July 1, 2004
by Blake Nicolucci, BSc, DDS
In a great many of the cases that cross my desk for implant consultation, the teeth that are going to be replaced with implants have either:
1. been missing for a substantial period of time, or
2. have recently been extracted by a ‘what ever it takes’ style of dentistry in which the labial bone has been sacrificed for the sake of getting the tooth out in one piece, or during the ‘excavation’ of the residual root tips.
Sometimes an implant dentist will be tempted to do what ever it takes to ‘get the case’ when it comes to treatment of a patient with dental implants. Unfortunately, implants are only being placed in areas where there is an abundance of bone, and they will often be omitted in an area where they should ideally be placed. Dentists are forgetting that ‘prosthetics drives the treatment plan’. Once you know what kind of house you are going to build, then you can construct the appropriate foundation. I’ve even seen implants placed in the anterior areas of both ridges because of lack of bone in the posterior segments. The prosthetics are then cantilevered back–so that a single or double sinus elevation need not be performed. There is one of two reasons for this. Either:
1. The dentist is not proficient at performing this particular type of surgery, or
2. The cost of performing the surgery would increase the fee to the point that the patient would decide against the implant therapy, and choose a treatment with a more reasonable cost.
The fact is that with the repairs required from an inadequate foundation (which include prosthesis fracture, solder joint fracture, and/or porcelain fracture) the cost will ultimately be as much as–or more than–if the case was done properly in the first place. The only difference is that they now become hidden costs–and a surprise to both the dentist and the patient. Not a good way to develop a trusting relationship with your patients!
I can understand the dilemma with the second option of chasing a patient away, but at least they have been given the opportunity to choose a more financially reasonable treatment. And for a patient with the stress and financial hardships of a huge dental bill, implants may indeed not be the treatment of choice. The psychological pressure of ‘shortage of money’ can loom as a heavy burden over anyone at any given particular point in time.
Getting back on topic, the bone site (where the treatment plan is placing the implant) is usually deficient. This can be overcome from some very simple (and yes some very complicated) bone grafting. All of which the general dentist is capable of performing once he has taken the appropriate continuing educational courses.
The following are a number of cases that began with insufficient bone for implant surgery, and how they have easily been treated to create a more ideal implant site (usually in buccal lingual or buccal palatal width).
As you can see from the following six cases, it is not difficult to attain enough bone in a receptor site to ‘place the implants in positions where they were intended’. Not only does it make implant dentistry much easier for the dentist, but it reduces the risk of complication, and therefore makes the patients much happier as well. So don’t be lazy, get off the couch, and take a few ‘recommended’ courses. Everyone wins!
Blake Nicolucci is Oral Health’s implantology board member and president of the Canadian Society of Oral Implantology.
Oral Health welcomes this original article.