Viewpoint: When More is Less

by Milan Somborac, DDS

Clinicians often resort to conservative therapies to maintain patients with near terminal dentitions as long as possible. Viewed as a laudable approach, this strategy often leads to increasingly severe periodontal disease and has been dubbed “supervised neglect”. Allowing it to get to a hopeless situation late in the patients’ lives can transform a simple procedure into a difficult management case. Hence the service of heroic maintenance, albeit laudable, in fact becomes a disservice given the predictability of the implant option. This is true considering that trauma of what can be considered a routine surgical procedures is better tolerated in the earlier years of life when we are free of systemic diseases.

Many such patients can be treated early with implants in a more definitive manner. Ludwig Mies van der Rohe (1886-1969), the famous German architect said that, “less is more”. That view is defensible in architecture, but in implant dentistry, often the reverse is true: more is less. More definitive early implant treatment, a proactive approach in other words, can ensure less disease and morbidity down the road. Years of life with advanced periodontal disease can be changed to years of life with healthy peri-implant tissues. With the recent accumulation of evidence linking chronic periodontitis with several systemic diseases, the implant option has to be addressed at an earlier stage of the disease process. Four cases underlining the concept outlined above will be shown, all in their third year of loaded function.


An 87-year-old female with advanced mandibular periodontal disease reported complaining of generalized pain in the lower jaw. Maxillary bridgework was adequate. Maxillary periodontal disease could be managed with root planing and curettage. She was in good general health, a non-smoker and a moderate drinker.

She was informed that the prognosis for the remaining mandibular teeth was guarded and that a complete lower prosthesis was preferable to a more elaborate periodontal treatment. She was also told that the dental literature can now validate immediate implant placement and that would give her a stable overdenture that she could not have without implants. She was advised that the degree of perceived trauma would be similar with extractions alone or extractions and implant placement at the same time. She agreed to accept immediate implant placement.

Root planing and curettage were completed before the surgical appointment. This was desirable to create a more favourable soft tissue environment for the planned surgery and thus reduce the risk of post-surgical complications. Then, using oral sedation, anti-inflammatory and antibiotic premedication and local anesthesia, all mandibular teeth were removed, interseptal bone was harvested, morcelised and placed into osseous defects resulting from the extractions. Implants were placed in sites with the maximum bone height and width while ensuring the broadest possible base of support for the overdenture. An immediate denture was inserted after relieving the acrylic over the implants to minimize the risk of overload. It was placed primarily for cosmetic reasons. Ten weeks later, overdenture abutments were cemented into the implants and the immediate denture was modified to connect to them. The patient has enjoyed problem-free function since.

Mandibular treatment and results for the other three cases shown are similar.

Tenax Dental Implant System implants were used in all cases illustrated in this article.

Dr. Somborac is in private practice and is a shareholder in Tenax Implant Inc.

Oral Health welcomes this original article.