A dental implant is a robust solution used by dentists to support a dental prosthesis such as a crown, bridge or denture to act as an anchor for orthodontic treatment. Within Dental Protection subscriptions, implants are defined as: “The placement and/or restoration of a missing tooth with an osseointegrated dental implant where the implant is placed within the tooth-bearing bone, ie, in the mandible and maxilla only.”
These implants can be used in oral surgery, maxillofacial surgery, prosthodontics and restorative dentistry or orthodontics. The aim of implant dentistry is that the restoration provided will be in harmony with the existing dentition.
The cases currently seen by Dental Protection tend to be around inappropriate placement, poor treatment planning, consent and unrealistic patient expectations. Due to the fact implant dentistry almost always falls under private dentistry, patients are usually less willing to tolerate any unfavourable outcomes.
The planning stage is of the upmost importance when a patient is having a dental implant. You should record the patient’s main concern and the reasons for the implant placement. Make sure you take the time to get to know your patient and discuss any alternative treatment options first.
You need an up-to-date medical – and dental – history to refer to during the planning stage, to ensure the plan is right for the patient. History of uncontrolled medical conditions, such as diabetes, that can affect the implant treatment, and records of medication such as bisphosphonates or any other medication that the patient is taking should also be noted and considered. If the patient has any dental history, such as chronic, untreated periodontal disease, then an implant may not be appropriate, and this all needs to be assessed and discussed with the patient as it may affect the overall plan.
As part of the treatment plan, you will need to screen for, assess and manage any relevant risk factors the patient may have, such as whether they are a smoker. The use of appropriate preoperative investigations such as radiographs and suitable CBCT scans will allow you to check for any other potential hazards that could crop up during an implant treatment.
The bone quality and quantity of the implant site is very important during implant placement. The option of a bone graft and its implications needs to be evaluated and discussed with the patient. Check the patient’s occlusion and how this will be affected by the proposed implants and the suprastructure.
In addition, the final prosthesis and the purpose of the implant placement should be carefully evaluated as part of the treatment planning. As a clinician you must always have the end result in mind, as this is what the proposed implant treatment is planning to achieve.
Consent it something that crops up time and time again, because it’s a crucial part of any dental treatment involving a patient. If you do not have appropriate consent, then you shouldn’t proceed.
Make sure the patient is aware of the purpose of the implant and the chances of success. They should know about any likely effects or risks, any possible alternative treatment options available that do not require implant placement and the need for preventive and postoperative care. Time frames should be taken into account and all potential limitations of the treatment need suitable explanation. These discussions with the patient must be documented in the records and, if possible, reinforced with a letter to the patient.
Dental practitioners cannot assume that because a patient has previously consented to a similar procedure, this creates open consent on future occasions – they must consent to every individual procedure carried out.
Effective communication between dentist and patient is important. Understanding the patient’s expectations at the planning stage is key to a successful outcome.
From the very beginning it’s important to close the gap between meeting a patient’s expectations and what is actually possible. The best way to approach this is to assume the patient has no background knowledge whatsoever, and think what you would want to know if you were them.
Check what your patient would like to achieve with the treatment and that they understand the risks and what the likely outcome is. Discuss all the limitations with the proposed treatment and what alternative treatment options can be offered. This way you can ensure you are on the same page when it comes to treatment results and any postoperative care required. It is important that you feel comfortable discussing this with your patient and explaining gently if their expectations cannot be met. Do not be afraid to mention if things do not go to plan and the reasons why this has happened. If possible, offer remedial treatment but do not get trapped in a prolonged remedial treatment plan that is beyond your capabilities as a clinician.
It’s important to make sure that you have the appropriate training and only carry out treatments within your competency levels. If the implant treatment plan is too complex for you and your skills, consider appropriate referral. Ensure that the adequate bone support is there for the implant and all stages of implant placement are clearly documented in the records.
The use of surgical stents is recommended for complex procedures. You should always have in mind the final restoration when you place the implant, so you will need to refer back to your study models and the restorative treatment plan at the placement stage.
The implant position should be identified and suprastructures should be designed in a way that allows for sufficient access when it comes to regular diagnosis via probing, along with personal and professional oral hygiene measures.
If the procedure isn’t going to plan, then it’s important to recover the situation the best you can, which may mean referring the patient to a specialist. Tell the patient what to look out for after the placement in case of potential nerve injury, and make regular follow-up appointments in the days after the procedure to check on the placement of the implants.
A complex case of implant failure
A young adult was referred to a restorative dentist for placement of implants at the UL23 area. Both the lateral incisor and canine had been subjected to trauma when the patient was a child, and there was resorption of the UL2 root and a fracture of the apical third of the canine root.
The clinician planned to place two implants at the UL23 area and restore with crowns. A bone graft was discussed due to the poor quality of bone at the UL23 area that was diagnosed with a CBCT scan. The unrestorable UL23 was extracted but bone graft was not placed after extraction.
Three months later the dentist assessed the area and although he mentioned that there was potentially a need for bone graft, this was not planned or performed. Two weeks later he placed two implants – one at the UL2 and one at the UL3 area. The implants were placed too close to each other, due to the softness of the bone and the lack of adequate buccal bone that was identified at placement. After osseointegration, when it came to place the crowns, it was not possible to place two separate crowns at the area, so two small conjoined crowns were placed.
The patient was not happy with the end result aesthetically and he could not clean the area adequately. He raised these issues with the dentist. The dentist tried to adjust the crowns to improve their appearance and the access for interdental brushing. Due to the continuous problems with plaque accumulation, there was peri-implantitis at the area, and bone loss around the implants occurred. Both implants eventually became mobile and, in addition, the central incisor was affected, as the bone around it resorbed as a result of the periodontal problems.
Eventually both implants were removed, along with the central incisor, and the patient had a bone graft and two implants placed at the UL1 and UL3 positions to support a three-unit bridge.
Success or failure with implants is not usually dependent on any single factor, but on a combination of factors. Careful treatment planning, assessment of complications and appropriate remedial treatment reduces failure by eliminating those cases that are unsuitable for treatment.
This article was first published by Dental Protection in January 2019.