As the Baby Boomers age and continue to focus on active lifestyles and maintaining a youthful appearance, demographic trends will drive an increasing number of patients toward fixed implant supported restorations over the next several years. These treatments are extensive, expensive and require a team effort among the dental team of restorative doctor, surgeon, imaging specialist and lab technicians.
One of the challenges in treatment planning and beginning these cases is setting realistic patient expectations about the course and timing of treatment from the first visit until the final prosthesis is seated and beyond. A second significant challenge is establishing the patient’s responsibilities for keeping appointments and for home hygiene. In our experience, it is particularly important to provide the patient (and anyone the patient involves in decision making) with an overview of the extensive planning and analysis that occurs prior to surgery since that set of activities represents a significant portion of the case expenses and takes place without the patient being present.
While the entire process is described and disclosed during the initial discussions with the patient, most patients can focus on only two topics at that point: will it hurt? and how much will it cost?
As a result, it is imperative to outline the treatment process in the written treatment plan and to refer back to that roadmap as treatment progresses.
The Treatment Process
The process consists of four phases:
Prosthetic and surgical planning
Surgery and provisional placement
Follow-ups and fabrication of final prosthesis
Phase I – Information gathering
For the patient with terminal dentition, information gathering includes impressions, photographs, video-taping mandibular motion, phonetics assessment, a comprehensive prosthodontic assessment, a Cone Beam Computerized Tomography scan, and a variety of other measurements and assessments (e.g., rest position, occlusal planes, incisal edge positions, midline, freeway space, vertical dimension, esthetic plane, gingival and tooth shades, etc.)
Phase 2 – Planning
During the second phase, a number of planning sessions are held among the surgeon, restorative dentist, biomedical engineer, imaging specialists and laboratory technicians. Decisions about the materials to be used in fabricating the final prosthesis are made (as material selection will influence implant placement and abutment selection). Waxups are made and approved, implant placement is planned, surgical guides are designed and fabricated, and the conversion denture is fabricated along with a night guard.
The most often overlooked area of planning is determining the amount of restorative space needed. Precise measurement and communication to the surgeon of the planned bone reduction is crucial. This professional communication should be by written prescription and facilitated with well-conceived surgical guides. When alveolectomy is called for, it should be visualized before surgery and outlined directly on the CBCT images.
Phase 3 - Surgery
Extractions, implant placement, abutment orientation, modification and conversion of a prepared denture to a fixed prosthesis and placement of the prosthesis as a provisional.
Phase 4 - Follow-ups and Final Prosthesis
Surgical follow-up at one week and then monthly for four months. Prosthetic follow-up (and adjustments) at one week and monthly until osseointegration has occurred. Home hygiene instruction. Demonstration and documentation of competence by the patient of home care proficiency. Photographs and impressions. Fabrication and delivery of the final prosthesis. On-going hygiene appointments (6 times annually for the first two years).
In most cases, surgery takes place within 30 to 45 days of acceptance of the treatment plan. Seating of the final prosthesis generally occurs 6 to 9 months post-surgery. If the final prosthesis is zirconia, the timeframe is somewhat longer due to technical sequencing and to allow more time for tissue maturation as zirconia is difficult to modify.
Given the duration of these treatments, it is important and helpful to maintain frequent communication with the patient, particularly in the weeks leading up to surgery and during the time needed to fabricate the final prosthesis. Having someone on staff designated as responsible for keeping the patient informed is optimal. In addition to on-going communication, we provide the patient and anyone the patient involves in decision making the opportunity to view a brief PowerPoint presentation that reviews the treatment process, answers frequently asked questions, and gives visual representation to words and concepts.
In addition to outlining the patient’s responsibilities in the written treatment plan, he or she is also asked to sign a contract detailing those responsibilities and acknowledging that additional fees will be incurred for further treatment required that results from failure to maintain appropriate home hygiene (for example). Items covered in the contract include keeping scheduled appointments, not smoking, chewing or otherwise using tobacco, following post-surgery dietary and hygiene guidelines, wearing the supplied night guard, maintaining home hygiene, making and keeping professional hygiene and checkup appointments, etc.
While these process steps are second nature to the professional team, they are new territory for patients who are undertaking major dental restorations. By carefully outlining the process, setting clear expectations for patient responsibilities and communicating frequently with patients and anyone they’ve involved in decision making we can increase patient satisfaction and avoid misunderstandings.