Dental implants
A role in geriatric dentistry for the general practice?
Clark M. Stanford, DDS, PhD
lder patients visiting a
O dental office often have a
constellation of medical,
dental, social and
patient-specific issues
that can challenge the diagnostic
and therapeutic capabilities of the
dental clinician. When patients
need and desire tooth replacement
therapy, this can vary from conven-
tional removable or fixed prostheses
to a combination of fixed and remov-
able implant-supported forms of
tooth replacement.
DENTAL IMPLANT THERAPY
For the majority of the population,
the clinical success of dental implant
therapy has improved such that
some clinicians consider it to be a
form of standard of care.1 However
provocative this assessment may be,
clinicians should not ignore the role
of implant therapy to support the
oral rehabilitation of the elderly pop-
ulation and of other medically com-
promised patients. The patient,
caregiver, family and clinical team
need to weigh the inherent advan-
tages and costs of implant therapy.
Tooth replacement therapy can vary
from single-tooth replacement with
conventional or implant-supported
restorations to full-arch replacement
with individual implants/tooth-to-
34S JADA, Vol. 138 http://jada.ada.org September 2007
Copyright ©2007 American Dental Association. All rights reserved.
ABSTRACT
Background. In the general population, the use of dental implants
has become a management strategy for replacing missing teeth. As part
of the treatment plan for the aging population, general dentists should
consider this treatment modality in their practices.
Overview. This study reviews specific issues concerning the aging pop-
ulation and tooth replacement therapies. Older people often desire to
replace missing teeth, but they have complex medical, social, economic
and resource issues that must be accounted for in their treatment plan.
Dentists need to give careful attention to the patient-based assessment,
diagnostic criteria and diagnostic steps to help the patient and family
understand the strengths and challenges of each type of tooth replace-
ment therapy. The author emphasizes the importance of careful evalu-
ation and assessment of fixed versus removable implant–retained pros-
theses in the aging population.
Conclusions and Clinical Implications. For many general den-
tists, dental implants have become an increasingly common treatment
option for missing dentition. With the population becoming increasingly
older worldwide, the general dentist will be confronted with patients who
have complex medical and social histories who desire tooth replacement
therapy. The rational delivery of this oral health care will assist in pro-
viding a high quality of life for these patients.
Key Words. Dentures; diabetes mellitus; aging; decision making;
health care delivery; dental care for elderly patients; dental care for
people with disabilities; dental implants; medical history taking; risk
assessment.
JADA 2007;138(9 supplement):34S-40S.
Dr. Stanford is Centennial Fund Professor for Clinical Research, Dows Institute for Dental Research and
Department of Prosthodontics, University of Iowa, N447 Dental Science Building, University of Iowa,
Iowa City, Iowa 52242, e-mail “Clark-Stanford@uiowa.edu”. Address reprint requests to Dr. Stanford.
implant–supported overdentures. Each of these
options (including no tooth replacement) has
advantages and costs that must be weighted in a
multifactorial consideration of patients’ desires,
understanding, resources and perspectives.2-4 The
predictable esthetic and functional outcomes of
care depend on a comprehensive diagnostic evalu-
ation and treatment planning.5
Patients who undergo implant therapy face
medical and surgical risks that are similar to
those of outpatient oral surgical intraosseous pro-
cedures. The surgical team should evaluate the
patient for systemic conditions that may compro-
mise healing (for example, immunocompromised
states, uncontrolled diabetes) and the systemic
effects of medications. In general, the survival
rates of dental implants in older patients can be
affected by certain systemic conditions associated
with aging, including long-term smoking, dia-
betes and postmenopausal estrogen therapy.6 In
addition, the use of multiple medications influ-
encing bone metabolism (for example, steroids,
bisphosphonates) has the potential to alter the
outcomes of implant therapy.7,8 For instance,
investigators recently have become concerned
about surgical interventions in patients with
osteoporosis who receive long-term oral bisphos-
phonate therapy.9-11 As part of a careful informed
consent process, the dentist needs to provide the
patient and his or her family with an accurate
assessment of the procedures, the length of treat-
ment time, risks and alternatives to implant
treatment (including no tooth replacement and
conventional fixed or removable prostheses).
Investigators often point to the ability of bone
to heal in the older patient as a concern with
regard to implant outcomes. Researchers have
addressed this question through the clinical
assessment of implants placed in the anterior
mandible, a region of the oral cavity that does not
experience significant age-associated
osteopenia.12-14 Implants placed, restored and
functioning in areas of predominantly trabecular
bone (for example, atrophic maxilla) are at a
higher risk of experiencing complications.
Implant interfaces are maintained through
dynamic modeling and remodeling processes
within the bone of these regions. (“Modeling”
refers to any net change in bone shape, whereas
“remodeling” refers to the continuous turnover of
bone without a net change in shape or size.)
These processes (referred to as “the adaptive
capacity” by Stanford and Brand15), in turn, allow
Copyright ©2007 American Dental Association. All rights reserved.
bone to respond to the clinical procedures and
occlusion over long periods.
Patient assessment. The predictable esthetic
and functional outcomes of implant treatment for
geriatric patients require comprehensive diagnosis
and treatment planning.5 The clinician should
assess the patient’s medical and dental history for
bruxism, periodontal disease, tobacco use, uncon-
trolled diabetes mellitus and metabolic diseases of
bone.7 Some investigators have reported elevated
complications related to smoking after controlling
for age and other medical conditions.6,16 Diabetes,
especially type 2, is a disease of increasing concern
in which control (as measured by hemoglobin A1C
levels < 7.0 percent) is considered important for
successful long-term outcomes of implant
therapy.8,17 Throughout the surgical and prosthetic
phases of implant reconstruction, the general den-
tist should review the treatment with the patient
and any key significant others and obtain compre-
hensive written and oral informed consent from
the patient.6,18 It may be helpful to have a private
discussion with the patient to assess his or her
specific needs and desires and balance them with
those of the caregiver.
To improve treatment outcomes, the dentist
should design and compose the proposed pros-
thesis during the diagnostic phase. Planning will
include issues such as the type of prosthesis
(removable, fixed or a combination). Clinicians
should consider the use of implants in combina-
tion with removable partial dentures in a compro-
mised dentition to provide greater support,
esthetics and potential function for the partial
denture.19 On the basis of the acquired diagnostic
information, the dentist can use a surgical guide
or denture to indicate the desired implant posi-
tion, angulation and need for hard- and/or soft-
tissue augmentation before or during implant
placement. The clinician should carefully eval-
uate the patient’s soft- and hard-tissue changes to
encourage realistic patient expectations.
For geriatric patients who have a single edentu-
lous arch or a partially edentulous arch, there is a
balancing of treatment options that include fixed
partial dentures (FPDs), adhesive resin restora-
tions and single or short-span implant restora-
tions, as well as no tooth replacement. The final
decision is made after considering the patient’s
ABBREVIATION KEY. FCD: Fixed complete denture.
FPD: Fixed partial denture.
JADA, Vol. 138 http://jada.ada.org September 2007 35S
 A

C
Figure 1. An 85-year-old frail woman visited her dentist (C.M.S.)
with extensive caries under the anterior retainer for a fixed partial
denture (FPD). Caries extended under the anterior retainer with loss
of the coronal tooth structure (A) and extended to the radi-
ographic alveolar crest (B), creating a challenge to conventional
approaches. After a careful assessment and discussion of the risks
and benefits, the patient chose a treatment plan that involved an
FPD from an implant placed in the canine to the endodontically
treated molar. Extraction of the canine and immediate implant
placement allowed fabrication and placement of a titanium scal-
loped abutment (C) restored with a new FPD (D). D
desires, treatment objectives, clinical capability of
the clinician, dentist’s expertise and training, of tooth replacement.
treatment costs, treatment time and potential Diagnostic phase. During the diagnostic
morbidity. Occasionally, given a stable occlusion, phase, the dentist should assess the number of
the dentist might consider a rigid tooth-to- missing teeth the patient desires to be replaced
implant fixed prosthesis (a design that does not for a functional and esthetic dentition. The clini-
allow any movement between the two cian also should consider a shortened dental arch
retainers)20,21 (Figure 1). Preoperative planning with restoration though the second premolars.23-25
helps to achieve rational, functional and esthetic When replacing multiple adjacent teeth with
goals by ensuring that the final restorative dental implants, clinicians often find it clinically
therapy is in the patient’s best interests.22 As part useful to replace three teeth with a short-span
of the informed consent process, the clinician FPD on two implants, using the pontic to adjust
should discuss with the patient treatment plan for contours and the final implant position
alternatives with regard to the ability to control (Figure 2). This approach is especially useful in
esthetics and function with the various methods the anterior maxilla in cases involving multiple

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Copyright ©2007 American Dental Association. All rights reserved.
 A B
Figure 2. An 83-year-old man visited his dentist (C.M.S.) with a fractured first premolar though the first molar. The clinician placed two
implants (A), one in the first molar and one in the first premolar region, and fabricated a three-unit fixed partial denture to restore pos-
terior occlusion on the patient’s right side, thus providing enhanced function and occlusal stability (B).

teeth in which the smallest tooth to be replaced is
planned as a pontic with implants placed in the
canine and central incisor region.
The clinician should consider and plan for site
development. The dentition tends to be positioned
more facially or buccally relative to the central
axis of the alveolar ridge, resulting in a thin facial
plate of bone over the teeth.5 In the mandible, the
resorption pattern can occur at an uneven rate,
leading to increased bone loss on the thin supe-
rior regions and producing a wider ridge with ele-
vated muscle attachments, making denture sta-
bility potentially difficult.
The optimal tooth position for a functional and
esthetic prosthesis starts with a mounted diag-
nostic setup consisting of denture teeth on a trial
base, with soft- and hard-tissue contours waxed
to full contour. Low cusp-angle denture teeth are
useful for this purpose, because their reduced
occlusal table size potentially limits excessive
mechanical load.26 A vacuum-formed matrix of
this diagnostic setup assists the surgeon in deter-
mining the position, placement and volume of the
site (that is, hard- and soft-tissue grafting)
needed before implant placement. Because
implant position in the partially edentulous or
single-tooth situation is critical to achieving a
predictable esthetic outcome, the dentist should
discuss these risk factors with the patient and
members of the implant team. He or she should
evaluate osseous contours through palpation,
sounding with anesthesia (that is, inserting a
needle through the gingiva to the bone to meas-
ure mucosal thickness) coupled with two- and
three-dimensional radiographic imaging studies.
Depending on the patient’s esthetic expecta-
tions, the dentist should evaluate the periodontal
tissues carefully to assess their biotype. This
assessment can be of particular significance in
older patients who have a history of recession.
Thick periodontal tissue typically has thick, flat-
tened osseous plates and offers a higher resis-
tance to recession than does thin periodontal
tissue. In contrast, patients with a thin peri-
odontal tissue biotype have a thin erythematous
periodontium covering a thin or nonexistent facial
alveolar bone, which can be associated with soft-
tissue recession.27,28 For patients with a thin peri-
odontal tissue biotype, the clinician may need to
consider connective-tissue grafting.
TREATMENT PLANNING FOR THE OLDER
PATIENT
The edentulous arch presents unique challenges,
especially when it is in a state of advanced
atrophy. The mandibular arch can be restored by
using a fixed complete denture (FCD), an FPD or
an overdenture. The FCD typically is a prosthesis
designed with acrylic resin teeth bonded to a
casting or a titanium framework milled via
computer-aided design/computer-aided manufac-
turing. These prostheses are designed to replace
as many teeth as possible by using four to five
interforaminal implants.29
If the clinician anticipates a fixed approach for
the edentulous arch, the diagnostic workup
should include impressions, jaw relationship
records and an esthetic try-in involving the use of

JADA, Vol. 138 http://jada.ada.org September 2007 37S

Copyright ©2007 American Dental Association. All rights reserved.
 A
Figure 3. A 78-year-old man with long-standing Parkinson disease
visited his dentist (C.M.S.) with the inability to wear his lower den-
ture even though he had adequate anatomy (A). Provision of a
B
two-implant free-standing ball attachment overdenture (B)
enabled the patient to insert the denture (shown) and provided for
function, stability and access for oral hygiene (C).

prosthetic teeth on a mounted trial denture base.

He or she should evaluate lip support with the
smile line (that is, the anterior and posterior
occlusal planes) of the diagnostic denture setup in
the mouth. The dentist should assess the
patient’s lip support with and without the ante-
rior facial denture flange being present. The
anterior smile line (relaxed and exaggerated) not
only demonstrates the degree of tooth exposure,
but also provides clues about the expected crown
length, gingival display and potential need to use
gingival tone porcelain for appropriate tooth
length and esthetics.
The incidences of esthetic, phonetic and oral
hygiene problems are higher with a fixed maxil-
lary prosthesis compared with an overdenture
prosthesis; this is, in part, associated with exces-
sively long anterior teeth, excessive facial can-
tilever pontics and mesiodistal complications
with embrasure forms.27 During the diagnostic
phases, the dentist should discuss with the
patient the advantages and disadvantages of the
FCD compared with those of an overdenture.
When using a ceramometal full-arch fixed recon-
struction, the dentist should consider replacing
every three teeth with a three-unit FPD on two
implants.5 Because of the clinical and laboratory
complexity and costs associated with these types
of prostheses, a maxillary overdenture on four to
six implants, typically connected with a rigid bar-
and-clip attachment system, may be an alterna-
tive solution.28,30,31
Overdenture. An overdenture may be the
treatment of choice for patients with moderate-to-
severe resorption and problems with dexterity
and management of phonetic palatal contours.32
On the other hand, overdenture therapy has been
C
associated with more postinsertion complications
and higher maintenance costs, which should be
discussed with the patient and family.1,2,33-36 An
overdenture designed to attach to the implants
via a bar-and-clip assembly or free-standing
attachments (for example, ball attachments,
Locator attachments [Zest Anchors, Escondido,
Calif.]) is useful, especially as a means to provide
function and lip and esthetic support in a reduced
amount of time and with less morbidity relative
to the restoration of implants with conventional
crowns or FPDs37-40 (Figure 3).
An overdenture should use a sufficient number
of implants for long-term stability, typically four in
the maxilla (canine and second premolar region)
and two in the lower canine or first premolar
region.41 Using the denture setup, the clinician fab-
ricates a radiographic guide with radiopaque
markers (for example, gutta percha, bur shanks or
prosthetic teeth containing barium sulfate) at the
sites of interest within the surgical guide.
In the mandible, the trial setup is useful to
evaluate the height and position of the prosthetic
teeth relative to the symphyseal cross-sectional

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Copyright ©2007 American Dental Association. All rights reserved.
anatomy.42 Radiographic information and the
diagnostic setup will help determine the type of
definitive prosthetic design. On the basis of the
skeletal classification, the biomechanics of
implant loading can influence the type of pros-
thesis selected. Skeletal class I and II relation-
ships with minimal resorption may allow normal
contours and lip support with an FCD, while a
prognathic class III relationship can increase pros-
thetic problems, especially if implants cannot be
placed distal to the mental foramens. In such
cases, an overdenture approach yields a more pre-
dictable result.
The overdenture approach in older patients pro-
vides significant treatment flexibility. In a recent
consensus conference report, the consensus panel
recommended treatment of the edentulous lower
jaw with two implants and an overdenture.43 This
approach results in significant improvement in a
patient’s physiological bone mass, quality of life
and, possibly, nutritional status.43-45 Two implants
spaced between 12 millimeters and 16 mm apart
(edge to edge) in the mandibular canine region can
be restored with free-standing attachments such
as ball attachments, Locator attachments (Zest
Anchors) or ERA attachments (Sterngold Dental,
Attleboro, Mass.) or with an overdenture bar
system (for example, Hader bar, Sterngold Dental)
and a plastic clip attachment in the denture. Bar
reconstructions are appropriate for nonparallel
implants in which the connecting bar is designed
to be parallel to the retromolar pads (fulcrum of
rotation), allowing the overdenture to gain reten-
tion from the bar and support from the mucosal
tissue.
The method of overdenture rehabilitation has
been controversial, but recent long-term studies
have documented little difference in outcomes
between bar-and-clip–retained and free-standing
overdenture abutments.37,38 In patients with
advanced mandibular resorption, an implant-
supported bar on three or four interforaminal
implants can provide support for the implant over-
denture while avoiding pressure on the supra-
crestal mental nerve and thin mucosal tissues.
Implant complications. Implant therapy,
while highly effective, does have the potential for
both technical and biological complications, as
well as the potential for psychological complica-
tions if the patient’s expectations are not met or
are impossible to satisfy with this approach. Loss
of an implant may be a catastrophic complica-
tion—or a simple inconvenience, especially if the
Copyright ©2007 American Dental Association. All rights reserved.
clinician can retrofit or modify the existing pros-
thesis to allow it to continue to function. The
patient also should be aware that implant parts,
especially overdenture attachments, are designed
to wear out and that ongoing maintenance will be
needed.
Clinicians should inform patients that they will
need to return for annual recall visits so that the
prosthesis can be checked and adjusted. These
types of recall schedules can create challenges
with regard to travel and costs and pose an addi-
tional burden on family members. Thus, before
starting implant therapy, the clinician should dis-
cuss these issues with the patient and his or her
family members. It is important to provide clear
information to the patient, caregiver and family
members to ensure that their expectations can be
met by the surgical and restorative team and to
ensure informed consent.
CONCLUSION
Dental implant therapy can significantly improve
the lives of older people. Through discussions
with the patient, his or her caregiver and, pos-
sibly, other family members, the clinician needs
to assess the patient’s expectations and desires
carefully and balance them with the time and
resources needed to accomplish acceptable out-
comes. The provision of care should be patient-
centered. It should best address the rational
needs of the patient while offering an improved
quality of life. This can range from complete
implant rehabilitation to no treatment at all.
In the end, clinicians need to be sure that,
regardless of the treatment strategy proposed, the
patient must understand and desire it, and it
must be in concert with what we as a profession
can provide. ■
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