How do you treatment plan for restorative implantology?
Ricardo A. Boyce, DDS, FICD; Gary Klemons, DDS
- More than 30 million people Americans are missing their teeth, according to the American Academy of Implant Dentistry.
- The restorative dentist should inquire about:
- If there were any surgical complications,
- Insertion torque,
- If there was a need for bone grafting or sinus lift,
- The size/diameter of the platform and length of the implant,
- The implant manufacturer,
- The estimated time of placement of the healing cap, and
- The clearance from the surgeon to begin the restorative treatment.
- When there is teamwork between the surgeon, restorative dentist, and the laboratory technician, the result can be a masterful replica of a normal oral cavity.
- All discussions should be finalized with the patient so that they understand the risks, benefits, and options/alternatives from a surgical and restorative standpoint.
- Patients should know in advance approximately how many office visits are involved and should be given a cost for the restoration(s), including parts.
Review of Past Medical History
- Lengthy and complex implant cases may not be suited for patients with multiple medical disorders in the ambulatory setting, so good judgment is needed with these patients. This group of patients may be better managed in a hospital setting, particularly in the operating room (OR).
- The patient interview of the history is the most important part of the diagnostic patient workup, because it is imperative for the clinician to properly diagnose, collect data (i.e., laboratory tests), consult with primary care physician/MD or specialists, and allow for the development of a good doctor-patient relationship.9
- The medical history comprises a systematic review of the patient’s chief complaint, information about past and present medical conditions, pertinent social and family histories, and a review of systems.8
- The term cluster phenomenon was used to describe a group of patients with implant failures with multiple systemic disorders and medications that include but are not limited to osteoporosis, diabetes, mental depression, heavy smoking habits, and parafunctional mandibular movements.15
Dental Imaging: Radiographs/Cone-Beam Computed Tomography
- Preoperative consultation with an oral and maxillofacial radiologist can be helpful especially when there is a need to rule out and interpret disease (especially intraosseous disease).
- The surgeon must be cautious of certain anatomic structures in the maxilla and mandible before implant placement, such as the inferior alveolar nerve (IAN), mental nerve, nasopalatine canal, bony defects found on the facial surface of maxillary anteriors, the lingual concavity of the mandible, and pneumatization of the maxillary sinus.17
- The use of CBCT may be overemphasized, because there are times when patients seem to have sufficient bone (mesiodistally) with conventional film; however, after the use of CBCT, the patient may not have adequate bone for an implant buccolingually, which can lead to perforations or fenestrations, which can result in failure.
- The CBCT or three-dimensional (3D) imaging shows the alveolar bone in relation to the ideal tooth position with low radiation doses.23
- Some surgeons prefer the use of computer-aided implant placement with or without the use of a surgical guide. Several systematic reviews have been published 25, 26 regarding the accuracy of computer-aided implant placement to serve those who doubt their usefulness.
- Dental splints with radiopaque markers are intended to be used for the scanning procedure, to establish position, and inclination of the proposed implant.28
Oral Examination and Occlusion
The restorative dentist should:
- Be able to visually see the outcome of a restoration or prosthesis.
- Be astute enough to be able to identify any problems that could arise surrounding a partially dentate or completely edentulous oral cavity.
- Be able to assess and diagnose (and document in the chart) periodontal disease (PD) in the dentate (and partially dentate) patient.
- Be aware of the process of seeding, when bacteria from a periodontally diseased site incorporates the site of an implant, which can lead to inflammation and destruction of the surrounding bone.
- Ask the patient if they are aware of periodontal disease developing, or if they have ever been told.
- Spend time with the patient to explain the current status and progressive nature of periodontal disease. Provide the patient with a good understanding in layman terms of their condition.
- Tell the patient the truth about their periodontal status.
- Document radiographs and probing depths in the chart to support the diagnosis.
- It is imperative for the restorative dentist to relay the proposed or foreseen treatment of extraction, enameloplasty, and also root canal treatment because of a foreseen encroachment of the nerve of a tooth or group of teeth to reduce the occlusal height of a tooth, by establishing a more ideal plane of occlusion.
- Clinicians should evaluate patients in Kennedy class I, II, III, and IV to determine if teeth need to be altered or sacrificed (as mentioned earlier) or if an alveoplasty or augmentation with bone graft of the edentulous alveolus is needed as a result of loss of bone or excess of bone.
- The restorative dentist should identify teeth that are not in ideal occlusion so that patients can understand various malocclusions.
- This dialogue with the patient builds trust; however, it should be documented in the chart to prevent any confusion in the future when modifications (i.e., enameloplasty) need to be made.
- Here is a list of things to observe while charting at the time of examination:
- Status of the remaining teeth,
- Probing depths,
- Keratinized tissue,
- Interarch space,
- Interteeth distance,
- Ridge width,
- Tilting of adjacent teeth,
- Occlusal/incisal plane,
- Smile line,
- Does soft tissue appear in the smile?,
- How many teeth appear in a wide smile?,
- Do the present teeth appear esthetic?,
- Is the current removable prosthesis stable and retentive?,
- Can the current denture be used as a provisional prosthesis?, and
- Are there any acute/chronic infections present?
Fixed Prosthodontics versus Removable Prosthodontics
- There are a variety of prostheses to consider, based on the existing dentition or lack thereof, including
- A single tooth replacement(s),
- An FPD bridge or removable partial denture,
- A full-arch fixed prosthesis roundhouse (in the completely edentulous dentition), or
- An overdenture (implant retained overdenture or implant retained and supported overdenture).4
- The placement of the implants at times is determined by available bone. In these cases, the restorative dentist needs to understand the limitations of the surgeon and has an obligation to explain any additional costs to the patient.
- One aspect of implant maintenance that is occasionally encountered by the restorative dentist is when the crown becomes loose as a result of the screw.
- On removal of the crown and screw, it is recommended that the old screw be discarded and a new screw placed and torqued in (according to the manufacturer’s recommendations).
- There are certain groups who because of their medical conditions cannot avoid a deterioration in their oral hygiene (e.g., the elderly, patients with dementia, multiple sclerosis, or cerebral palsy); therefore, efforts by a caregiver or family member are needed.
- On recall visits (every 3 months within the first year, every 6 months in the partially dentate patient, annually in the completely edentulous patient), when it is determined by the dentist to take radiographs, then, measurements should be taken and the probing depths or any changes in bone height should be documented.
- All advice for implant maintenance and good oral hygiene should be discussed at the beginning, throughout the delivery process, and during follow-up care.
- From the beginning to the end of treatment and maintenance, there should be a satisfied patient, the dentist should have an interesting collection of histories and images, and most importantly, everyone should be. all smiles.