Dr Vivek V. Nair
Editor, JPID
Beyond Implant Survival:
Rethinking Success in Implant Prosthodontics
The field of implant dentistry has changed
prosthodontic rehabilitation so that replacing missing
teeth is now more predictable than it ever has been.
However, even though the rates of implant survival
continue to be impressive, there is still a question
which deserves to be looked at again: if an implant
survives has the treatment certainly been a success?
The answer might be no.
Although implant survival is a significant endpoint, it
accounts for only one aspect of treatment success. It
is possible for an implant to be osseointegrated even
if the patient suffers from peri-implant inflammation,
prosthetic complications, recurring
technical
issues, poor esthetics, functional limitations, or
dissatisfaction. Long-term evidence shows that
implant-supported prostheses can survive even when
biological and technical complications continue.¹
It can happen that the implant survives while the
rehabilitation process is unsuccessful.
In the field of prosthodontics this distinction is
especially significant since the implant itself is not
the treatment but rather the rehabilitation is. The
final result depends on a number of factors including
biological health, prosthetic stability, occlusion,
comfort, esthetics, hygiene accessibility, maintenance,
function, and patient expectations. There is now increasing evidence to reveal that patient-reported
outcomes form an essential aspect of implant
rehabilitation and one that cannot be obtained solely
from conventional clinical parameters.2,3
This leads to an unpleasant question: are we focusing
on what is easiest to measure rather than on what
is most important to the patient? Although implant
survival is objective and easy to quantify, comfort,
confidence, chewing ability, esthetic satisfaction,
the burden of maintenance, and quality of life are
more complicated. It is these latter outcomes that the
patients actually experience.
Imagine two patients: in one case the implant survival
is excellent but there are recurrent fractures of the
prosthesis, poor access for hygiene, the need for
frequent maintenance, and dissatisfaction regarding
the appearance; in the other case the implants are
stable, the prosthesis is easy to maintain, function
is comfortable, the esthetics are acceptable and
satisfaction is high. When assessment is made solely
on the basis of implant survival, both treatments
seem to have been successful; but when evaluated in
terms of rehabilitation, they are clearly not the same.
The prosthesis is therefore not merely a passive
component of the implant. The way in which the prosthesis is designed, the materials chosen, the
occlusion, the distribution of the implants, the ease
with which hygiene can be carried out, and the
maintenance requirements can all have a substantial
effect on long-term results. There is evidence to
show that the material and design of the prosthesis
influence biological and technical complications in
implant-supported multi-unit prostheses.⁴ Implant
success cannot be divorced fromprosthodontic
decision-making.
Maintenance should be given just as much attention.
The delivery of an implant-supported prosthesis is
not the conclusion of treatment but rather the start of
a lifelong journey of maintenance. The peri-implant
tissues need to be monitored, the prosthetic parts
have to be assessed, and the restoration must allow
for effective hygiene and access by professionals. The
evidence relating to the removal of full-arch implant
prostheses stresses the importance of supportive peri
implant care and maintainability, as well as pointing
out the limitations in the current evidence concerning
optimal maintenance protocols.5
It is perhaps now the time to shift from a focus on
survival to one on rehabilitation. Rather than simply
asking “Has the implant survived?”, we should ask
whether the peri-implant tissue is healthy, whether
the prosthesis is stable and can be maintained,
whether the patient can function comfortably, whether
the patient is satisfied with the esthetics, whether
their quality of life has improved, and how much
maintenance has been needed?
Future research should therefore include information
on implant survival together with details of
biological complications, prosthetic complications,
maintenance treatments, patient-reported outcomes,
function, esthetics, and quality of life; survival should be kept as an important endpoint but should not be
the only one.
The main aim of implant prosthodontics is not merely
to keep titanium in the bone; it is to restore function,
comfort, confidence, and the quality of life. When
an implant rehabilitation is carried out technically
successfully, patients should be able to function,
communicate, smile and socialise without having
to constantly think about their prosthesis. Perhaps,
therefore, the question we should ask is no longer:
“How long did the implant survive?” but instead “Did
the patient truly thrive with it?” Because implants
may survive for decades—but it is the patient, not the
implant, who defines success.