the most important part of implant planning
I'm always amazed how often surgeons only look at bone when planning implants and spend little time looking at the future restoration. Carl Misch used to say that no one wants implants, they want teeth. This patient was a second opinion for an implant to replace #11, he was already scheduled for the implant in another office, but his wife is a patient and asked him to see me first. The surgeon told him this was a very straight forward implant case.
The first thing I do on every implant case, even before taking a CBCT, is scan the edentulous site, draw a margin, and get a crown proposal. If I see a problem with the proposal, the patient and I can have a conversation about how to move forward. This patient had plenty of bone for his implant, but he has some choices to make about creating room for the restoration. The point is, we can talk about it before surgery. I'm a firm believer in anything you tell the patient before treatment is an explanation, anything after is an excuse.
Great post Dan. I have not thought about doing it this way prior to referral to surgeon. Thanks.
That's so true, Dan, but I've also seen it go both ways with non Cerec dentist referrers.
I've had problems on cases like these where I start talking about alignment, spacing, and tooth size discrepancies that show up in the crown proposal.
The patient sees the issues clearly on the screen, then says "why didn't my dentist tell me about this?".
I have a number of ways of dealing with this in a professional manner, so we discuss it and move forward, but it's still awkward.
The third side is the patient. Many times they've told their GP that they don't want orthodontic treatment or the type of prosthetic treatment that the patient in your scan could use to get a better anterior guidance and occlusal relationship. When one of the teeth eventually needs extraction (like #11 in your case, no surprise), they often still don't want to look at even the rest of the social six. They want their hole filled, that's it.
I'll set up a treatment conference with the GP and send screenshots to show the issues, and we try to find the best solution, even if it's not implants.
Thanks for posting this case, it really shows problems we all deal with every day.
So, if this patient asked you to just place the implant and crown for #11 only, what would you do?
I agree absolutely with you, Daniel.
On the other hand most cases are straight forward. But it is necessary to check all important aspects before.
But also with this method alone you cannot be absolutely safe.
I just had an implant bridge that brought a problem that I did not see arise, especially as a relative Cerec newbie.
Had to extract #13 that carried a bridge from #11-#14 (#14 was cantilever, #15 and #16 missing)
Placed implants at #12 and #14 with.
Everything went smoothly but when doing the bridge I had minimal thickness issues on both implants because the vertical was too small. I needed 0.5-0.7 mm more.
I had already reduced the crowns in the opposing arch and was confident it would be enough clearance. But...
On 5/14/2019 at 4:09 am, Douglas Smail, OMFS said...That's so true, Dan, but I've also seen it go both ways with non Cerec dentist referrers.
I've had problems on cases like these where I start talking about alignment, spacing, and tooth size discrepancies that show up in the crown proposal.
The patient sees the issues clearly on the screen, then says "why didn't my dentist tell me about this?".
I have a number of ways of dealing with this in a professional manner, so we discuss it and move forward, but it's still awkward.
The third side is the patient. Many times they've told their GP that they don't want orthodontic treatment or the type of prosthetic treatment that the patient in your scan could use to get a better anterior guidance and occlusal relationship. When one of the teeth eventually needs extraction (like #11 in your case, no surprise), they often still don't want to look at even the rest of the social six. They want their hole filled, that's it.
I'll set up a treatment conference with the GP and send screenshots to show the issues, and we try to find the best solution, even if it's not implants.
Thanks for posting this case, it really shows problems we all deal with every day.
So, if this patient asked you to just place the implant and crown for #11 only, what would you do?
Doug, I hope your referring docs know how lucky they are to have you, I'm sure you've bailed out more than a few.
I'll post a screen shot when I get to the office, but I altered the proposal of #11 in front of the patient to show a short tooth in crossbite and said you can have this or ortho (I didn't give him the option to prep #22 because I thought it would be too aggressive of a prep). He liked my initial proposal better and has an ortho consult scheduled for next week.
