A Case Against the Implant

Episode #616 with Dr. Bill Robbins

More and more people have dental implants, and that number keeps growing. But is it always the best option for patients? To reveal why some implants are problematic, Kirk Behrendt brings back Dr. Bill Robbins, co-founder of the Global Diagnosis Study Club, to make a case against some of the most commonly placed implants in “younger” patients. It’s the way we've always done it, but there’s a better way! To unlearn what you've been taught about implants, listen to Episode 616 of The Best Practices Show!

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Links Mentioned in This Episode:

Learn more about Global Diagnosis Education

Register for the Global Diagnosis Education Symposium (September 7-9, 2023)

Sign up for Dr. Robbins’s lecture “My Failures and Lessons Learned”

Main Takeaways:

Don't get stuck in the “that's the way we’ve always done it” mindset.

Understand why certain implants will inevitably fail faster.

In some cases, implants should be the last option.

There are better options than implants. 

Treatment plan for the long term. 

Quotes:

“Dentistry can be a fairly dogmatic discipline. I've seen that through my 50 years, that people learn some piece of dogmatic information, and they learned it maybe in dental school, and they've continued to believe it, repeat it, and do it dogmatically — and they'll fall on their swords for it. That's true, especially with younger dentists. They come out of dental school. They believe that they had a great dental education, and really wonderful faculty, and because their faculty taught them that, it's got to be true. And it may not be true, or it might be partially true. But they live with that partial truth for the rest of their lives, and they never really are open to asking the question, ‘Is this really true? Is this really the best way to do it?’” (5:07—5:58)

“Implants have been available to us in our profession for about 40 years. As we all know, they've been incredibly successful. It has become the go-to way to replace missing teeth all over the mouth, and certainly in the anterior maxilla. Through my many years of being involved in the placement of implants in the anterior maxilla, I have become more and more reticent to place them in the anterior maxilla, for reasons we're going to talk about. In the last five or six years, my statement has become this: I do not treatment plan single implants in the anterior maxilla in the young adult.” (6:43—7:31)

“I'm still fairly active in my practice, and I get referrals commonly from a patient or a dentist who has told this patient, generally an orthodontist, that, ‘We're going to align your teeth to your implants. When you get to be 18 or 19, you'll go see Dr. Robbins. He'll put an implant in, and that will replace your upper missing lateral incisor.’ That's what I did for many years. And then, I started looking at some of the long-term results of my implants in the anterior maxilla. About ten years ago, I started developing a concern about this. And, by the way, I'm not unique in this. We're starting to hear more and more from the podium speakers saying, ‘We need to take a closer look at implants. They're not doing as well as we thought they might be doing long term. We need to be a little bit more analytical about the placement.’ So, I'm not the only one that's saying this. I'm just one of the ones that's carrying the banner right now.” (7:38—8:41)

“I started making the transition away from replacing especially maxillary lateral incisors. It's a very common tooth to be lost for two reasons. First of all, it's the second-most common tooth to be missing, genetically. It's just not there. The other is trauma. It's a very common tooth to be avulsed and lost during those formative years between the years of, say, eight to 14. I used to replace those lateral incisors routinely with an implant. I had concerns about it, but we didn't have a good solution to the problem until a number of years ago. For me, it was about six or seven, and that is the bonded bridge . . . The bonded bridge has become my go-to replacement for the maxillary lateral incisor.” (8:43—9:42)

“We were traditionally taught that using either wrist films or serial cephalometric X-rays that are overlaid over each other, starting at about age 18, you could tell whether or not a person's growth was complete. Once you can confirm that their growth is complete, then you can feel comfortable placing an implant. Generally, that was in the range of age 18 for females, and around age 21 for males. Those were the common ages that we were given. And so, we were told you can do these wrist films or cephalometric X-rays that are overlaid to determine if it's now finally the time to place the implant. Well, it turns out that neither of those are predictors of whether or not growth is complete.” (11:06—11:52)

“This is a lovely young woman in my practice that was 20 years old. We confirmed that her growth was complete, so we placed an implant in the number seven site replacing a lateral. She was missing a lateral and a canine on the other side, so we placed an implant in the canine site and put a pontic off the canine. So, two implants replacing three teeth, 2004. I saw her back on recall through the years, but didn't pay really close attention up until 2019, which is a 15-year post-op on her. It looked like, to me, things were changing. And so, I took a photograph of the way she looked in 2019. I had a wonderful photograph, exactly the same magnification that was taken in 2004. When I put those two photographs up next to each other, there had been tremendous changes in this young woman in 15 years.” (12:01—13:00)

“What happens [with single-tooth implants] is if a patient grows, the maxilla grows down vertically, and the teeth move with the maxilla as it grows vertically — but the implants don't. They are like an ankylosed tooth that stays in the same space as the other teeth continue to grow. In this period of 15 years, her other teeth, adjacent to the implants, had grown vertically more than two millimeters, compared to the implant. It was becoming obvious now that her implants were no longer in the correct positions in her face because her maxilla had grown vertically and brought teeth down with it, but the implants didn't move with the maxilla. So, the implants are high. The edges of the implants are three millimeters apical to the edges of the adjacent teeth. The gingiva is also in the wrong place because the implant holds the gingiva up. So, this was a seminal turning point for me when I finally came to the conclusion that it made no sense to use implants to replace missing single anterior teeth in a young adult.” (13:01—14:13)

“Now, let me make a caveat here. I'm not talking about a patient that's missing a bunch of front teeth either due to trauma or agenesis. We don't have a good solution for those people other than implants. So, I'm talking about the single tooth that's missing in the anterior maxilla. I no longer believe in the young adult — and when I say young adult, I'm talking about 20, 30, 40. I don't think we should be putting single implants in until other ways have failed. That's my whole point today. If things that are available to us have failed, then we can move to the implant as the last treatment option. But the implant is, by far, the most aggressive way to replace a tooth. We have much more conservative ways. That's my belief system today.” (14:14—15:07)

“The second thing that happens to implants, long term, is the tissue tends to thin over the implants with time. As it thins, the color of the implant and the abutment starts to show through, and now you can see the grayness or blueness under the tissue. It's a giveaway that this is not a natural tooth. The other problem is that as we age, the maxilla moves back in this direction. If the implants are here, and the maxilla is moving more centrally over 20, 30, 40, 50, 60 years, the implants are no longer in the correct position. They're facial to the rest of the bony housing. So, I think the important question we have to ask is, when we replace a missing maxillary lateral incisor with an implant when the patient is 20 years old, how long does this have to last? Assuming that the person we place it in doesn't have a major illness by the time they're age 70, there's a very high probability they'll live to be at least 100. So, we're expecting this implant that we're putting in on a 20-year-old to serve them successfully for another 80 years. My question is, what are the chances? And we don't have the data. We clearly don't have any 80-year data on implants. But I think our hearts tell us what the answer is. And the answer is, in a lot of circumstances, this implant has not a chance to be successful for the next 80 years, first of all, because of growth. Secondly, because of tissue thinning.” (15:08—16:52)

“I had another seminal patient recently in my practice. This patient, we placed implants in number nine and number 11, and did a three-unit bridge when he was 80 years old. Eighty years old, two implants in the central and the canine, a three-unit bridge. I recently saw him on a 15-year post-op. This gentleman is now 95. He's still a really cool guy, a wonderful person to be around. The edges of his implants were up here, and the edges of his natural teeth were down here. So, not only do we not know who is going to have late growth, because it doesn't happen to everybody, but we don't know how long it's going to occur. This gentleman had vertical growth of his maxilla from age 80 to age 95. And so, these patients that I'm taking a close look at are making me very nervous about not only my patients, but the whole world of dentistry that are putting in tens of thousands of implants in the anterior maxilla every year with really no thought of the long view. We have to do our dentistry with the long view.” (16:53—18:07)

“When I first started [my lecture, “Failures and Lessons Learned”], it made me a little nervous because I'm standing in front of a group of dentists that are the referrals of the surgical specialists, and I'm saying, ‘I absolutely believe we should stop placing implants in the anterior maxilla in young adults.’ But here's what I found very interesting. Over the last four years, I've probably presented this lecture 50 times. Never have I gotten pushback from the surgical specialists. And my case is a really strong one. It's a very strong case when I go through the literature of the point I'm trying to make. So, there may be some that are not willing to argue the case because I've made a strong case. But most of the surgical specialists say, ‘I absolutely agree.’ So, it's interesting. Even though they have all continued to put implants in the anterior maxilla, especially the lateral spot, when I bring it up as a subject to be discussed, I almost never get any disagreement from the surgical specialist. And so, I really believe the profession is open to hear this. I believe that it has become an automatic response to a missing lateral incisor. You put an implant in when the patient is 18 or 21. It's “just the way we've always done it.” So, it's not necessarily that everybody believes it's the best. It's just the way we've always done it. And the other problem is, our profession is not really up on the alternative treatments. And, of course, you can't just talk about the problem. You’ve got to talk about the solutions.” (19:51—21:33)

“Another problem is mechanical failure of the implants. Everybody that has done implants has dealt with broken screws and broken implants, and there are more and more of those issues to deal with because we have more implants in the head now. It's the worst call ever, as a restorative dentist, when you get a call and your front office person comes and says, ‘Mrs. Jones just called, and her implant crown is loose.’ Ugh, that's the worst because you don't know if the implant is loose, or if the screw is broken. The majority of the time, it's not the implant, it's the screw. And as a restorative dentist, you don't know how long it's going to take to retrieve that screw, or whether you're going to be able to retrieve it at all.” (21:40—22:24)

“Here's one practice management trick. When you have a patient in to deal with a broken screw in an implant, it should always be the last patient of the day. You don't want to get them in at 1:00 or 1:30 and get into it, because once you get into it, you can't quit. It's an anterior tooth. You can't send the patient home without some replacement. So, you may be diddling with this all afternoon, and you don't want to foul up your afternoon. It must be the last patient of the day when you start to try to retrieve a screw.” (22:24—22:58)

“The fourth problem is an interesting one, and it's a new one to the profession. In the last six or eight years, we've been starting to talk a lot about maxillary palatal expansion in adult patients. In the old days, the only way we could do that was with orthognathic surgery, SARPE, Surgically-Assisted Rapid Palatal Expansion, where you would have an adult patient with sleep apnea, a very narrow arch, all those issues we deal with every day. In the past, the only way we could widen the arch to make more tongue space and a larger oral airway was to do a complicated oral-maxillofacial surgery. Well, today we've got the ability, more and more, to do this palatal split more conservatively with many implant-assisted rapid palatal expansion devices. Up until recently, we could only do that in maybe up to 20-year-old males and 40-year-old females. But now, they're making custom appliances that go into the palate. And they don't have just four implants holding the appliance — they have six or eight. They're custom made for the patient. And there's getting to be a lot of reports now that we can do the palatal expansion on older males, which is very exciting. But the problem is, if the older male has an implant in the anterior maxilla, one of the four incisors, and the palatal split is done, the orthodontist can't redistribute the space to make it all work at the end because you can't move the implant. So, once we put an implant in the anterior maxilla, that inhibits the ability of our profession to ever do a palatal expansion on that patient. And as we get better at that and pay more attention to it, we're going to be doing a lot of palatal expansions on adults as we become more influenced by the airway part of dentistry. That wasn't a problem ten years ago. It's a new problem. It's going to be, I think, a giant problem because anybody that's got an implant in the anterior maxilla, we cannot do a palatal expansion on.” (23:00—25:17)

“As I start looking at the literature now in terms of problems with implants, I started looking at medications. It turns out that there are a significant number of medications that at least have a correlation with implant failure. I'm not proposing that it's a cause and effect. The data is not really strong on a lot of these medications. But there's a bunch of medications that appear to have a negative impact on long-term success of implants. For instance, SSRI, Lexapro, Prozac — all the mood elevator drugs. There is a relationship between implant failure and those drugs. There is also a relationship to vitamin D deficiency. There is also a relationship to proton-pump inhibitors. That is, omeprazole, Nexium. How many people in the world are taking large doses of Nexium? Well, there's a relationship between that and implant failure. Another one is allergy to penicillin. Who would have ever guessed that there would be a relationship between penicillin allergy and implant failure? But it turns out that it may not really be related to the penicillin allergy because many clinicians that place implants put the patient on a short course of antibiotics before the implants are placed. Amoxicillin is the antibiotic of choice. But if a patient is amoxicillin/penicillin allergic, then commonly, the next choice was clindamycin. It turns out that clindamycin is a very poor choice as an antibiotic prior to placement of implants, and there is a relationship between using clindamycin prior to implant placement and an increased risk of failure. And after having said all of that, then you've got genetic factors. There are clearly some genetic factors that lead to implant failure also. So, when you put all that together it becomes, I think, an anxiety-producing procedure, especially in the anterior maxilla. I'm much more comfortable placing an implant in the posterior maxilla or the mandible because the results of a failure are commonly hidden from view. But in the anterior maxilla, you can't hide it. That's the problem. There is no good way to hide it. And once the failure occurs, sometimes it's very, very difficult to recover from that failure.” (25:22—28:06)

“The final and most common reason that implants fail is periimplantitis. When we look at the literature, we can assume that of all the implants that we place across the world, somewhere between 25% and 50% of those implants will suffer periimplantitis. So, there are a lot of reasons for our profession to have anxiety about the placement of implants. And I think we should be more thoughtful in the future about where and when we place implants, especially in the replacement of missing anterior teeth.” (28:10—28:53)

“Implants aren't going away. We're going to be replacing missing teeth with implants forever because they're such a wonderful adjunct to what we do. But I'm talking about a much more specific circumstance, and that is single teeth in the anterior maxilla. I would hope that the implant companies would be open to the idea that we need to look at that. And if, in fact, replacing a maxillary lateral incisor with an implant isn't the best idea, then let's not recommend it there. Let's recommend other options and let's put implants in places where they're going to function the best. Now, I