Thomason JM The McGill Consensus Statement on Overdentures. Mandibular 2-implant overdentures as first choice standard of care for edentulous patients. Eur J Prosthodont Restor Dent. 2002; 10:95-96
Thomason JM, Feine J, Exley C Mandibular two implantsupported overdentures as the first choice standard of care for edentulous patients – the York Consensus Statement. Br Dent J. 2009; 207:185-186
Guidelines for selecting appropriate patients for treatment with dental implants: priorities for the NHS. 2012.

Redeemed through the miracle of osseo-integration

From Volume 51, Issue 2, February 2024 | Pages 80-81


Nick Malden

Consultant in Oral Surgery

Articles by Nick Malden

Email Nick Malden


At the age of 15 I was allowed to go on a school skiing trip to Austria. It was a memorable week on many levels, especially as I had never skied before. The soaking wet clothes to dry at the end of the day, and the pain from ‘snow ploughing’ for hours, but after a few days, some of us were allowed up to the top of the mountain. As I neared the top, my skis got into a rut and I was about to keel over and be dragged unceremoniously up the last pitch like some novice ski boarders I've seen, so I let go of the T-bar. I can see it now as it reeled itself in, swinging high and down, straight across a kid's face. As I approached, he held out his bloodied hand with what I presume were bits of his front teeth. His dad (I assumed) was quickly beside him and he turned and shouted, pointing, gesticulating at me, roughly translated it came across as ‘Hey look what you've done to my son's mouth’! I turned on to the piste and off I went, my snow plough turning quickly into some kind of downhill posture. Rounding the first bend, onto a steeper bit, fir trees began to flash by, as in my panic, I imagined a posse of incensed Austrians in pursuit. Another bend and some sort of ‘parallel turn’ appeared from nowhere, if I lost control now, I would be in the trees! But I made it to the end, and looking back, I was alone. My pals turned up shortly, expressing some admiration on my technique. When I filled them in on the circumstances, it was agreed I best keep off the mountain for the rest of the trip. Did I tell my teachers? No, I don't think I remember sharing this experience with anyone else, my teachers, or parents for that matter.

Wind on to the following summer and I found myself working in a brush factory for 3 weeks. This experience left me in no doubt that I was not ready to work for a living, so this meant staying in the education system and to attain, somehow, university, to study what? It didn't matter at this point. So, I started to buckle down and teachers noticed and some tried to help me and managed to get me into the sixth form to take A levels. I was thinking maybe engineering to satisfy my practical bent, but wait a minute, my older cousin had recently qualified in dentistry. He was in the process of building his own house with swimming pool and drove a sports car, but I was a needle phobic, vaccinations gave me the screaming abdabs! I wrestled for a night or so with this before rationalizing that the needles weren't coming at me, they were going into someone else. So, decision made, I swapped maths to biology. After the first year, much to my surprise, I was awarded the chemistry prize. My pal who normally came top without trying, you know the type (perhaps that was you?) piped up in class: ‘Sir, why did Nick get the prize, when he came nowhere near the top?’ Good question, I thought to myself. ‘Well, he worked hardest out of all of you’ replied the teacher. Good answer I thought to myself. The classroom went quiet, maybe there was some collective self-reflection going on, or perhaps like me, they were all mulling over the absurdity of awarding a prize for mediocrity! What if I had come last, would I have still got the prize? Hey, no point over-thinking it. I shot a smirky grin across to my pal who was looking rather pensive. I graciously accepted the prize of a book token, even though my dad bought all my books, and I resisted the temptation of asking for cash in lieu, choosing not to push my luck too far on this occasion.

Roll on a year and I was accepted into dentistry. Fortunately for me, in the early 1970s you could get in with middling grades. My plan was to get rich quick, buy a shack on a desert island and sail and fish my days away. I remember the excitement of being on the cons floor treating patients and the demonstrators who were an interesting bunch. Some paid such attention to detail they filled us with dread, but also there were one or two who spent most of their session in the tearoom chatting with their cronies until a queue of students was lined up outside. They would then scoot around giving a cursory look at our work, which they passed with occasional comments. At least they didn't hold us up and they would often give us tips learned from their many years of NHS experience. But it was the first time, I think, that I noticed the caring attitude that some staff members showed towards patients, did it leave an impression on me? Anyway, the rest is history and wind on the clock 20 years and I was working in the oral surgery department of a teaching hospital. I had put to rest any romantic notions regarding desert islands; my brief sojourn in the South Pacific had enlightened me as to how inhospitable these places could be, not to mention the doldrums. My career plans were now a bit more long term and down to earth. I considered myself most fortunate to have gotten involved with implants, quite possibly the only constructive procedure I ever performed in oral surgery, and on this particular day, I had been asked to examine a young man who had lost three anterior maxillary teeth. He attended with his mother and she explained that he was hoping to start university, but was so self-conscious about his having to wear a denture and with the trauma and all that he was thinking of pulling out. I asked how it happened. ‘It was a skiing accident, someone let go of a T-bar and he was in the way’. I got a prickly feeling up the back of the neck, was this my hair standing on end? I felt a bit disorientated, time slowed down, was she looking at me I thought, is my face losing its colour? Will she notice? Now there could have been a completely plausible explanation for this inexplicable coincidence, like T-bar incidents are so common that every spring dentists up and down the country are being asked to deal with the consequences; or, someone, unbeknown to me, had put an ad in a national newspaper suggesting any T-bar injuries be referred to my clinic for free implant treatment; or, I was just having a bad dream. Now I understand the faith community refer to these uncanny coincidences as ‘God incidences’, but I would suggest to you that the focus of one's attention isn't so much as to how these events happen, but as to why. For me, it was clearly a spotlight shining on my past, like a giant hand pointing at me, albeit not with the dire portent of king Belshazzar's finger on the wall! No, the finger pointing at me came with a question: what had I done with the irresponsible, dishonest, cowardly, self-absorbed teenager who was me all those years ago? Something else that can result from such an uncanny experience is a change of behaviour, but in my case, I was always intending to provide implants for this young man if I could, and that's what I did.

Now in those days, I was working to the false premise that implants were best placed in the position that the natural tooth root had been, and maybe I should have placed three instead of two implants. I believe my restorative colleagues weren't totally enthused with my handiwork, but they did manage to use my implants and, within months, our patient was able to confine his denture to his bedside cabinet. Both he and his mother were delighted (thank goodness for a low lip line). A couple of years later, I saw them both again and they were still most appreciative, he was enjoying university and although there was the offer of a remake with a third implant and grafting, they were not in any hurry.

For me the miracle of osseo-integration had provided me some form of redemption, but for many patients like this young man, the positive benefits can be life changing. In Scotland, it is not so much victims of skiing accidents, rather those suffering with the atrophic mandible resultant from long-term edentulousness. It grieves me that 22 years on from the McGill Consensus,1 14 years on from the York Consensus,2 20 years on from the RCS report on implants in the NHS3 and almost 20 years on from the Scottish Needs Assessment Report (SNAR),4 so little has been done to address this ever-enlarging group. I believe the best place to provide this treatment would be the teaching hospitals, but alas, lack of experienced teachers? Lack of funding? Lack of enthusiasm for treating these patients? I don't think it is a shortage of skills because when you look at the clinical staffing of our teaching emporiums, it reads like the ‘who's who’ of private implant dentistry. So, it is more likely the latter reasons. Yes, funding is a big issue, but higher trainees come with funding, as do master's students, and they want implant experience. Are implant companies vying with each other to get their systems into the hands of these trainees, the specialists and sometimes consultants of tomorrow? If not, why not? These companies should rather be paying for the privilege of having their systems placed in these trainees hands. SNAR 2004 considered four groups deserving of special attention and by implication, help within the NHS and teaching hospitals. Postcancer reconstruction, traumatic injuries (for example RTAs and T-bar injuries), anodontia/hypodontia and finally the atrophic edentulous mandible. These groups were also included in the RCS 2012 report. So teaching hospitals should be concentrating their dental implant programmes on these groups. I note some teaching hospitals do not include the atrophic mandible as a condition accepted for consideration. If you do not offer a certain treatment, then you don't have a waiting list for that treatment, and therefore you can't breach a waiting times directive. Could this indirectly be considered a form of ageism? Maybe I have said enough, especially as I am no longer in the system to help, and frankly, I don't have any quick fix suggestions. Perhaps another approach would be to refer your long-suffering patient in for consideration for implant treatment (not for further advice on how to improve their current denture) and reference McGill, York, SNAR and the RCS, now I think I have definitely said enough.

Oh, just one last thing, should you find yourself on a crowded ski slope, hanging onto one of those antiquated T-bar things, please try to resist the urge to let it go early.