The Optimal Treatment Sequence Used For Complex Cases in Implant Dentistry

by Yvan Poitras, DMD

With the majority of implant treatment plans, the practitioner will usually plan the implant surgery, wait a few months (three to eight depending of the bone density) and place the abutments at a subsequent appointment. The final restoration will then be completed in the following weeks or months. The old prosthesis can often be relined with a soft liner and used as a provisional during the treatment period.

In the last decade, the one stage implant has gained in popularity because of the decreased number of surgeries required. Immediate loading of these implants has also gained in popularity. This considerably reduces the time required for prosthesis delivery and the need for a good provisional restoration. With good bone density, and a treatment plan that respects all biomechanical principles, this is the almost the ideal situation for the patient… and the practitioner.

But for a significant number of our patients, this approach cannot be used. The old days have gone where implants were placed ‘where there was sufficient bone’, and then referred to the lab technician, who was given the responsibility of building “something” suitable for a final restoration. In present day implantology, for the majority of our cases (and especially for the maxilla) we should “rebuild” the bone volume where the implants should ideally be placed prior to any implant placement. This will often increase the number of appointments, delay completion of the final restoration, and also add to the complexity of the provisional or temporary restoration.

When trying to accomplish all of these goals, an advanced implant dentist can decrease the number of appointments by combining several of these steps whenever possible. This will usually increase the amount of autogenous bone available when it is time to place the implants without jeopardizing the outcome of any particular one of the procedures. And if we decrease the time and the number of surgical procedures (while still optimizing bone volume), case acceptance by patients can be increased dramatically.


A root form implant was placed with a subperiosteal implant to replace a cantilever bridge for this 48 year old lady, seven years ago. She was so happy with her teeth that she asked for fixed teeth in the maxilla.


A 58-year-old female presented in the clinic complaining of persistent problems with almost all her remaining teeth. Her periodontist told her that it was almost impossible to stabilize her teeth appropriately for any definitive long-termed prognosis. She travels a lot and is a very active person. After weighing the advantages and disadvantages of implant therapy, she decided to extract the remaining teeth and have implants placed as soon as possible.

There was no acute infection, which made it possible to place immediate implants.

We decided to extract all her natural teeth and proceed with implant-supported bridges in both arches.


This 64-year-old man is a speaker on the lecture circuit. He had severe periodontal problems and he wanted to replace his upper teeth with an implant-supported prosthesis. His main concern was his ability to speak while wearing a provisional prosthesis during the healing phase.


This fourth case involves tooth removal, implant placement in the mandible, bilateral sinus elevations and a symphysis graft all in one surgical step. This is for a 53-year-old man who would like fixed teeth in both arches.


This last case illustrates how we can minimize the time, number of appointments and the amount of post-op discomfort for the patient while maintaining as much autogenous bone as possible. This is a healthy 50-year-old lady with a conventional upper denture and a partial lower denture. She wants fixed teeth in both arches. She needs vertical bone augmentation (& sinus lifts) in the posterior maxilla. She also requires an onlay graft horizontally in the pre-maxilla for bone volume and lip support. However, her few remaining teeth are mobile and problematic.


Increasing the number of appointments will significantly increase the treatment time for final prosthesis delivery. The patient acceptance will usually be reduced and they are more often exposed to more post-op discomfort (requiring them to take more medication).

Complex implant cases should be performed in an orderly sequence. Combining multiple stages of treatment can reduce chair side time in the hands of an experienced practitioner. This also decreases the complexity of the preparation for the provisional restoration, and will maintain most of the autogenous bone in the grafted sites. Both good treatment planning and an orderly sequence of appointments consolidating treatment are major keys for success.

Dr. Yvan Poitras is Founder and Director of the Canadian Implant Institute (Recognized provider ADA CERP), which provides training in both surgical and prosthetic aspects of Implantology. He divides his time between his private practice limited to Implantology, teaching and international lectures. He is affiliated with the research group in Biomechanics/ Biomaterials at l’cole Polytechnique de Montral.

Oral Health welcomes this original article.


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