good bone contact faster than the older                                 decrease in the number of pluripotent cells within
                    one. The results suggested that the rate and volume                              the bone marrow [14,15] and the reduced numbers
                    of new bone formation around implants decrease                                   of osteogenic cells at recipient sites combined with
                    with age [7]. Other studies on implant treatment                                 low vascularity [16] are suggested factors that might


                                  OPEN ACCESS This is an Open Access article under the CC BY-NC 4.0 license.
                                  Peer-Reviewed Article
                        Citation: Masri D, Chaushu L, Nissan J, Naishlos SA, Chaushu G. Is there an age limit for implant dentistry? Stoma Edu J. 2020;7(2):102-107.
                        Received: May 05, 2020; Revised: May 13, 2020; Accepted: May 15, 2020; Published: May 18, 2020
                        *Corresponding author: Dr. Daya Masri, DMD, Department of Oral and Maxillofacial Surgery, Rabin Medical Center-Beilinson campus, Petah Tikva, Israel;
                        Department of Oral & Maxillofacial Surgery, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
                        Tel.:+972-528836333; Fax:+972-37715001; e-mail: dr.dayamasri@gmail.com
                        Copyright: © 2020 the Editorial Council for the Stomatology Edu Journal.




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Age limit for implant dentistry
Fig. 1 Patient distribution according to age
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                                                            extracted and manually screened twice by 2




                                                                                                                          Original Articles
                                 Age distribution           examiners (DM and GC).
                                                            Inclusion criteria – Complete documentation; mini-
                                                            mum follow-up – 12 months following prosthetic
                                      16%       11%         delivery.
   20-40                                              13%   Exclusion criteria – history of head and neck cancer and/
   41-55                        15%                         or immune deficiency due to immunosuppressant
   56-65
                                                            medication, uncontrolled systemic diseases, heavy
   66-70                                              24%
   71-75
                                      21%                   smokers, untreated periodontal disease.
   76-91                                                    The following parameters were recorded:
                                                            m age
                                                            m gender
                                                            m physical status according to American Society for
                                                            Anesthesiology (ASA)
 Figure 1. Patient distribution according to age.
                                                            m implant location
                                                            m implant dimensions (length, diameter)
compromise bone grafting in the elderly. Implant            m bone augmentation prior to or simultaneously
failures can be divided into early and late [17]            with implant installation (yes/no)
according to timing of failure - abutment connection        m number of implants placed
[18,19]; loading [20]; several weeks after placement        m early implant failure (EIF) – lack of osseointegration
of the final prosthesis [21]; 12 months after loading       up to 12 months after prosthesis delivery and
[22,23]. Late failures are associated with moderate to      occlusal loading (yes/no; primary outcome variable).
severe bone loss, a larger number of failed implants
per patient, a higher incidence in men, and mostly          2.2. Statistical Analysis
in posterior areas. Early failures are associated with      The descriptive statistics were calculated for patient-
minimal bone loss, occur more in women, and in              and implant-related characteristics. The cohort was
most cases the implants were intended to support            classified into 2 age sub-cohorts: (1) 20-65 years old at
single crowns [17]. There are studies indicating that       time-point of implant installation) and (2) ≥ 66 years
increasing age alone is not a contraindication for          old at time-point of implant installation. The Fishers’
implant treatment [24-28]. However, there is still lack     exact test or chi-squared test was used to assess any
of information on early implant failure (EIF) in the        potential differences regarding the various categorial
elderly (implant loss up to 12 months post loading).        parameters (gender; ASA status; implant location;
Therefore, the aim of the present study was to assess,      implant dimensions; bone augmentation; number
retrospectively, EIF rate in an older (≥ 66 years old)      of implants placed; number of EIF). Patient specific
patient cohort up to one year after prosthetic              parameters have been compared at patient level,
delivery, and to compare it with a younger (20 to 65        while implant specific parameters at implant level.
years old at time-point of implant installation) one.       A statistical analysis was performed using SPSS
                                                            Version 24.0 (SPSS Inc., Chicago, IL, USA) and p-values
2. MATERIALS AND METHODS                                    < 0.05 were considered as statistically significant.

The present retrospective, cohort study is based            3. RESULTS
on dental records of the Department of Oral and
Maxillofacial Surgery, Rabin Medical Center, Campus         3.1. Patient population
Beillinson, Israel, which were selected automatically       Most of the patients were between 56-70 years old
(electronically) based on information from the den-         (45%) (Fig. 1). Out of 121 patients, the younger group
tal implant records, from 01/2017–12/2018. All treat-       comprised 57 and the older 64. Mean age was: 50.5
ments were performed by experienced oral and                ± 0.53 years (range: 20-65 years; 61.4% females) vs.
maxillofacial surgeons and the only implant type            73.1±5.65 years (range: 66-91 years; 65.6% females)
installed was molecular precision implant (MPI™),           respectively.
endosseous, conical, sand-blasted and acid-etched
surfacing (Ditron Dental, Ashkelon, Israel). The study      3.2. ASA status
protocol was approved by the ethics committee of            All patients had physical status either I or II. No statis-
the Rabin Medical Center, Campus Beilinson, Israel          tically significant differences between the groups
(0674-19rmc). The present manuscript complies with          (p>0.05).
the STROBE guidelines.
                                                            3.3. Implant data
2.1. Patient population                                     The younger patient cohort received 192 implants
The dental records of all patients who had received         (mean: 3.25±3.68, range: 1 to 16 implants per
an MPI™- (Ditron Dental, Ashkelon, Israel). Dental          patient) vs. 171 (mean 2.78±1.91, range: 1 to 11
implant between 01/2017 and 12/2018, were                   implants per patient) in the older group. Data on



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                    Masri D, et al.
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Original Articles    Table 1. Implant number and dimensions (diameter & length) according to location.

                                                                                Diameter (mm)                               Length (mm)
                                                      Number        Mean         Min.       Max.     Median        Mean     Min.    Max.    Median
                           Maxilla                       163
                           Anterior         Young         33         3.70         3.3       3.75         3.75      11.90     8       13      11.5
                                             Old          32         3.83         3.3        4.2         3.75      11.97     10      13       13
                          Premolar          Young         34         3.86         3.75       4.2         3.75      11.67     8       13      11.5
                                             Old          21         3.85         3.75        5          3.75      12.40     8       13       13
                            Molar           Young         24         4.18         3.75        5          4.2      11.375     8       13      11.5
                                             Old          19         4.16         3.75        5          4.2       11.5      10      13      11.5
                          Mandible                       200
                           Anterior         Young         35         3.76         3.75        5          3.75      11.56     10      13      11.5
                                             Old          38         3.74         3.3        4.2         3.75      11.32     8       16      11.5
                          Premolar          Young         37         3.71         3.3        4.2         3.75      9.97      8       13       10
                                             Old          34         3.74         3.3        4.2         3.75      10.15     8       13       10
                            Molar           Young         29         3.98         3.3         5          3.75      9.29      6       11.5     10
                                             Old          27         3.99         3.3         5          3.75      9.26      8       11.5     10

                    implant locations- number of implants per jaw area                     no significant differences of implant survival (94
                    and implant dimensions (length and diameter) per                       vs. 95%, respectively) [30]. The failure of osseo-
                    area are presented in Table 1. The older group did                     integration was suggested as the main reason for
                    not differ significantly (p>0.05) from the younger                     EIF [31]. Contributing factors may be patient-related
                    group in any of the parameters. Bone grafting was                      [18,19], surgeon-related [22], and biomaterial-
                    performed in 14/57 (24.6%) of the patients in the                      related [32].
                    younger group vs. 18/64 (28.1%) of the older group.                    These studies used many implant systems with
                    Mean follow-up was 27.3±8.4 months in the younger                      different designs, which could have greatly affected
                    group vs. 24.9±6.2 months on the older one.                            the results. Consequently, we concentrated on a
                                                                                           single implant from a single implant system in the
                    3.4. Early Implant Failure (EIF)                                       present study. The group comparison accounted for
                    In the younger patient group, 2 patients had one                       5 factors, i.e., gender, ASA status, jaw site, implant
                    EIF each. EIF on implant and patient level was 1.0                     characteristics (number and dimensions), and need
                    and 3.5%, respectively. In the older patient group 2                   of bone grafting, while some other factors were
                    patients had one EIF each. EIF on implant and patient                  controlled through inclusion criteria - choosing the
                    level was 1.1 and 3.1%, respectively.                                  same type of implant (i.e., MPI / Ditron™ Dental) and
                                                                                           implant insertion by experienced oral and maxillo-
                    3.5. Patients ≥80 years old                                            facial surgeons.
                    A special attention was given to 7 patients (3 females                 A review points out 65 years of age has been as the
                    and 4 males) ≥80 years old (Table 2). A total of 12                    cut-off to define "older" in several studies [29]. That
                    implants were placed (1-3 per patient). The locations                  is the reason for choosing this age as cut-off in the
                    varied. Bone augmentation was not performed in                         present study. The age of 7 patients was ≥ 80 years
                    any of the cases. One implant failed in the oldest                     old, contributing 12 implants. Bone augmentation
                    patient (91 years old). EIF at implant and patient level               was not performed in any of those patients and the
                    was 8.3 % and 14.3% respectively. We speculated                        number of implants did not exceed 3 implants.
                    that the extremely poor-quality soft bone of the                       Those facts emphasize the desire to keep implant
                    posterior maxilla could be the failing reason.                         dentistry at age ≥ 80 years simple and with minimum
                                                                                           potential morbidity. EIF at implant and patient level
                    4. DISCUSSION                                                          was 8.3 % and 14.3%, compared with the entire older
                                                                                           (≥66 years old) patient group, in the present study,
                    In the present study EIF were not more frequent                        which resulted in EIF of 1.1% and 3.1%, respectively.
                    in older (≥ 65 years old) vs. younger patients (20-                    Nevertheless, it should not be forgotten that these
                    55 years old), and in general rare (around 1% on                       fractions still represent only one EIF case. This EIF
                    implant and between 3 to 4% at patient level). This                    is compatible with previously reported risk factors
                    corresponds with the existing literature on implant                    for EIF – women and implants intended to support
                    therapy in the elderly. A review on implants in older                  single crowns [17]. Correspondingly, other studies
                    patients reported implant survival rates of 98% at                     reported higher EIF in patients ≥ 80 years old [33,
                    1 year and 91% at 10 years [29]. Another review on                     34]. Specifically, 4.5% at implant level [33], or 9.7% at
                    implant failure in older vs. younger patients, reported                patient level [34]. Still, 6/7 patients aged ≥ 80 years



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Age limit for implant dentistry
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                                                                                                                                                       Original Articles
 Table 2. Implant characteristics for patients ≥80 years old.

 Age (years)                                                    80          80           80          83           84             90        91
 Gender                                                    Female      Male            Male         Male       Female           Male     Female
 Number of
                                                                 1          1            1            2            3             2          2
 implants
 Follow up (months)                                             20          28           22          24           38             23        26
                                   Location                     27          23           21          35           42             42        15
 1st Implant
                                   Dimensions                   4.2/   3.75/           3.75/         4.2/        3.75/          3.75/     3.75/
                                   (mm)                          13    11.5             13           11.5         10            11.5      11.5

                                   Location                                                          41           43             43        26
 2nd implant
                                   Dimensions                                                        4.2/        3.75/          4.2/       3.3/
                                   (mm)                                                              11.5         10            11.5       11.5
                                   Location                                                                       44
 3rd implant
                                   Dimensions                                                                    3.75/
                                   (mm)                                                                           10
 Bone
                                                                No      No               No          No           No             No        No
 augmentation
 Failure                                                        No      No               No          No           No             No         1



old in the present study showed successful primary                               CONFLICT OF INTEREST
osseointegration and received final prosthetic resto-
                                                                                 The authors declare no conflict of interest.
ration.
Considering the limitations that the present study is                            AUTHOR CONTRIBUTIONS
retrospective, the physical status of both elderly and
younger patient groups was good, the operators                                   DM: conception and design of the study, acquisition of data,
were experienced oral and maxillofacial surgeons,                                analysis and interpretation of data, drafting the article, final
and only few EIF were observed, it is still reasonable                           approval of the version to be submitted; LC: conception and
to conclude, that there is no age limit for implant                              design of the study, analysis and interpretation of data, drafting
dentistry.                                                                       the article, final approval of the version to be submitted; JN:
                                                                                 conception and design of the study, analysis and interpretation
5. CONCLUSIONS                                                                   of data, drafting the article, final approval of the version to be
                                                                                 submitted; SAN: conception and design of the study, analysis and
Elderly patients ≥65 years old presented a similarly                             interpretation of data, drafting the article, final approval of the
low EIF rate as younger patients 20 to 65 years old,                             version to be submitted; GC: conception and design of the study,
while patients ≥80 years old may have a slight ten-                              acquisition of data, analysis and interpretation of data, drafting
dency for a higher EIF rate. Hence, there seems to be                            the article, final approval of the version to be submitted.
no age limit for implant dentistry.




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                                                                                                                          Daya MASRI
                                                                                                                             DMD
                                                                                 Department of Oral and Maxillofacial Surgery
                                                                    Rabin Medical Center- Beilinson Campus, Petah Tikva, Israel
                                                                                 Department of Oral and Maxillofacial Surgery
                                                              The Maurice and Gabriela Goldschleger School of Dental Medicine
                                                                                              Tel Aviv-University, Tel Aviv, Israel




                    CV
                    He graduated from the Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel. He is
                    chief resident at the Department of Oral and Maxillofacial Surgery in Rabin Medical Center- Beilinson Campus. He is a member
                    of the Israeli Society of Oral & Maxillofacial Surgery, and also a member of the Israeli Dental Association. He lectures nationally
                    and internationally. His private practice is in Tira, Israel.




  106               Stoma Edu J. 2020;7(2): 102-107                                                             pISSN 2360-2406; eISSN 2502-0285
Age limit for implant dentistry
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Questions




                                                                                              Original Articles
1. Timing of early implant failure in the present study?
qa. At surgery;
qb. At 2nd stage surgery;
qc. Up to one year after loading;
qd. Up to 6 weeks after loading.

2. EIF rate for patients ≥80 years old?
qa. Was similar to younger group;
qb. Was similar to older group;
qc. Had a slight higher tendency;
qd. Was better than younger group.

3. The main wound healing problem in the older?
qa. Lack of myofibroblasts;
qb. Reduced numbers of stem cells;
qc. Lack of osseointegration;
qd. Lack of ossification.

4. Implant dimensions in the older were?
qa. Similar;
qb. Higher;
qc. Lower;
qd. Not recorded.




Stoma Edu J. 2020;7(2): 102-107                            pISSN 2360-2406; eISSN 2502-0285   107