The rising tide of implantology

Implants are the buzzword in dentistry at the moment – patients want them and everyone wants to do them. The uptake of implants in the UK is far behind our European and American colleagues, but is expected to catch up with annual growth at 40% year on year. This article looks at the benefits of an implant surgical service placed directly under the GDP’s nose, and how this has increased the referrals to our mobile practice to more than 250 implants a year for each surgeon.

There are great benefits from working on a peripatetic basis – I don’t think anyone has ever come running to me for help saying the suction has just packed up, or the computers have crashed again. From a financial perspective, the overheads are obviously limited, but when you consider everything has to be available in your kit for every possible scenario, the boxes you travel with suddenly contain £40,000 worth of implants and associated paraphernalia.

There are, however, high demands placed on the surgeon who comes into practices to plan and place implants. We work in different rooms every day with different chairs, different layouts and most importantly different nurses. Fortunately, we carry everything with us so the variability of equipment quality is removed. This has been a challenge that everyone has worked together to manage. Some will scorn at the idea of nurses not being fully trained in implant surgery, but with time, patience, and the fact that we set the surgery up ourselves, this is easily overcome.

It is wonderful to be able to work with a number of different GDP’s, all of whom have different skills, interests and ideas for you to learn from. In return, we have had to “train” these dentists with regard to implant restoration. I put this in inverted commas because the necessary skills from years spent fitting crowns and bridges on teeth are frequently more complex than the implant restorations, if implants are planned correctly and placed accurately.

At the most basic level, the Bicon implant system allows dentists to simply prepare and restore individual crowns as they have done in the past. Everything goes back to occlusion, contact points and treatment planning.

Most of the dentists I work with would rather take an impression of the implant and allow the lab to prepare the abutment for them. The lab then has the abutment to work on directly, taking out any discrepancies and ensuring fantastic margins every time. Add to this the possibility of extra-oral cementation and the attraction with implants is obvious.

Compare this with trying to preserve what is left of a carious root under a crown, brittle from the root treatment, desperate for every millimetre of crown height to gain what retention you can – and you soon see where the more complex dentistry lies.

The training required is where implants can go and where they can’t. This is as big a part of the restorative planning as it is surgical. We are all taught that implant dentistry is a prosthetically-led speciality, and while this was a good argument from days gone by when the surgeon was left to his own devices to put implants into bone where he wished, there is far more concentration on the surgical positioning of implants today than there ever was.

The world of implants now revolves around the biological width, and how to trick the tissues with this contentious issue. How deep to place the implant? How far apart should they be? How much bone should be left buccally? How narrow can the implant get to go between teeth? And today’s latest and greatest implant fad – how much can you platform switch to reduce the importance of biological width. My view is to use of any implant system with a conical tapered internal connection, this will reduce or prevent micro leakage so eradicating the microgap and reducing bone loss in this vital area.

Of course, we cannot place implants where we like and we are led by the required position of teeth, but we are governed by surgical principles for the aesthetic outcome. Where there is simply not enough bone we look for boney surgical grafting, where we look for thicker tissues we look for soft tissue surgical grafting, or particulate grafting with collagen membranes.

There are multiple restorative issues such as position of contact points, crown contours, emergence profiles, linking of implants and the use of pink restorative materials. The overriding area has to be occlusion and its management, especially in bruxists. There is always a reason the tooth you are replacing has failed, and if this is occlusal (as is so often the case, always with posts!) this must be changed to prevent the failure of the implant for the same reason.

So, I believe in implant surgeons and restorative dentists who will work together rather than the encompassing term of ‘implantologist’. It is truly a shared speciality where we need to communicate effectively not only to the patients but to each other to satisfy the high patient demands.

There is a huge amount of flexibility in many of today’s implant systems, and more and more people are admitting to many ‘rules’ based on historical opinions being outdated. However, flexibility does not allow for mistakes, and we all still make these however many implants you place. It is a sad fact that there have now been five deaths in Europe due to implant surgery.

There are all the aspects of occlusion to consider, however this is no different to what should be practised with your everyday crown and bridge work. If you have the skills to do this, you have the ability to restore implants. You just need the interest and enthusiasm to learn the nuances of the implant system. Some are simple, others are not. I am not suggesting that this comes easily, and I also do not believe a weekend course will give you this knowledge (far from it), but with mentoring over cases this is not out of the realms of interested GDP’s.

The time issue is one of the costs in implant dentistry. Implants take no time to place at all, at the most 15-20 minutes. However, everything else takes a surprising amount of time. As we all know, planning cases is vital – the restorative dentist will have seen the case initially and taken study models, radiographs etc, prior to the surgeon being involved. The surgeon then takes 45 minutes to examine and discuss all aspects of the treatment. A plan is written and forwarded to the patient, who may be reviewed if they wish.

The surgery is booked for 90 minutes for most cases – time to consent, clean, set the surgery, place the implants, give instructions, write notes and sterilise before the next case. Add to this the review appointments, the second-stage surgery, impressions and fitting of crowns, plus the time taken should the implant fail, and you suddenly realise that, even with experience, several appointments can add up to a few hours.

Everyone wants to have a go at implant surgery, and with simple cases this is fine – but experience is needed to spot which case is going to be straight forward, something the implant companies never market. Without the skills to be able to offer – as a minimum – ridge splits and particulate grafts with membranes, you have to be very positive that these will not be required as you embark on a case.

Many dentists now look at CT scanning as the ‘get-out clause’ to have security in what they will find. This is obviously an aspect we use, but if you do not place implants regularly, you should not be considering cases that may require CT scanning – you should be sure you have more bone than you know what to do with.

There is a consistent pattern of referrals to us from dentists we work with. The initial days are very quiet, then one or two cases appear and the implant process starts. All being well, things grow from there. Over the next three-to-five months these cases are completed and a handful of new ones are offered. Most have been well screened but some will be unsuitable. As the number of surgeon visits to practices increase and the dentists have a constant stream of reminders that implants are available, the flow picks up pace.

So what exactly boosts the number of referrals? Is it the success of a few initial cases that reassure the dentists? Or does the fact that we are on the doorstep more often stimulate them to think more often about implants for their patients? I feel the body language of the dentist changes and influences patients to simply ‘buy’ the often overwhelming fact that on implant is the best option. Just ask yourself what you would have done if you were in your patients’ position.

There are many ways of selling something to a patient. Most dentists will understand the need to offer implants as part of all treatment plans – but there are many ways of doing this. Perhaps the dentist who never refers implants gives a different emphasis on the cost or extent of surgery, compared to the dentist who is referring 40 cases a year.

Another concern for some GDP’s is the potential litigation behind not offering implants. This lack of offer is now the highest cause of medico-legal claims in the USA today. Perhaps jotting down on the notes that implants have been mentioned will cover most claims, but what will really benefit the patient? Re-crowning those already stressed teeth and adding to the load with a three-unit bridge, or adding an implant in the middle and diluting the stress of occlusion?

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