On challenges to the prosthodontics stewardship of the edentulous patient.

Clinical experience underscores the disappointing clinical reality that predictably successful denture-wearing outcomes cannot be routinely claimed. Numerous learned texts and lecturers readily cite both favorable and adverse prognostic indicators; yet a diagnosis of being prosthetically maladaptive almost invariably occurs following stoic and persistent efforts by patients and their dentists to overcome an unsatisfactory denture-wearing experience. Brånemark’s introduction of osseointegration dramatically influenced edentulism management. It raised predictable and successful treatment outcomes to a new level of patient satisfaction. The net practice result of the enriched synergies between surgical and prosthodontic protocols was prosthesis stability. This assured predictable adaptation via simple and readily affordable overdenture “conversions,” to immediately loaded full-arch maxillary prostheses supported by a minimum number of implants in scrupulously located host sites. I do not risk going out on a limb by asserting that a successful maxillary complete denture outcome has traditionally been far easier to prognosticate than a mandibular one. Consequently, dentists remain inclined to prioritize implant therapy for the mandible far more often than they would for the maxilla. And yet, the proliferation of surgical skills and prosthodontic techniques that reflect ongoing clinical ingenuity and brilliance continue to make a strong case for clinical protocols that promote implant therapy for the edentulous maxilla to routine status. This makes for an exciting and perhaps even alarming management narrative for patients who are now tempted with the claim of a virtual panacea for their maxillary predicament; even if the latter may be regarded at this time as a more dentist-mediated conviction, as opposed to a patient-determined one. A values-based assessment, rather than an overambitious evidence-based one, demands equating rapidly evolving surgical specialist skills, minimally invasive procedures, better diagnostic tools, improved alloplastic materials and their prosthodontic applications with better prognoses for even severely atrophic edentulous maxillae. Similar optimistic pronouncements have already led to dental implants becoming an integral and beneficial part of the “spare parts” culture that dominates my discipline. Nonetheless, the lingering implant therapy narrative of aggressive marketing, enlightened empiricism, and entrepreneurial spirit cannot be overlooked; and the inherent risk of biotechnological brilliance usurping ethical considerations must never be ignored. We already have far too many tenors singing the same arias on too little a stage in the implant therapy saga. And those of us in their audience must resist being distracted by the turned up decibel count. I invited Professor Paolo Pera from the University of Genoa to submit a Commentary on this fascinating topic. His prudently argued response offers the IJP’s global readership a timely synthesis of the clinical challenge to our discipline’s presumed stewardship of edentulous patients’ true needs.