CHAPTER 3 ESSENTIAL SYSTEMS FOR TEAM TRAINING IN THE DENTAL IMPLANT PRACTICE

Once the clinician has sufficient mastery of the products and procedures required to successfully complete implant cases, the next challenge becomes training the dental team. This involves a two-tier approach in which clinical and patient informational skills must be learned and implemented. This chapter looks at the systems that must be incorporated by the entire staff in order to grow the implant practice.

After the root-form implant was introduced into the United States in 1983 ¹ a generalized separation of duties specific to practice type developed. Initially, oral surgeons and then periodontists were the primary sources of surgically placed implants. In most cases, the restorative dentist referred implant candidates to these specialists, who sent them back to the restorative dentist for prosthetic completion after the surgical phase. Unfortunately, the initial lack of prosthetic training made completion of implant cases frustrating for surgical and restorative dentists, as well as for the patients. Although this trend has been significantly remedied with the increasing prevalence of implant prosthetic courses and literature, widespread confusion continues about how the surgical and prosthetic offices can best work together for the seamless completion of implant cases. In other practices, the prosthetic dentist does both surgical and restorative procedures.

Whatever the mechanism for case completion, the office staff must become an integral part of implant education, procedures, and follow-up.² Without the support of the entire team reinforcing the dentist’s recommendations, developing an implant practice can be very difficult if not impossible.

Four Presurgical Phases

Implant case development usually involves a joint effort between the restorative and surgical offices, facilitated by a protocol for interdisciplinary treatment planning. The following four phases are recommended for analyzing the prospective implant patient’s options for treatment and then delivering them to the patient.³

1. Diagnostic work-up

2. Laboratory procedures

3. Treatment planning conference

4. Case presentation

These phases follow the initial exam to confirm that the patient has an existing condition that is treatable with dental implants.

All dental team members must be cognizant of this presurgical planning system. They must understand why it is important to properly plan the case and how to carry out these phases in a professional and organized manner.⁴

Diagnostic Work-up

The patient who presents with a need for tooth extraction(s) or is already edentulous in any area qualifies as an implant candidate. This can be determined at an initial appointment with a visual exam and radiographs. The patient is then advised that a diagnostic work-up is needed to properly analyze the case and develop an appropriate treatment plan.⁵

From the first patient contact with the office by phone, email, or other means, each team member should have a working understanding of how the patient is to be guided through an educational process that will allow the patient to make an intelligent decision about treatment. The new patient calling to inquire about dental implants will be scheduled for a limited exam with x-rays, typically one or more periapical radiographs of a specific area and a panoramic radiograph. A preprinted form is used by the scheduler as a guide for gathering pertinent information (Figure 3-1). The appointment coordinator schedules this appointment and sends a health history and other pertinent administrative information to the patient to complete and bring to the appointment. The dentist then examines the area of concern and determines whether the case can be appropriately treated using implants. Additional diagnostic information is recommended, leading into the diagnostic work-up. Once the patient agrees to proceed, the work-up can be completed at the first appointment or scheduled for a later date.

Figure 3-1. Telephone information slip.

(Courtesy Pride Institute, San Francisco, CA.)

In addition to the necessary and appropriate radiographs, maxillary and mandibular diagnostic impressions are made using vinyl polysiloxane (VPS) impression material. VPS impression material is preferred over alginate impression material because it facilitates pouring of multiple stone casts. Fast setting (2 to 3 minutes) medium-viscosity VPS works very well to capture the detail needed for a diagnostic impression. If significant undercuts exist or if the dentition is periodontally mobile, extra-light-viscosity material is syringed into these areas with medium-viscosity material used in the impression tray. The extra-light material will usually pull out of the undercuts without danger of disrupting the teeth or existing restorations (Figure 3-2). In severe cases of undercuts and/or mobility some form of block-out material should be placed. A bite registration is then made, either in the patient’s acquired maximum interdigitation or in centric relation.

Figure 3-2. Diagnostic impression made from vinyl polysiloxane (VPS) impression material.

A series of photos are taken to document the patient’s existing condition (Figure 3-3). Additional digital photographic views may be helpful in thoroughly analyzing the case. The dentist or assistant may be aided by taking courses in dental photography or reading the existing literature on the techniques and equipment needed to acquire these images.⁶^,⁷

Figure 3-3. Photos taken to document a patient’s existing condition. A, Full face photo. B, Unretracted smile. C-E, Retracted views at 1:3 (C), 1:2 (D), and 1:1 (E). F, Retracted lateral view. Maxillary (G) and mandibular (H) occlusal views taken in a mirror.

A complete charting is made of the patient’s existing restorations, missing teeth, occlusal classification, temporomandibular joint (TMJ) status, and periodontal condition. The periodontal charting includes six sulcular measurements per tooth, plus notations of bleeding on probing, mobility, furcation involvement, plaque and calculus status, recession, and clinical attachment loss.

The diagnostic work-up includes a facebow transfer for a semi-adjustable articulator, a centric bite registration, a full set of periapical and bite-wing radiographs, a panoramic radiograph, and a discussion with the patient regarding his or her long-term goals and desires from implant therapy. This discussion allows the clinician to form an idea of the patient’s attitude about dental treatment in general and implants in particular. Allowing the patient to review previous dental treatment will provide some insight as to how difficult or reasonable the patient may be if the clinician’s recommendations are accepted. It is recommended that a full diagnostic work-up should be completed for moderate to complex implant cases.

For simple cases involving one to three implants, a limited work-up may suffice. In this case, diagnostic impressions, bite registration, and a more limited number of radiographs and photos should be taken. A panoramic radiograph is always taken due to the valuable information that can be gained by viewing all of the two-dimensional bone in the proposed area of implant placement.

A properly trained clinical assistant can perform the facebow transfer procedure and take the photos that illustrate the patient’s preoperative condition. The ability to perform these procedures unsupervised adds to the value of the assistant as a team member by allowing the dentist to delegate these duties. If the patient is totally edentulous, notations are made of the ridge consistency (flabby, loose, or firm), arch form (square, tapering, ovoid), and vertical dimension (closed, open, or normal).

The final part of the diagnostic work-up consists of a discussion with the patient regarding goals and expectations. Open-ended questions such as “What would you like to change about your existing smile and teeth?” tend to be the most helpful. In many cases, the patient wants a brighter smile, straighter teeth, closed spaces between teeth, or some other aesthetic improvement. Others may simply want the improved function that implants present by changing from a conventional denture to an over-denture or hybrid appliance. The patient’s responses to these types of questions can provide invaluable information. Because this is a rapport-building period, it is important for the clinician to listen. Let the patient talk as much as is possible to gain insight into exactly what he or she desires; there will be plenty of time later on to go into specifics about the details associated with treatment plan options. Active listening can be used here not only to display genuine interest and concern but also to verify that you understand what the patient is saying.⁸

Once the conversation about the patient’s desires and expectations is completed and documented, the patient makes an appointment to return for a case presentation. In the interim, the diagnostic impressions are poured in laboratory stone and mounted on a semi-adjustable articulator. It is a good idea to double pour the impressions to provide a duplicate set of diagnostic casts for the surgeon (if applicable) and/or laboratory technician. From the mounted casts the restorative dentist can determine the available inter-arch dimension for the final restoration as well as other pertinent information such as mesial-distal and buccal-lingual estimates for implant placement, existing occlusal relationship, arch form and length, and options for fixed or removable prosthesis fabrication.

Laboratory Procedures

In working up the treatment plan, the restorative dentist will produce diagnostic casts from the preliminary impressions and mount them on a semi-adjustable articulator. Subsequent working models will be mounted on this same articulator for consistency and comparison with the preoperative condition. From the facebow transfer, the maxillary model can be mounted on the upper member of the semi-adjustable articulator (Figure 3-4). The mandibular model is mounted on the lower member of the articulator using the centric bite registration.

Figure 3-4. Maxillary model mounted on the upper member of the semi-adjustable articulator and mandibular model mounted on the lower member of the articulator.

The semi-adjustable articulator and facebow transfer procedures facilitate the accuracy of all restorative procedures. In general, this is because the case can be mounted closer to the true arc of closure of the mandibular teeth relative to their interdigitation with the maxillary teeth.⁹ This principle of restorative dentistry, although always important, is particularly essential when opening the vertical dimension of occlusion (VDO). Having the models track on, or very near to, the arc of closure will reduce the occlusal adjustment needed upon delivery of these types of cases. In many instances, the VDO is opened in patients who have used partial or complete dentures for many years or who exhibit worn dentition. The mounted casts are reviewed along with the radiographs, photos, and chart notes including pertinent periodontal measurements. One of the valuable insights gained from the mounted casts is the determination of how much inter-arch space is available to the proposed implant restoration.

In addition to the technical benefits of using a facebow transfer to mount models on a semi-adjustable articulator, there is an additional benefit to the clinician. Many patients have not experienced this procedure in previous dental treatment, and they often equate the facebow procedure with a higher level of restorative dentistry. Many patients have remarked about the “sophistication” of the clinical procedures after having the facebow transfer completed. This perception can only increase the patient’s confidence in the clinician’s technical background and capabilities, an aspect of case acceptance and general rapport that cannot be overemphasized.