Prof. Cemal Ucer: Optimising outcomes in complex dental implant cases
The ability of the human body to heal itself is a remarkable thing. Much of medicine is an exercise in aiding or exploiting the body’s own healing and immunological processes. Surgery is thoroughly dependent on healing. Without it – no matter how brilliant the technique – surgical intervention would be fruitless at best, if not downright harmful.
Understanding, aiding and encouraging the body’s regenerative processes is therefore crucial to optimising interventions. The oral mucosa is one of a rare set of tissues where virtually scar-free healing is possible in adult humans. Cuts that would leave disfiguring scarring on a patient’s skin can potentially heal to the point of near undetectability.
Popular culture considers scars as a mark of toughness, and that their rougher texture makes scarred areas are more resilient to damage. In reality, this is not the case. At best scarred skin only ever achieves around 80% of its original strength, owing to a significantly less elastic fibre structure that is more vulnerable to shear forces.
Scarred skin will not regenerate functional features including pigmentation, sweat glands and hair follicles. Though the mucosa has formidable regenerative capabilities, it can be inhibited by an absence of underlying healthy bone, thermal damage, and infection, or be unnecessarily degraded without careful surgery .
Saliva is highly beneficial to oral tissue healing, and may help healing elsewhere in the body (potentially explaining why animals evolved to instinctively lick their wounds). Saliva aids wound closure, increases cell turnover, encourages the release of growth factors and has beneficial antimicrobial and anticariogenic properties [2,3].
Over 99% of saliva is composed of water with the rest composed of proteins, ions and enzymes. The average person produces between 0.5 to 1.5 litres of saliva per day. All patients benefit from making sure they are adequately hydrated by drinking water, as it will help maintain their saliva levels (while also benefitting kidney function and avoiding painful kidney stones). It is especially important during healing after oral surgery [4,5].
In humans, the epidermal growth factor, basic fibroblast growth factor (bFGF), and insulin and insulin-like growth factor family have been detected in saliva, but their physiological role remains unclear. Recent studies have, however, demonstrated beneficial effect of salivary bFGF on re-epithelization of mucosal epithelial defects.
Although saliva is a natural reservoir of growth factors, these can be supplemented following surgery with platelet derived growth factors. Activated platelet rich plasma (PRP) and platelet rich fibrin (PRF) products have been extensively employed to aid wound healing and tissue repair in different fields of medicine and surgery.
These derivatives have different strengths; PRF provides a scaffold for tissue regeneration and healing, and has a consistent preparation protocol. PRP is enriched with PDGF-AB, which has an important role in wound healing and re-vascularisation. PDGF encourages bone cell replication and collagen production.
Both PRP and PRF release significantly higher concentrations of growth factors than found in whole blood . Both platelet derivatives have been used to enhance the healing bone grafts and sinus augmentation procedures, as well as socket healing following tooth extraction and soft tissue injuries. Some research indicates PRP can aid osseointegration, though more research is needed to confirm this [7,8].
Without proper case assessment aspects can be missed or overlooked, and outcomes for patients might even prove disastrous on occasion. Particular care must be taken with patients who have failing implants, as previous surgery or infections can leave surrounding tissue scarred or damaged. Bone quantity and quality may have declined between procedures, potentially requiring grafting procedures [9,10].
Dental implants placed in previously failed sites witness a rise in post-operative pain and a notably lower survival rate than initial placements (95.4% for initial implants, 77.4% for first reimplantation), which continues to decline with successive attempts (second reimplantation 72.7%, third 50%) .
Even first-time placements may encounter novel anatomical differences that introduce complications if not accounted for. Understanding the case history, and having access to accurate and clear diagnostic imaging can do much to help optimise patient outcomes.
If you are dealing with a complex case, such as a failing implant requiring surgical intervention, consider referring your patient to the Centre for Oral-Maxillofacial and Dental Implant Reconstruction. Using its state-of-the-art facilities, including the use of platelet derived growth factor therapy, the Centre offers a wide variety of advanced procedures, including nerve lateralisation and repositioning, major bone grafting, and rehabilitation of atrophic jaws with zygomatic ZAGA implants or 3D printed customised dental implants.
Dental implants depend on the bone healing and bonding with the surface of the implant. Many factors can influence the osseointegration process, and some patients need additional surgery in order to meet the bone depth and quality required. Thanks to the Centre’s wealth of experience and understanding of our bodies' healing processes and limitations, it can assure patients of improved treatment outcomes.
1] Politis C., Schoenaers J., Jacobs R., Agbaje J. Wound healing problems in the mouth. Frontiers in Physiology. 2016; 7: 507. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089986/ February 7, 2020.
2] desJardins-Park H., Mascharak S., Chinta M., Wan D., Longaker M. The spectrum of scarring in craniofacial wound repair. Frontiers in Physiology. 2019; 10: 332. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6450464/ February 7, 2020.
3] Stookey G. The effect of saliva on dental caries. The Journal of the American Dental Association. 2008; 139(Suppl. 2): 11-17. https://jada.ada.org/article/S0002-8177(14)63877-0/fulltext February 7, 2020.
4] Popkins B., D’Anci K., Rosenberg I. Water, hydration and health. Nutritional Review. 2010; 68(8): 439-458. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2908954/ February 7, 2020.
5] Roblegg E., Coughran A., Sirjani D. Saliva: an all-rounder of our body. European Journal of Pharmaceutics and Biopharmaceutics. 2019; 142: 133-141. https://doi.org/10.1016/j.ejpb.2019.06.016 February 7, 2020.
6] Arora S., Kotwal U., Dogra M., Doda V. Growth factor variation in two types of autologous platelet biomaterials: PRP versus PRF. Indian Journal of Hematology & Blood Transfusion. 2017; 33(2): 288-292. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5442062/ February 7, 2020.
7] Pirpir C., Yilmaz O., Candirli C., Balaban E. Evaluation of effectiveness of concentrated growth factor on osseointegration. International Journal of Implant Dentistry. 2017; 3: 7. https://journalimplantdent.springeropen.com/articles/10.1186/s40729-017-0069-3 February 7, 2020.
8] Thalib B., Machmud E., Dharmautama M., Surya E., Hasyim A., Hasyim R. Differences of post-placement bone implant contact (BIC) value of dental implant coated and not coated with platelet rich plasma (PRP). Global Journal of Health Sciences. 2018; 10(2). https://doi.org/10.5539/gjhs.v10n2p11 February 7, 2020.
9] Sirajuddin S., Kripal K., Kumuda M., Chungkham S., Rafiuddin S., Chandrashekar B. Iatrogenic damage to the periodontium caused by implants and implant treatment procedures. Open Dentistry Journal. 2015; 9: 200-202. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4541314/ February 7, 2020.
10] Frizzera F., de Oliveira G., Shibli J., de Moraes K., Marcantonio E., Marcantonio Jr E. Treatment of peri-implant soft tissue defects: a narrative review. Brazilian Oral Research. 2019; 33(Suppl. 1). http://dx.doi.org/10.1590/1807-3107bor-2019.vol33.0073 February 7, 2020.
11] Agari K., Le B. Successive reimplantation of dental implants into sites of previous failure. Journal of Oral and Maxillofacial Surgery. 2019. https://doi.org/10.1016/j.joms.2019.10.001 February 7, 2020.