In the last instalment of the treatment journey for our patient NC, we had established the overall dental status, and that both upper central incisors, due to an extremely poor prognosis, required extraction.
NC had also informed us that he was keen to avoid a partial denture at any stage, if at all possible, and it was established that the treatment option of choice was to be two dental implant-retained crowns. During this initial consultation and discussion, the fundamentals of the treatment plan were formulated.
A detailed treatment plan letter was prepared, something we do for all cases involving the provision of dental implants. This letter should always contain the following:
- a summary of the current situation, often presented as a problem list
(Treatment Planning in General Dental Practice, Bain C, Churchill Press)
- an explanation, if possible, as to why the current situation has occurred
- the variety of possible treatment options
- a description of what a dental implant is and how they are to be used in that particular case
- any possible requirements for hard or soft tissue augmentation
- reassurance that although it involves surgery, and that this is relatively minor, some swelling, discomfort and bruising should be expected for a few days post-operatively
- a sequencing of the treatment stages, including an estimate of the time from beginning to end
- any risks and complications
- the implications of no treatment
- what is expected of the patient following completion of the treatment, including any follow-ups and aftercare
- the likely costs and settlement terms.
- Two copies are produced and a paragraph accepting all the terms and conditions added, which is countersigned by the patient. This forms the consent for the procedures planned.
In the case of our patient, NC, the following treatment plan was formulated:
1. Remove two upper incisor tooth roots and fit provisional restoration
2. Two months after extractions, place two implants, in UR1, UL1. Bone augmentation to be carried out simultaneously
3. Following a suitable healing period, assess for need for soft tissue augmentation
4. Four months after placement, uncover implants and attach healing abutments
5. One month later, begin construction of provisional crowns on implants
6. Two weeks later, fit crowns on implants
7. Once we are happy with the shape, size, contour and gum condition, fabricate and fit the definitive crowns
8. Regular reviews and maintenance with a suitably trained hygienist.
In this particular treatment plan letter, special reference was made to the local and systemic risk factors for peri-implantitis and the fact that this was a case where there was an increased chance of this being a problem somewhere down the line, when taking into account the history and reasons for extraction.
Informed consent having now been obtained, NC then attended an appointment where impressions were taken for the provisional restoration and, fortunately, the very mobile11 was not removed with the impression… This was a very real concern as the 11 was that mobile!
The dental laboratory selected for this case was Dental Technology Services (DTS), and following a discussion with Sandy Littlejohn, it was decided to construct an adhesive bridge out of reinforced GE composite, using the palatal surfaces of the two lateral incisor abutments, for the bridge to be adhered to.
One week later, NC returned for the extractions and fit. On informing the patient that we did not have a removable denture, but an adhesive bridge, he was delighted. Any time one can deliver something in excess of a patient’s expectations is a positive and will enhance the dentist patient relationship; this was one such instance.
Following buccal and palatal infiltration with Lignocaine (2 per cent with 1:80,000 adrenaline), the two upper central incisors were gently removed. Normally, I would be using a combination of periotomes and luxators in order to preserve the bony housing. However, in this case with so much tooth mobility, it was only gentle elevation with a pair of bone rongeurs that removed these teeth.
The sockets were thoroughly debrided with hand instruments (a Lucas curette and a Columbia 4R/4L London design), to remove any granulation tissue and remnants of the periodontal ligament. Following this, the sockets were sounded with a Williams periodontal probe and in this particular case it was noted that there was the almost complete loss of the buccal plate of bone on the 11, with a smaller crestal defect on the 21.
Collagen sponges were placed into the sockets so that good haemostasis could be achieved prior to fitting the provisional restoration.
The adhesive bridge was tried in and checked for a good fit, aesthetics and occlusion. The palatal surfaces of the lateral incisors were etched/bonded with a one-stage bonding resin (G-Bond, GC) and fitted with a dual-cure luting medium (Rely X Unicem, 3M ESPE).
NC was delighted with the result and following issuing with verbal and written post-operative instructions, together with ongoing oral hygiene advice, the next appointment was scheduled.
We shall be describing the final implant planning, the use of Cone Beam CT scanning, the placement of the implants and immediate follow-up.
The patient’s perspective
I don’t know if many of you will have noticed, but using the ‘F’ word at volume – Gordon Ramsay style – tends to place a great deal of stress on your two front teeth.
Relevance? I’ve now discovered, to my enormous embarrassment, that it’s highly preferable NOT to use this expletive when you no longer have your maxillary central incisors, but a perfectly formed bridge lightly held in place by adhesive to the adjacent laterals.
Result? On being ‘cut-up’ on the M8 approach to the Kingston Bridge by a young woman determined to turn her car at right angles to my own, inches from my front bumper, I unwisely decided to remonstrate (scream) at her and include the ‘F’ word in my tirade. The instant explosion of pressure behind the teeth had, what you might have already surmised to be, the obvious result: the bridge shot straight out of my mouth faster than you can say ‘-ck’, hit the windscreen in front of me, and fell directly onto the dashboard, where it grinned back at me with a particularly amused look to it.
Instant panic. If one can be fined up to £2,000 for using a mobile phone while driving, what would the courts make of a driver steering through the early evening traffic mayhem with his knees, while using both hands to push his two front teeth back into place? I can’t imagine the sheriff accepting the plea in mitigation: “But I looked ridiculous: I had to do something!”
However, miracle of miracles. The bridge that was so brilliantly constructed by the very clever people at DTS, slipped straight back into place and my vanity was assuaged, if not my pride; the hysterical look on the face of the woman in the car next to me who witnessed everything will live with me for ever…
Now, as I have said previously, I knew the teeth had to go but I was very concerned that I was to have a plate fitted. So, when I arrived to have the failing incisors removed, the wave of relief that swept through me when I discovered that the dreaded plate was not required cannot be over stated.
When the good Dr Jacobs showed me the little piece of genius that had been devised by DTS, I could have kissed someone – clearly not with the teeth out you understand.
It may be that I face other moments of embarrassment, the adhesive does have a tendency to weaken and pressure can l
eave the bridge needing to be reset every so often. But it is so dramatically better than having the plate that I would absolutely recommend it wherever and whenever possible.
Once again, communication has been a vital factor in this stage of the process. The old teeth are gone, the new bridge is working (most of the time), and the next stage to place the implants has been explained in sufficient detail for me to maintain my high level of confidence in the man who will soon start to drill deep into my skull (I’m a journalist, I exaggerate). More drink please, doctor!
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About the author
Dental fx is based in Bearsden Glasgow and was founded by Dr Stephen Jacobs in 2006. Although dealing in all aspects of dentistry, Stephen has a special interest in implants and has been placing implants for more than 20 years.
Dental fx is a teaching centre for dentists and nurses interested in learning more about dental implants and to this end Stephen runs a number of courses throughout the year.
Please contact us for more information regarding the courses by emailing our course co-ordinator ator visit our web site http://www.dentalfx.co.uk