Implants: Built to Last or Doomed to Fail?

Treatment planning usually includes the final restoration, but, what if we took this one step further, to include maintenance? We must prioritize how patients will maintain their full-arch restorations through personalized recare and self-care regimens. This is especially true for implants placed as part of full-arch workflows, where 61% of immediate implants develop peri-implant disease after at least 10 years in function.¹ Local, patient, and environmental risk factors should be controlled in the initial treatment plan to mitigate such complications, or worse, failure.

How patients lose their teeth should influence whether a removable or fixed prosthesis is pursued. Plaque is the strongest risk indicator for peri-implantitis, and compounded by a lack of maintenance, leads to a greater conversion of diseased patients over 5 years.² This is only exacerbated by a history of periodontitis. Even in patients with treated severe periodontitis, a majority required multiple surgeries, chemotherapeutic interventions, and/or implant removal in a 10-year follow-up.³ Removable prostheses may be the preferred option here, as they provide greater retention and stability than  conventional dentures with improved retrievability and cleansability.

The worn dentition presents its own challenges, as implants lack a periodontal ligament to absorb and distribute forces under pressure.⁴ The differences in biting forces and occlusal schemes vary among individuals, and can be destructive, if left untreated. Factors including bruxism and prosthetic cantilevers contribute to occlusal overload.

Without managing occlusion to a physiologic limit translates the original problem to the final restoration.⁴ A lack of proper bone reduction to recreate the interarch space needed for the implant abutments and prosthetic materials in cases of severe wear will lead to failure. If a fixed implant-supported prosthesis is pursued, an interim distal cantilever or destruction from the opposing dentition or prosthesis via parafunctional habits must be avoided.

Implants are often heralded for their inability to develop caries. But, in a patient with generalized caries, a sugar-enriched diet has recently been linked to the development of peri-implantitis.⁵ It suggests the same concerns for a lack of maintenance and self-care on the peri-implant microbiome. The conversion from health to disease is difficult to predict. In health, inflammatory cells are present. A bacterial or mechanical insult can disrupt homeostasis, eliciting a host-immune response. Once a mucosal lesion forms with associated pocketing, bleeding on probing, and/or suppuration, bone loss is inevitable in the right patient.⁶ The options for a removable or fixed implant prosthesis should therefore be carefully weighed against other risk factors and their commitment to a recare program.

Patients with an implant overdenture should be encouraged to brush twice daily with specialized brush heads that debride both the prosthetic attachments and intaglio surfaces. An overdenture should be rinsed in an antimicrobial mouthrinse before re-insertion.⁷ A waterjet should be used on a low to medium setting at least once daily for improved plaque removal. Flossing around implants is no longer encouraged, especially when threads are exposed, as submucosal floss remnants have been led to peri-implant tissue inflammation.⁸ A near identical workflow can be implemented for fixed full-arch implant restorations. Patients should be encouraged to remove this prosthesis at least once every 12 to 18 months, or 6 months in cases of severe medical comorbidities or neglect.⁷

We should look to prevent, instead of reverse, peri-implant disease. Success should not be defined solely by the placement of implants or the delivery of a final prosthesis. True success lies in long-term stability achieved through intentional planning that considers maintenance as a clinical endpoint, not an afterthought. By integrating risk factors, biological considerations, and functional demands into the treatment plan from the outset, we can shift our focus from reactive intervention to proactive preservation.

References

1. Parvini P, Obreja K, Becker K, Galarraga ME, Schwarz F, Ramanauskaite A. The prevalence of peri-implant disease following immediate implant placement and loading: a cross-sectional analysis after 2 to 10 years. Int J Implant Dent. 2020;6:63.
2. Costa FO, Takenaka-Martinez S, Cota LO, Ferreira SD, Silva GL, Costa JE. Peri-implant disease in subjects with and without preventive maintenance: a 5-year follow-up. J Clin Periodontol. 2012;39:173-181.
3. Roccuzzo M, Fierravanti L, Pittoni D, Dalmasso P, Roccuzzo A. Implant survival after surgical treatment of peri-implantitis lesions by means of deproteinized bovine bone mineral with 10% collagen: 10-year results from a prospective study. Clin Oral Implants Res. 2020;31:768-776.
4. Sadowsky SJ. Occlusal overload with dental implants: a review. Int J Implant Dent. 2019;5:29.
5. Vilarrasa J, Peña M, Gumbau L, Monje A, Nart J. Exploring the relationship among dental caries, nutritional habits, and peri-implantitis. J Periodontol. 2021;92:1306-1316.
6. Schwarz F, Derks J, Monje A, Wang HL. Peri-implantitis. J Clin Periodontol. 2018;45 Suppl 20:S246-S266.
7. Bidra AS, Daubert DM, Garcia LT, et al. Clinical practice guidelines for recall and maintenance of patients with tooth-borne and implant-borne dental restorations. J Prosthodont. 2016;25 Suppl 1:S32-40.
8. Kotsakis GA, Lian Q, Ioannou AL, Michalowicz BS, John MT, Chu H. A network meta-analysis of interproximal oral hygiene methods in the reduction of clinical indices of inflammation. J Periodontol. 2018;89:558-570.

From Decisions in Dentistry. May/June 2025;11(3):46.