By Dr Jess Maguire
Clinician – London
Jessica Maguire discusses the importance of case selection when considering full arch dental implant rehabilitation for a prospective patient.
OVERVIEW
Losing your teeth is a terrifying prospect for anyone. What can make it even more distressing is being told by your dentist that your only option is a denture. Case selection is the most important part of the process at Evodental when considering full arch implant treatment for a prospective patient. It is not only a treatment option for the fully edentulous but is also suitable for the multitude of patients who have terminal dentition. Meticulous treatment planning is required alongside excellent communication between the patient and the entire dental team. If carried out incorrectly, it would lead to an undesirable outcome and an unhappy patient. There are many factors involved in ensuring a successful result for all.
We must start with a comprehensive diagnosis, which includes 3D imaging to evaluate available bone. This should be carried out for all immediately loaded implant cases, alongside the patient’s aesthetic expectations, commitment to a rigorous maintenance regime and the financial obligations involved. Smoking must also be discussed and the risk factors it carries in relation to implant treatment.
CONSIDERING THE WHOLE PATIENT
From a medical point of view, we have to ensure that the patient’s general health comes first and this is why patients must be ASA grade 1 or 2 when considering treatment. Having healthy and functional dentition will help to improve a patient’s wellbeing, both physically and mentally, but we have to be sure that we are not risking their overall health by putting them through a surgical procedure.
A full volume CBCT scan is carried out prior to any implant treatment to assess the anatomy and identify any pathology which may warrant further investigation. It is also used to ascertain the quantity and quality of bone available. If the aim is to carry out a graftless procedure, then the patient needs sufficient bone to allow for bi-cortical fixation of four to six implants in the maxilla (to include pterygoids) and four implants in the mandible, ensuring AP spread is maximised. Cantilevers should be avoided.
Anatomical considerations must be taken into account when treatment planning. In the maxilla, areas which have been edentulous for some time, will often demonstrate expansion of the maxillary sinus into the alveolar ridge, due to lack of stimuli from the teeth. As time progresses, pneumatisation occurs which causes further bone resorption and can restrict the regions available for implant placement. This is a common scenario for most of the patients we treat on a daily basis. In a highly resorbed mandible, the mental nerve can be close to the crest and may have an anterior loop, which can extend up to 7mm anteriorly. This can again affect the choice of possible implant sites. There are some rare instances in which the patient has experienced such severe bone loss, that traditional full arch implant treatment will not be possible without significant grafting or considering more complex treatment modalities, such as zygomatic implants.
FULL PSYCHOLOGICAL ASSESSMENT
The presence of sufficient bone for full arch dental treatment is not the only deciding factor. The psychological analysis and whether this is the right treatment for the individual patient really boils down to whether they understand the irreversible nature of removing all of their teeth and having fixed implant retained prostheses. They must also appreciate the ongoing maintenance regime required. Too often, patients think that implants are a “fix and forget” scenario, and it is our job to educate them on the importance of good aftercare to ensure they have a healthy and functional smile for years to come.
The psychological assessment must also consider the patient’s expectations, alongside a custom OHIP-14 form, which measures the social impact of their oral health. If the patient believes that the teeth will be moved significantly from their existing location, and thus positioning them outside of the anatomical envelope, we need to explain why this is not feasible. Moving a patient’s teeth beyond the biological limits would affect function and speech, so we must ensure they understand the rationale behind tooth placement. Teeth must always be placed in the anatomically correct position in any field of dentistry. Having fixed prostheses will provide improved aesthetics, which can be life-changing and confidence boosting for the patient. Ultimately, this is not primarily a cosmetic procedure. The main focus of the treatment will always be to restore health and function; achieving a beautiful and confident smile is an added bonus.
TREATING A YOUNGER PATIENT
Patient DC presents to our clinic, as a 46 year old woman with failing long-span bridgework and periodontally involved teeth. She was told by her dentist that dentures will be the next option due to her extensive bone loss. On viewing her CBCT scan and carrying out a comprehensive clinical examination, it is clear that her remaining teeth have a poor prognosis. This is carried out using a traffic light system that consider pathology, periodontal status and surrounding bony support plus the amount of tooth structure remaining. The teeth are colour coded individually to help us explain to the patient the current state of their dentition. The colour red is used to indicate the tooth in question has perhaps weeks or months at most, amber implying 3-5 years and green 5+ years. This helps to assess the whole mouth rather than focusing on just one tooth. It also helps the patient to visualise the current situation they have presented with. If they are deemed to be terminally dentate, they are suitable for treatment at our clinic, which focuses exclusively on full arch dental implant solutions.
Alternative treatment options for this lady would be removal of the hopeless teeth, maintaining any restorable teeth and having partial dentures, or full clearance and an implant supported removable overdenture. However, in the mind of a patient, both of these options still result in a denture which has to be removed daily for cleaning. Removable prostheses can still be a great source of anxiety for patients, even if they have excellent retention. Implant retained over dentures are often less hygienic, as it is more difficult for the patient to clean around the bar. The components often wear quickly and need to be replaced regularly. In addition, more prosthetic space is required which is not ideal as we would always aim to keep alveoplasty to a minimum.
With a young patient such as this, we also need to have the discussion surrounding longevity of prosthetics and implants. Patients need to be aware that a revision procedure to replace an implant or repair a fractured prosthetic within 10-15 years of initial treatment is a possibility. For younger patients, it is of utmost importance to have this conversation so that it does not come as a surprise later down the line. It does not necessarily mean that they will require a full arch surgery again, but that small revisions may be required as they progress through life. Revisions are an inconvenience, but not a disaster. Our in-house technical team at Evodental allows us to carry out repairs at the same appointment, so the patient never has to be without their fixed prostheses.
TREATING AN OLDER PATIENT
At the other end of the spectrum, patient PR, a more elderly patient should not assume that they are too old to undergo full arch implant treatment. If a patient’s dentition and oral health is negatively impacting their quality of life, then it does not matter what age they are. For to socialise with friends and family is priceless. Ultimately this is a major surgical procedure and the patient must be prepared for this.
The recovery period and adjusting to their new smile takes time, but everyone deserves to live their life to the fullest at any age.
Patient PR was so overwhelmed with the outcome and has now started dating again at 77.
You can see from his post-op OPG that 6 implants in the maxilla were not possible in this particular case but with 5 we have achieved excellent primary stability and good AP spread, so 6 implants are not always necessary to provide a great outcome.
At EvoDental, we are constantly evolving and have now upgraded our bar designs, using new and improved biomaterials to ensure we are always providing the best for our patients.
RECOGNISING WHEN PROSPECTIVE PATIENTS ARE UNSUITABLE
Finally, we have the patients who attend wanting implant work, such as patient RR, but after assessment we realise that extracting their teeth and placing a full arch fixed implant prosthesis would not be the right solution for them.
With good bone levels, a restorative treatment plan with single implants would be a more appropriate option. Sometimes patients say they do not want the hassle of multiple dental appointments as well as the potential for increased costs, but it is our duty to inform them of their alternative options and explain why full arch implants may not be suitable for them at this stage. At Evodental we only provide full arch implant treatment, so for patients who do not fit this criteria, we endeavour to refer them for alternative treatment.
Discussion and assessment of all cases are carried out at our weekly multi-disciplinary meetings, where both clinical and technical teams come together to ensure the patients chosen will be suitable for a full arch solution.
All must be in agreement that they fit the criteria to proceed. This method ensures that the cases are rigorously checked prior to starting on their journey with us.
Evodental carries out full arch implant rehabilitation for our patients every day, providing immediately loaded fixed prostheses.
There are very high success rates demonstrated across dental literature of immediately loaded implant treatment. The systematic review by Del Fabro et al. demonstrated that immediate loading has long term predictability with average implant survival rates of 97.4%.
The meta-analysis by Zhang S. Wang S. & Song Y also showed there was significantly less marginal bone loss demonstrated than non-immediate cases. However it is still vital for thorough case selection protocols to be carried out to provide the desired outcome for both dentist and patient in a predictable manner.
This is why it is our treatment of choice. But it isn’t our only measure of success; our main focus will always be the quality of life of our patients – at the end of the day, their smiles truly speak volumes.
REFERENCES
Del Fabro et al Dec 2019
Systematic review of survival rates for immediately loaded dental implants
Zhang S, Wang S, Song Y 2016
Immediate loading for implant restoration compared with early or conventional loading: A meta-analysis