CHAPTER 16 COMPLEX IMPLANT RESTORATIVE THERAPY
Treatment of the severely compromised patient requires drawing on all the skills of the treatment team. Patients requiring these types of complex restorative plans challenge the entire restorative, laboratory, and surgical group. However, even more highly tested is the ability of the team to communicate. The success or failure of the restorative outcome is directly related to the time spent in planning the case, pretreatment discussions with the patient, and an understanding by all involved of their responsibility in patient care.
It has been known for years in restorative dentistry that success is determined well before the bur touches the tooth. It is imperative to expand this philosophy to the arena of advanced restorative implant therapy. Sequential treatment planning necessitates following a series of fixed processes, which, if utilized, will provide a result that not only reaches but exceeds a patient’s expectation.
Evaluation of the patient involves much more than just a simple examination of the oral condition. Patients requiring complex care present with myriad physical and psychosomatic issues. Ignoring these issues can doom treatment to failure before it even commences.1–6
The initial patient interview may be the most critical portion of the evaluation process. This step allows the practitioner to ascertain not only the patient’s history but also the patient’s personal goals and objectives. We need to know, in the patient’s own words, the chief complaint and the past and present medical history. With a clear understanding of the patient’s concerns, we can tailor the course of treatment to allow the patient to participate in this complex process in a comfortable, nonthreatening fashion.1–8
The patient’s questions should allow the interviewer to determine why the patient has reached his or her current state. What has kept the patient from care in the past, and what are the patient’s fears of dental treatment? The chief complaint is the starting point for all later presentation for the patient. This allows the team insight into the patient’s mindset. What are the patient’s specific concerns? What treatment has been presented to the patient in the past? Why was the treatment either unsuccessful or never initiated? What we learn from the patient’s history will keep us from repeating failures from the past.1–10
Assessment of the patient’s goals and expectations allows the practitioner to create a treatment plan and presentation that will encourage the patient to accept treatment and achieve a successful result. Although we are first and foremost health care providers, we must also possess the skills and abilities to create a scenario that allows patients to consent to the initiation of treatment. Determination of the patient’s motivational keys is an additional goal of the interview. Because of the intricacy of the treatment, the complexity of the sequence of care, and the generally high fees involved, a treatment presentation directed toward these motivators, or “hot buttons,” may allow the patient to understand the value of the treatment. When we are personally seeking information and have to commit to a decision, we always want to know the benefits to ourselves. Business sales literature lists some of these hot button triggers relative to personal decision making as aesthetics, health, pain, business advancement, self-confidence, embarrassment, sex, and money. When the time comes to present the proposed treatment plan to a patient, knowledge of these motivators is invaluable.11–14 We commit to a course of action based on value—“what’s in it for me”—but we all view value differently. Throughout the evaluation process the dental staff must also assist in determining the patient’s motivators and what the patient is seeking from care, later discussing this information with the dentist. Care must be taken to ensure that a patient does not simply acquiesce to treatment but truly agrees with and comprehends the therapy and its relationship to his or her overall health and well-being.
As discussed in prior chapters, a complete medical history and medication list must be obtained. Patients requiring complex restorative care may be more medically compromised than the average dental patient. The interrelationship between medications, healing, and patient response should never be taken lightly. When necessary, a request for additional information and consultation with the patient’s physician should be obtained before proceeding with care.2–10,15,16,18,19
The basic fabric of a team approach necessitates continual communication, both verbally and in writing, between the surgical and restorative offices. Information garnered throughout the interview process in either office must be shared with the entire team. The patient must have confidence that the entire team is fully committed to his or her care. It is imperative that both offices communicate similarly with the patient. Each office must be fully aware of the patient’s concerns and goals and speak with a unified voice when discussing treatment issues with the patient. Lack of shared communications can be very frustrating to a patient who might be asked the same questions over and over again. Apprehension and confusion will frequently occur if the patient perceives that the treatment team is not organized. This turn of events may not only be disruptive to treatment; it also has the potential to create doubt in the patient’s mind, the suspicion that his or her personal goals are not understood or sincerely appreciated by the team. Because of the complexity of this level of care, any hesitation or doubt on the part of the patient can end discussions of treatment acceptance before they even begin.
Figure 16-1. A, Mounted diagnostic models are critical to the proper diagnosis of interocclusal space and ridge relationship. Note that the permanent molars are not in occlusion. B, Hand-held articulation of models without the use of an interocclusal registration showing extruded maxillary teeth and what appears to be several millimeters of interocclusal space. C, The same models as seen in B, now properly articulated with interocclusal registration demonstrating why proper mounting, not hand-holding of models, is imperative for the diagnostic process. Note that the interocclusal space that was thought to exist on the hand-articulated models actually does not exist.
Figure 16-4. A, The panoramic radiograph is the base standard for implant diagnosis and treatment planning. This panoramic radiograph shows the partial anodontia seen in the patient discussed in Case 4. B, Utilization of a 5-mm stainless steel ball bearing is an acceptable method of calibrating a panoramic radiograph when a computed tomographic scan is unavailable or deemed unnecessary. This panoramic radiograph was used in the diagnosis for the patient discussed in Case 1.
It is common for patients requiring complex care to require additional radiographic studies. Historically, computed tomography (CT) scan studies posed significant cost and inconvenience to the patient. Today cone beam CT scans and other types of lower-cost digital methodologies are readily available. These patients, who have generally lost significant amounts of bone, require significant numbers of implants to create long-term prosthetic stability and restoration of health.
Manipulation of the implant placement around osseous abnormalities, voids, and critical structures within the osseous frame frequently require much more information than can be garnered from a two-dimensional panoramic radiograph. Information from computer-assisted studies provides the surgical and prosthetic team with the precise location and volume of available bone, and the quality of the bone (Figure 16-5). The use of newer software programs provides the ability to generate surgical guides, prosthetic templates, and a provisional or final prosthesis before the beginning of any surgical treatment. Guided surgical and prosthetic therapy will significantly advance the treatment of these complex cases by providing access to areas of bone that were simply too difficult or too dangerous to approach with unguided techniques. These advances in diagnostic planning and directed surgical techniques will allow practitioners to provide implant restorative options to patients previously deemed unrestorable without elaborate surgical manipulations.*
It cannot be stressed enough that all of the advantages of these advanced radiographic techniques are lost if the prosthetic restorative team does not jointly analyze the information available and together plan the surgical prosthetic sequence to create the expected result for the patient. Once all of the diagnostic information is obtained, the team members should meet and plan the patient’s therapy. The team must make the following determinations before presenting any treatment to the patient.
Determination of the appropriate restorative prosthesis is a joint decision by the surgical restorative team, but that decision must fully take into account the patient’s needs and desires. The only limiting factors in this process are the ability to bioengineer the osseous support available and the imagination of the restorative team.
Fixed prosthetic options for the partially edentulous patient are generally variations of traditional crown and bridge techniques. With regard to implants, every attempt should be made not to attach implants to natural dentition.2–6,10,18,47 Creation of a prosthetic result that allows the patient to easily perform personal daily oral hygiene processes also must be discussed carefully with the often-forgotten members of the treatment team, the dental technician and laboratory.48 If large spans of missing teeth cannot be restored safely with a fully fixed prosthesis, a segmental removable prosthesis can be used in combination with fixed crowns and bridges. This type of prosthesis allows replacement of wide edentulous spans without overstressing the implants or natural abutments.* The segmental prosthesis makes use of the same principles as the fully edentulous variation, with the level of retentive stability dependent on the bar attachment devices selected.
The greatest variation in prosthetic treatment options is found in the treatment of the edentulous or soon-to-be edentulous patient. The base decision of placement of a fixed or removable prosthesis must be made early in the course of treatment. All patients would prefer to have their natural teeth back, and a fixed prosthesis is as close as possible to fulfilling that desire. It is critical that the team never forget the basic issues that caused the patient to lose the teeth. Patients who had difficulty maintaining their personal oral health may be poor candidates for a fixed prosthesis. These individuals may find that a removable prosthesis will allow them to more easily perform the oral care procedures necessary to prevent a recurrence of their past difficulties and failures.
Removable prosthetic options come in two basic types: with or without a bar. Lack of a bar definitely reduces the complexity of prosthetic fabrication, but a bar significantly increases the stability of the final prosthesis. The level of stability can range from limited retention of a two-implant self-standing prosthesis to a multi-implant spark erosion bar prosthesis that has the feel of a fixed prosthesis.* It is important for the team to remember, when planning the final restoration, that when patients think of implants they think of stability.
Fixed prosthetic options for the edentulous patient have undergone significant modification in recent years. Aside from fixed crowns and bridgework, the original Brånemark-style hybrid prosthesis is still the model on which most are based.5,53 The use of angled implants and fixation in nontraditional locations such as the zygoma has added tremendous additional treatment options for the patient. In concert with or without guided surgical techniques, these concepts are evolving rapidly.54–5781 The patient’s ability to create a long-term healthy environment must also be part of the planning process when developing the fixed implant prosthesis for the patient. If there is any question as to the patient’s willingness or ability to perform the necessary daily hygiene procedures, a removable prosthesis should be planned.
It is best that the restorative office first present the treatment plan to the patient. Discussions must focus on the patient’s chief complaint, desires, and expectations. It is imperative that these issues are addressed throughout the presentation. A patient who is concerned about function and stability will not be comfortable making a decision to proceed with treatment on the basis of aesthetics or engineering. Neither will a patient who is interested in aesthetics or business advancement base a treatment decision on a presentation of his or her problem from the direction of increased chewing function, support of the jaw, and preservation of osseous structure. Creating willingness on the part of the patient to come to an affirmative decision does not come without planning and effort. The reality is that patients will only accept treatment that they desire, understand, feel they need, and believe will benefit them. This is the value of the treatment to the patient, and people will purchase only what they appreciate and value. This is not to imply that any dentist should ever present to any patient treatment that is not appropriate for that patient and in the patient’s best interest. Traditional dentistry is complicated enough for patients to understand. When we begin discussions about dental implants and extensive complex restorations, we must understand that patients will listen to those discussions only in the context of their own concerns and what the value of that treatment is to them.
In general, it is not effective to discuss the specific details of treatment when presenting the plan to the patient. The patient does not need to be taught how to place an implant or achieve proper contouring of a crown during the consultation. Patients often are confused when we try to turn them into doctors by explaining all the intricacies of treatment. We must be sure that our patients understand what is being planned for them, the steps of therapy, and the anticipated outcome as well as the potential risks to achieve our responsibilities of informed consent. However, we must be careful not to overwhelm patients with too much information and create confusion. It should be noted that there are two exceptions to the rule of not discussing the details of the prosthesis with patients: the engineer and the researcher. Because of these individuals’ backgrounds and their more analytical approach to decision making, the practitioner must be ready to provide to them both the value-building piece and the specifics of the therapy during the consultation. It should still be noted that even with such detail-oriented individuals, the decision to commit to treatment is still based on their individual values and goals.4,5, 12–14, 58–62
When the total restorative and surgical treatment plan is finalized, an anticipated timeline must also be presented to the patient. Patients have no basis for comprehending the exceptional complexity of these therapies and the amount of time it takes for healing and fabrication of the final prosthesis. It can easily take from 6 to 24 months to complete a complex treatment plan. It is imperative that during the treatment presentation we address one of the patient’s greatest unspoken concerns over this type of extended therapy: How will they function, both physically and aesthetically, during the course of treatment? 1–5,7,10
When planning a patient’s complex case, a multistaged treatment plan should always be developed. Often an extended multistaged plan will mandate use of two or even three sets of provisional restorations. This must be considered before the patient’s consultation because the cost of provisional restorations can be significant and must be included in the fee presentation before the onset of treatment.
It is always preferable to provide an immediate fixed provisional restoration for the patient. This is generally the most comfortable option for a patient because it obviates the need for a removable prosthesis, which may be foreign to the patient. It also allows for passive healing of the tissues without direct pressure during function, eliminates the risk of movement or dislodgment for the patient, and prevents coverage of the palate when the maxilla is involved (Figure 16-6). As part of the treatment planning process the team must determine before the consultation if it will be possible to place the implant fixtures at the initial surgery.*
Unfortunately, it is not always possible to provide a fixed provisional restoration for every patient. Placement and loading of the implant fixtures are totally dependent on adequate osseous support, acceptable levels of initial torque on the fixtures, and the presence of stable soft tissues at the point of surgery. If implant fixture placement or loading is not initially possible, a complete or partial provisional denture prosthesis may be necessary. This type of prosthesis may be problematic because it is generally in direct contact with the surgerized tissues. Excessive pressure must not be applied over the suture line, underlying grafted bone, subgingival fixtures, or exposed fixtures. To avoid this pressure, a semi-flexible base material should be used on the tissue surface of the prosthesis (Figure 16-7). A variety of materials are marketed as soft or transitional reline materials, and one should be selected based on ease of application and ability to trim cleanly with a bur, blade, or electric hot knife. The material should adapt fully to the current ridge to provide support to the tissues. Because the semi-flexible base has very little strength, consideration must be given to provide enough bulk of acrylic within the prosthesis to prevent fracture during function. Do not assume that the soft liner will provide enough protection to keep an implant with an exposed healing cap totally out of function. All soft lining materials will load an exposed healing cap if in direct contact and this can be problematic during the 2- to 8-week relaxation stage of integration. To prevent this problem, trim away any base material that comes into direct contact with the fixture or healing cap.
When using a removable prosthesis to fully seat the prosthesis by hand, it is imperative to stress to the patient not to “bite” the prosthesis into place. Doing so can adversely load the implants, damage the healing soft tissues, and tear open the suture line. If significant buccal osseous augmentation material is added, removal of the buccal flange should be considered to prevent pressure and manipu/>