Stop, collaborate and listen – a collaborative approach with dental implants

Stop, collaborate and listenPavandeep Khaira discusses how multi-disciplinary team meetings ensure the best possible outcome for the patient.

Repetition of a certain skill leads to muscle memory over time. In 1993, Anders Ericsson wrote a paper called: ‘The role of deliberate practice in the acquisition of expert performance’. He concluded that 10,000 hours of quality practice in a given field gives a higher level of performance.

At Evodental, repetition is a part of daily life. By limiting the treatment we offer to full arch dental implant rehabilitation only, the focus on obtaining the best possible outcomes for patients using specifically full arch implant retained prosthetics is at the core of our ethos.

This focus allows the team to brainstorm ideas, clinical steps and concepts. It also allows the team to critically analyse the evidence and develop an implementation protocol. This results in the workflow evolving to accommodate best practice and emerging evidence.

An area of recent evolution has been the development, testing and implementation of a digital workflow. One that simplifies the clinical and technical steps required to deliver a full-arch implant rehabilitation. Introducing this has:

  • Increased efficiency and predictability of the outcome
  • Reduced chairtime
  • Eliminated steps that most workflows could not manage without, such as:
    • Pre-operative impressions
    • Model articulation
    • Diagnostic wax-ups
    • Fabrication of prosthetics for ‘conversion’ after implants are placed.
Figure 1: The patient’s dentition pre-treatment

Collaborative approach

Critical to the success of this workflow is collaboration of the entire clinical and technical team, which occurs during a weekly multidisciplinary team (MDT) meeting. This includes a detailed discussion, prosthetic design, and surgical planning – using a facially generated treatment approach to ensure good aesthetic outcomes – for every patient scheduled for the upcoming week.

For those patients with upcoming appointments for the fitting of their definitive prosthetics, the clinical and technical teams collaborate to finalise the digital designs for the subframes and super-structures of the prostheses. All designs are approved by the responsible clinician prior to manufacturing taking place.

The rich discussions and debate that take place at the MDT meeting have ensured that all clinicians at Evo have a deep understanding of the technical processes and complexities. While all of the dental technicians appreciate the surgical and prosthodontic nuances to full-arch implantology.

The meeting also allows the overall complexity of a case to be determined to ensure the patient is looked after by a team of an appropriate skillset and minimises the risk of crucial details being overlooked at the assessment stage.

  • Figures 2 and 3: Pre-operative radiograph with use of X-Resin Flow radiopaque silicone on the denture to aid in diagnostic set up

Overview

A 65-year-old male, EM, attended with significant problems relating to his masticatory function due to old removable prostheses and few natural teeth, all of which had an extremely poor prognosis due to periodontal disease.

He had decided to look at fixed rehabilitation using dental implants and was not interested in a removable option.

As with many patients who have a terminal dentition, he was desperate to undertake treatment due to the limiting influence his oral health was having on his life.

Medically EM was hypertensive, under good control with statins and beta-blockers. Otherwise, the medical history was unremarkable and the patient was a non-smoker.

Comprehensive examination and planning

A comprehensive examination using a facially generated treatment planning approach and a psychological assessment (OHIP-14) is the cornerstone of our treatment planning philosophy. This ensures the treatment is justified based on being able to not only secure a patient’s oral health, but provide a measurable improvement to the patient’s quality of life.

The workflow in treatment for EM was greatly beneficial. The patient had grade III mobile teeth, which would have been difficult to impress using standard techniques. Such mobility of teeth would also prevent accurate data collection with an intraoral scanner due to the moving teeth preventing accurate ‘stitching’ of images.

It came as a real relief for EM who had prepared himself to lose teeth in the process of having initial impressions taken.

Figure 4: Provisional plan based upon MDT meeting

Treatment options

Treatment options discussed for EM included:

  • Dual arch clearance and fixed implant retained rehabilitation using immediate implants and pterygoid implants
  • Dual arch clearance, bilateral sinus lift and delayed implant placement and loading
  • Periodontal treatment and keeping two teeth with the understanding the prognosis for these teeth were not good; teeth would need replacing with a removable prostheses. Although this is a treatment option that we do not offer, and would require a referral to an external dentist, the team is aware of all treatment options and these are offered to patients regardless
  • Due to the abundant residual bone quantity and quality, EM was not suitable for a zygomatic approach; all patients are informed zygomatic implants may be required in the future if a ‘rescue’ is required.

Figure 1 illustrates the initial state of the EM’s dentition. It was noted that the denture provided EM with good upper lip support. The tooth mould was of appropriate shape and size for his face. The lower teeth were pathologically proclined and met his upper denture in a class 3 edge-to-edge position and pushed his lower lip forward.

Due to the possible need to place the pterygoid implants using a trans-sinus technique, and the atrophic bone in the premaxilla and anterior mandible, the team determined the case to be of higher surgical complexity.

Prosthetic issues

In addition to provisional surgical planning, the team aimed to troubleshoot potential prosthetic issues prior to surgery. Such technical discussions include:

  • Anticipated AP spread. In particular, the team assess the lower arch and position of the mental nerves, and whether implants can be predictably placed distally to these or whether we should place the implants between the mental foraminae
  • Vertical and horizontal discrepancies, which may cause space or mechanical issues. The team considers the expected final thickness of the prosthesis and whether there will be any issues with hygiene
  • Occlusal design, OVD, lip support and alveoplasty. The basis of the individual treatment of each patient derives from skeletal classification. Also, the appropriate occlusal scheme is designed through current occlusion and facial architecture. This means there is no ‘cookie cutter’ approach
  • Assessment of patient phonetics, based upon a video recording taken at the time of the comprehensive examination. This is an important step for the team, hereby an assessment of how the patient forms their words is undertaken. This ensures any alterations to incisal edge position or thickness, or arch form are less likely to have an impact on phonetics.

Surgery

With the digital workflow, no provisional prostheses were manufactured prior to surgery. No intraoral bite registration was required. EM’s treatment was seamless and the primary treatment objectives achieved were:

  • Removal of all teeth and subsequent excision of granulation tissue with degranulation burs
  • Alveoplasty to ensure adequate prosthetic space and a flat interface to aid in a hygienic prosthetic fit-surface contour
  • Use of Tapered External-Hex Implants (Southern Implants, SA) which feature a unique co-axis platform for sub-crestal angle correction, and a machined surface to resist bacterial adherence and peri-implant disease
  • High primary stability and engagement of cortical plates for sustained implant stability for the duration of the integration period
  • Ensuring adequate keratinised tissue around the implants
  • Optimising load distribution by utilising pterygoid implants and therefore eliminating cantilevers.

Milled graphene-infused polymer provisional prostheses based upon the design agreed at the multi-disciplinary team meeting, fitted directly to the interface of the multi-unit abutment on the implant.

Figure 5: Final outcome, I modified implant positions intra operatively to optimise AP spread

Patient outcome

Figure 7 shows the patient with their provisional milled PMMA prostheses. Note the improved appearance and hiding of the transition line above the lip line, thus preserving aesthetic outcome.

No occlusal adjustments were necessary at the time of fitting EM’s provisional prosthesis; which is also a hallmark of a workflow that does not rely on intraoral bite registration at the time of surgery.

The occlusion and phonetics felt comfortable straight away because the joint position and tongue space were the same as his pre-operative situation.

Most importantly though was the patient’s confidence levels. It rose immediately upon seeing his reflection and the new smile looking back at him.

In summary

Figure 6: Pre-operative photograph showing inadequate tooth display, part edentulism and irregular contour and colour of remaining dentition

Traditionally, the most common way to deliver immediately-loaded implant prosthetics involves a pre-fabricated denture that is retro-fitted to the implants following an intraoral bite registration procedure that can be quite challenging. Particularly as an extensive surgery involving edentulation and alveoplasty can remove the anatomical landmarks necessary to ensure the denture sits in the pre-determined position, at the pre-determined OVD.

The Evosolution eliminates the uncertainty and relative unpredictability of such workflows, without resorting to surgical guides, which would increase the complexity and cost for the patient. As well as preventing the fluidity of decision-making processes that is necessary for complex surgical reconstructions.

Finally, I think it’s critical to obtain a collaborative approach between clinical and technical colleagues in order to achieve a predictable outcome.

With emphasis on diagnosis and planning rather than the separation of surgical, prosthodontic and technical duties that you often see in full-arch.

Figure 7: Patient post-treatment

To book a free open day with Evodental, visit www.evodental.com/evoexperience.

This article first appeared in Private Dentistry magazine. You can read the latest issue here.

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