INTRODUCTION
Being a general dentist usually makes you the first to be approached by patients seeking treatment for simple and, more often these days, complex situations. This means that it is essential to be familiar with and, ideally, proficient in the wide spectrum of dental treatment options available to anyone walking through your dental office door. Continuing education opportunities have become more readily available to any dental practitioner wanting to advance his or her knowledge and skills in almost any treatment modality you can think of. This, in turn, allows us to diagnose and successfully treat patients. After all, as Jonathan Raymond said, “You can’t know what you don’t know.”
Understanding our patients’ needs, their limitations, and their dental intelligence are important factors when offering treatment options. We can only establish this following a comprehensive examination of dental and perioral tissues after assessing the patient’s medical history and spending some time listening to his or her needs and wants.
Radiographic examination in both 2 and 3 dimensions has become of cardinal importance in the assessment of anatomical structures and the potential need for hard-tissue grafting in either staging potential implant surgery or as an adjunct procedure during implant placement.1
The availability of CBCT and its ease of use and interpretation, lower radiation exposure compared to medical CT, and lower cost have made it an important diagnostic and planning tool for dental implant surgery. More and more dental practices own a CBCT machine these days, which makes it so much easier to assess patients in a timely manner while also potentially involving them in your planning phase when discussing options and your rationale for your thought patterns in choosing options relevant for each patient’s specific situation and case.
By demonstrating your patient’s anatomy on a 3D rendering and what would be involved for each option offered to him or her, it could make it much easier for your patient to visualize and understand your options.
I will demonstrate how 2 patients with similar anatomical situations, wants, and budgets for dental treatment opted for 2 variations on the same dental treatment due to social factors and physical needs, and I will discuss their treatment processes, procedures, and outcomes.
CASE REPORTS
Case 1
A healthy, middle-aged male visited my practice with his mind already made up that he wanted dental implants to restore the appearance and function of his teeth. After a comprehensive medical, dental (Figures 1 and 2), and radiographic (Figures 3 and 4) examination, we established that he would benefit from a full dental clearance.
We discussed his treatment options, which included a conventional denture, an FP-3, an RP-4, and an RP-5.2 My patient felt worried about the idea of having a fixed prosthesis in his mouth that he potentially could have trouble cleaning if any food debris or plaque were trapped, but he still wanted a fully implant-supported prosthesis with no tissue support.
We decided on doing an RP-4 prosthesis with a full-arch, low-profile titanium bar with a superstructure for passive retention in the prosthesis utilizing Hader clips for active retention (Figures 5 and 6).3 Due to some flex in our mandibles because of complex muscle activity and being the moving part of our 2 jaws, implant placement was distributed in a specific way with only distal implants unilaterally (Figure 7) but that still allowed a good AP-spread, resulting in a bar design that would allow full-arch coverage.4,5 The prosthesis and bar were designed to allow adequate space for hygiene, which was an important prerequisite given by the patient when options were discussed (Figure 8).
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Case 2
A healthy, middle-aged male had an existing full upper denture and his own natural lower teeth, but due to periodontal disease, he found himself having trouble eating as a result of widespread tooth mobility and sensitivity (Figures 9 and 10). This gentleman wanted these remaining lower teeth removed and replaced with dental implants (Figures 11 and 12).
This patient has a disability due to a birth deformity where he only has one arm, and that hand doesn’t have a thumb nor an index finger, leaving him with decreased fine motor skills. This was an important factor to consider as his ability to maintain hygiene of his prosthesis was greatly affected. We’d have to find a solution where he would be able to clean his prosthesis without the help of a caregiver.
A fixed prosthesis was out of the question because of his inability to clean it adequately, and the patient wasn’t interested in an RP-5 due to the concern of too much bulk in the prosthesis potentially impacting his singing.
As a final treatment decision, we decided on an RP-4 (Figures 13 to 15), utilizing a titanium bar with a superstructure in the prosthesis, allowing for a prosthesis with deeper flanges with enough grip for the patient to still remove and insert it. Therefore, we had to plan our procedure to allow for enough vertical bone reduction to, in turn, allow for enough prosthetic space in the planned prosthesis so that the patient could grip it between the palm of his hand and his 3 remaining fingers.6
CLOSING COMMENTS
Approaching each patient as an individual with unique needs and circumstances allows us to establish a thinking process that can guide us toward a short list of possible treatment options. Customizing your processes and procedures comes with experience, competency, and our ever-increasing knowledge.
Understanding and recognizing our limitations is very important, and making use of the appropriate referral channels will ensure that our patients are taken care of and treated with the highest level of care and expertise. Digital dentistry, CBCT, smile design, and great laboratory communication allow us to streamline processes and treat patients more predictably. Dental implants are giving us so many treatment options, and by respecting the patient’s biology and inherent anatomical limitations, it aids us in drawing up a customized plan unique to each individual.
References
- Benavides E, Rios HF, Ganz SD, et al. Use of cone beam computed tomography in implant dentistry: the International Congress of Oral Implantologists consensus report. Implant Dent. 2012;21:78-86.
- Misch CE. Prosthetic options in implant dentistry. In: Misch CE, ed. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby Elsevier; 2008:92-104.
- Sadig WM. Special technique for attachment incorporation with an implant overdenture. J Prosthet Dent. 2003;89:93-96.
- Misch CE. The edentulous mandible: an organized approach to implant-supported overdentures. In: Misch CE, ed. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby Elsevier; 2008:293-313.
- Misch CE. The completely edentulous mandible: treatment plans for fixed restorations. In: Misch CE, ed. Contemporary Implant Dentistry. 3rd ed. St. Louis, MO: Mosby Elsevier; 2008:314-326.
- Alzoubi F, Massoomi N, Nattestad A. Bone reduction to facilitate immediate implant placement and loading using CAD/CAM surgical guides for patients with terminal dentition. J Oral Implantol. 2016;42:406-410.
Dr. Venter is a general dentist in Queensland, Australia. He is a solo practitioner at his own private practice, focusing on multidisciplinary oral rehabilitations, with a special interest in aesthetic and implant dentistry. He is a Fellow of the Australian Society of Implant Dentistry and a Fellow and Master of the International Congress of Oral Implantologists. He has published articles on aesthetic dentistry and multidisciplinary dentistry for the general dentist. He can be reached via email at info@orangemoosedental.com.au.
Disclosure: Dr. Venter reports no disclosures.
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