April 1, 2005
by Daniel T. Mayeda, DDS
Cosmetic dental patients may range from individuals seeking teeth lightening procedures to severely compromised patients who require full-mouth rehabilitation. Fortunately, teeth lightening procedures have become very predictable and expedient, thus bleaching treatments offer patients immediate satisfaction to their esthetic needs. On the other hand, patients requiring extensive esthetic treatment may require dental implant procedures, which usually require an extended amount of treatment time.
Complex treatment prescriptions/planning and time requirements often discourage patients from accepting treatment which includes dental implants. In fact, it has been reported that restorative dentists are frequently discouraged from including dental implants in their treatment prescriptions because of the following reasons. Levin1 reported that some of the reasons why dentists are not involved in dental implants are: 1. fear and confusion of the procedure, 2. lack of support from implant companies, 3. cost to the patient, 4. high lab fees, and 5. having to deal with too many surgical and restorative implant components.
The purpose of this article is to present dental implant and cosmetic procedures that can reduce the resistance of dentists from including implants in their treatment plans. Having more than 20 years experience in both placing and restoring dental implants, the author feels that with less complicated and more expedient procedures, patients will thus, understand and accept more implant procedures in their esthetic treatment.
Studies on conventional fixed prostheses, have shown that abutment teeth fail in 5-7 years because of decay and root fracture.2,3 Also, patients who require teeth replacements are now seeking more natural prostheses with individual implant supported crowns, as opposed to having to unnecessarily crown or involve other natural teeth. Based on these studies and observations, implant supported prostheses are the treatment of choice for replacing missing teeth.
The popularity of rootform implants in the early 1980s played an important but elitist role in surgical and restorative implant dentistry. Certain implant companies limited the sale of their products and training mainly to oral maxillofacial surgeons, periodontists and prosthodontists. Thus, the most predictable and restoratively useful implants were kept out of the realm of general dentistry. Also, restorative components that required multiple parts resulted in higher restorative fees, complicated treatment appointments and unesthetic gingival/ restorative interfaces.
Dentists who were aware of patients’ cosmetic concerns both in the esthetic zone and posterior segments, resisted replacing teeth with dental implants fearing the unpredictability of acceptable esthetic results. Fortunately, progressive implants companies started to allow surgical and restorative training of all dentists in the mid 1980s, but the perception that only one implant system works and that only specialists should perform implant procedures remained a stigma throughout the 1990s.
The evolution of esthetic implant dentistry was delayed by the insistence that the “retrievable multiple-part abutment” was the component of choice in restorative implant dentistry. Today, that past opinion is a myth as evident by the introduction of “preppable titanium alloy abutments” in the late 1990s by the once archaic manufacturers. Unfortunately, the impact of certain manufacturers’ marketing still influence and discourage dentists from including dental implants in their treatment prescriptions.
Levin in his 2003 article,4 states that manufacturers are now 1) simplifying prosthetic components and 2) simplifying procedures. As a result of these efforts, dentists are now 1) realizing that single implants are now more simple and 2) that the younger dentists are now not as afraid as in the past to include implant procedures. This paper presents two case studies in which the simplification process of fabricating and delivering implant support prostheses are explained. The cases are an anterior single tooth implant prosthesis and a maxillary/mandibular totally edentulous fixed implant prosthetic case.
Both of these cases utilize the same protocol that contributes to the simplification and facilitation of dental implant treatment in the cosmetic practice. The steps that are followed are: 1) impression of implants hex at time of implant placement 2) pre-fabrication of transmucousal abutment prior to the uncovery of implant 3) pre-fabrication of transitional prosthesis prior to the uncovery of implant 4) placement of transitional prosthesis at implant uncovery 5) teeth and gingival esthetics finessed with transitional prosthesis in place5 6) final impressions for predominantly “cement on crown” prosthesis.6
The main advantage of following this protocol is the patient benefits from having a fixed prosthesis at implant uncovery. This is unlike the typically recommended manufacturers’ protocol of using a “tissue healing abutment” at uncovery, followed by the impression of the implant hex after a four week tissue healing period. This antiquated protocol was originated by manufacturers who were influenced by team concept of separate practitioners placing and restoring implants.
The team concept of a trained dental practitioner surgically placing the implants, followed by a restorative dentist who would complete the prosthodontic phase of treatment is a valid protocol in providing implant services.7 The team concept is more expedient in providing an implant supported prosthesis when either the surgical team member or the restorative dentist places the transmucousal abutment and prosthesis at the uncovery.
Not only are implant surgeons encouraged to work “side by side” with their restorative colleagues at uncovery, but to learn to take implant hex impressions at implant placement. Working “side by side” with the restorative dentist at implant placement has its advantages. If the surgical practitioner elects not to take the transfer impression, the restorative dentist is available to do so. Also, if the planned position or trajectory of an implant needs to be altered, the decision between the surgeon and restorative dentist can be collectively made on the disposition of the proposed implant.
Two options of implant team members working together “side by side” make this concept advantageous for all parties. One option is the implant surgeon placing implants in the restorative dentist’s office. This option has these advantages. The patient does not have to go to another office and may feel more comfortable having the procedure performed in familiar surroundings including staff. The restorative dentist is available to take the transfer impression. Both dentists can discuss and decide on any alteration in treatment immediately. The main disadvantage of the surgeon placing implants in the restorative dentist’s office is the setting up of a surgical suite in another office.
The second option of team members working together “side by side” requires that the restorative dentist be present at the surgeon’s office at implant placement and uncovery. The advantages and disadvantages are the same as above, with the exception that the patient would have to go to another office. Regardless, implant teams working together “side by side” clearly contributes to the simplification and facilitation of providing implant procedures to the cosmetic patient.
Dental implant supported prostheses are viable options for single tooth and fully edentulous cases. Patients benefit from fixed prostheses at implant uncovery through proper sequencing and simplification of treatment steps. Dentists benefit by accelerating patient treatment to a plateau of custom fabricated transitional restorations. At this stage, esthetic, health and functional requirements are addressed, while the patient is already benefiting from a fixed prosthesis. Surgical and restorative dental professionals are encouraged to work clo
sely as a team to improve communication, professional relations and consistent successful results.
Dr. Mayeda graduated from the University of Missouri: Kansas City, 1976. He maintains a private practice in Maui, Hawaii. He is an international lecturer on cosmetic and implant dentistry.
Oral Health welcomes this original article.
1.Levin, R. Implant Dentistry, 2003; vol 12, no1, p 2
2.Walton JN. J Prothet Dent, 1986; vol 56: 416-421
3.Schillingburg HT, Hobo S. Fundamentals of Fixed Prosthodontics, 3rd ed, Quintessence, 1997
4.Levin, R. Implant Dentistry, 2003; volt 12, no1, p 2
5.Misch CE. Contemporary Implant Dentistry, 2nd ed, Mosby 1999. p 551, passive casting; p 553, p 624, progressive loading; p 623: implants in mandibular posterior regions.
6.Davapanah M, Martinez H. Cemented prostheses, esthetics, biomechanics and function, technique. Clinical Manual of Implant Dentistry. Quintessence, Surrey,UK, 2003; p 97.
7.Saadoun AP, LeGall M, Touti B. Provisional and prosthetic stage, selection and ideal tridimensional implant position for soft tissue aesthetics, Practical Periodont Aesthe Dent. 1999; vol 11, no 9, p 1063-1072.