Implant update for GDPs
The continued growth of implant dentistry will undoubtedly mean that as general dentists, we will regularly come across patients who either require implants or have been treated with implants.
The demands of our patients are changing and, although the UK has lagged behind the rest of Europe in the number of implants placed, the rate of growth is still expected to be 18.6 per cent in 2012 (MRG).
As dental professionals, it is expected that we offer the full range of treatments available and we need to be aware of the dental implant option and the unmet demand that exists in the UK. Patients will seek advice from their general dentist, who has skilfully looked after their health for a number of years and has built up a trusted relationship. It is the patient’s own dentist who will often drive this discussion and is best placed to advise the patient on the best course of treatment.
Dental implants have been shown to be predictable with many advantages over a more conventional approach. With this comes the need for further training and information so that we can pass this knowledge on to our patients and be able to contribute to their treatment. Unfortunately, there is very little undergraduate training in the UK, while postgraduate training is lengthy and inevitably costly. This article aims to give an overview of implant therapy, the terminology and the stages involved, so that dentists are more confident when discussing implant therapy with their patients.
Stages of implant therapy:
Treatment discussion and options
This is no different from any other treatment discussion and is dependent on the individual clinical situation and the patient.
Take, for instance, a common occurrence such as a failing post crown on an upper lateral incisor tooth. The options for the patient include:
1. no treatment
2. restoration with a partial denture
3. restoration with conventional or resin retained bridge
4. restoration with an implant retained crown.
The disadvantages of the more traditional options are numerous and include destruction of adjacent sound teeth, food trapping, the need to remove the restoration for cleaning and possible periodontal problems related to dentures.
The implant option has the advantages of being a fixed restoration while maintaining the alveolar bone and integrity of the adjacent teeth. We often perceive implants as the expensive option and while the initial outlay is high, implant therapy has been shown to have a longer-term cost benefit when compared to conventional fixed bridgework1.
These factors all stack in favour of the implant-based restoration being the treatment of choice for our patients (Figures 1 and 2).
Patients will have differing views on their treatment and the demands of each patient will naturally vary. It will often be dependent on their personality, their views of dental health and the part this plays on their general wellbeing. Patients will have concerns before embarking on an advanced course of treatment. Common questions include: Will it be sore? How long does it take? How much does it cost? Who carries out the treatment?
These concerns will vary as patients respond differently to the prospect of losing a tooth. For some it will be devastating and will impart a sense of loss while others will simply find it a minor inconvenience. However, it is the duty of every dentist to offer the patient a full range of options and it is essential to be able to justify the reason for the treatment proposed2. Stating that “we do not offer that treatment here” is not justification for not offering the implant option. A full discussion of the patient’s options is likely to determine their treatment choice.
For many patients, a replacement tooth – which doesn’t affect other teeth, maintains alveolar bone and looks and feels similar to the natural tooth – is the treatment of choice irrespective of financial outlay.
So what next? The classic option is to refer to an implant dentist who carries out all of the treatment and returns the patient back to their dentist once treatment is completed. Certainly a straightforward way of working, especially if, like many colleagues you are busy treating patients and running a business.
A newer way of working is for the patient’s own dentist to be involved in the implant therapy. The patient is referred to the implant dentist to carry out the surgical aspects of the case and the referring dentist then restores the implant. This requires a close working team relationship between the referring dentist and the implant dentist and often is of benefit to all parties involved.
The patient will gain from accessing the surgical expertise of the implant dentist, with the convenience of attending their own dental practice for the restoration. The GDP gains from being involved in implant treatment, which brings with it an increase in knowledge, professional satisfaction and financial gain.
Assessment and treatment planning
The discussion that has already taken place with the patient’s own dentist forms part of the assessment process and is integral to the ongoing consent process. X-rays, study models and investigations such as CT scanning will be carried out to assess the feasibility of implant therapy and to provide a treatment plan. This can be a lengthy process, ensuring that the patient is presented with a well thought-out plan that they are fully comfortable with.
Tooth extraction and ridge preservation
The amount of bone available at the implant site is key to the treatment proposal. Before embarking on an extraction, it is of benefit to be aware of the replacement option and plan accordingly. Once we know that the implant is to be placed, then atraumatic extraction is essential to preserve the surrounding alveolar bone. A careful approach with the use of periotomes and luxators helps to maintain the bone levels around the socket.
Often, but depending on the individual case, there will be a period of time to allow the hard and soft tissues to heal sufficiently. During this time, the patient will wear a temporary restoration. It is important that the temporary restoration does not impact on the healing site and, as such, patients are often provided with temporary restorations not normally seen in general practice such as a hybrid bridge or rochette bridge (Figure 3).
Due to the lengthy nature of implant therapy, these temporary restorations are often worn for a long period of time. They can, in fact, be used to guide the restoring dentist on ideal tooth form, emergence and tooth position.
If the bone is deemed to be deficient after extraction, a number of options are available to augment the site for implant placement. Again, this will depend on the individual case and can include bone grafting, sinus grafting, ridge expansion and GBR (guided bone regeneration). The implant dentist will, of course, advise on the best course of action.
At the appropriate time, the patient will undergo implant surgery. It is certainly possible to place an implant at the time of extraction. This will have the benefit of preserving the bone and reducing the number of surgical visits for the patient; however, it is only indicated in certain circumstances.
Once the implant has been placed, a cover screw is fitted to seal the internal chamber of the implant while the implant integrates. The soft tissue is then sutured down so that nothing is visible in the mouth. The patient will be reviewed regularly after surgery to ensure adequate healing.
Once the implant has integrated (normally three to six months after placement), then the implant can be exposed and the patient undergoes the second stage of implant surgery to expose the head (top) of the implant. A healing abutment/sulcus former (Figures 4 and 5) is placed which holds the soft tissues and shapes it re
ady for an impression. The healing abutment can also be placed immediately after implant placement, so negating the necessity for a second surgical procedure.
Once the implant has integrated and the soft tissues have matured, the healing abutment is removed and an impression is taken of the implant and transferred to the lab. This impression is then used to choose the appropriate abutment and fabricate the crown. An abutment is a cylindrical connector, which is screwed into the internal chamber of the implant (Figures 6 and 7). The crown is then made to fit the abutment.
There are various types of abutments, including stock abutments, cast abutments, milled abutments and CAD/CAM abutments. A variation on this is to fit a transitional acrylic crown on the abutment, which is easily altered, with the aim of shaping the soft tissues around the implant to ensure the correct contours and papillae formation. It is feasible for a patient to wear this acrylic crown for a number of months.
The final implant crown is then made and cemented over the abutment. A temporary cement (such as TempBond) is usually used so that the restoration can be easily retrieved. Another type of implant crown known as a screw-retained restoration is commonly used, whereby the crown is screwed into the internal chamber of the implant. This type of crown can be identified by a small filling on the occlusal surface of the implant crown, which covers the access hole to the retaining screw.
The patient will be returned to the referring dentist for regular examinations and hygiene treatment. Regular reviews with the implant dentist are needed to ensure the health of the implant.
Implant dentistry is certainly a rewarding field to be involved in and the benefits to our patients are there for all to see. The growth of implants is certain and with it will come pressures on the GDP to cater for this need. It is hoped that this article will give those not yet involved in this type of treatment some valuable background knowledge.
About the author
Dr Tariq Ali BDS (Glas) DipImpDent RCS (Eng) graduated from Glasgow University in 1998. He has been involved in implant dentistry for the past eight years and has trained at the Royal College of Surgeons England, attaining the FGDP Diploma in Implant Dentistry. He is involved in mentoring and accepts referrals for implants at his practice in Bishopbriggs, Glasgow (0141 762 3954).