The profile of the dental implant patient in my practice has gradually evolved over the years. Twenty years ago, most of the patients who were referred to me are those who are missing one or two teeth and looking for a replacement with fixed teeth. I would place the implants and then refer the patient back to his dentist for restoration with a crown. The increase in demand for dental implants and the wide availability of dental implant courses has resulted in many general dentists learning how to perform the surgical part of implant dentistry in addition to the restoration. Today, most cases can be managed by general dentists, without the need to refer to a specialist. While I still have a lot of “simple” cases, I certainly see more complex cases. When does a case become complex?
Before we think of complex, we need to know what is simple. Simple cases, are cases whereby the missing tooth has been missing for a while already. The bone and gum have healed completely into a well-contoured edentulous ridge with adequate bone to support an implant and good gum health through which the crown will emerge. The patient is in good health, with no underlying medical condition and able and willing to maintain good oral hygiene.
Complex cases are basically those that are lacking in some or all of the above conditions. I’ll group them into the following categories and discuss each in a separate individual post in the following weeks.
Types of complex cases
- Limitation of soft and hard tissues
This is probably the most common type of complex case. Teeth that were lost through trauma are often associated with lost of supporting hard and soft tissues, ie the jaw bone and gum. Teeth that were lost a long time ago and replaced with removable dentures are also associated with significant shrinkage of the bone and gum rendering their replacement with implants more challenging. Patients with these deficiencies need to be undergo additional surgeries to augment the shortage in order to have dental implants. Procedures such as bone grafting, gum grafting, distraction osteogenesis etc, can help to restore the tissue bed to an optimal state so as to house dental implants.
- Proximity of vital structures
There are vital structures in the vicinity of the jaw bones and in some cases, they may get in the way of implant placement. In the lower jaw, there is a nerve that runs within the bone, extending from premolar to the back of the jaw. This nerve provides sensation to the lower jaw as well as the lower lip. When the nerve gets in the way of the implant placement, we need to move the nerve aside so that the implant does not damage it. In the upper jaw, the sinus lies just above the roots of the upper teeth. Some sinuses dip down into the jaw bone and may be perforated during placement of dental implants. Sinus lifting is a procedure that move the sinus lining upwards to create space for the placement of implants.
- High aesthetic demand
Teeth, especially front teeth, are not just for biting but serve an important aesthetic function as well. Replacement of upper front teeth can be particularly challenging even in patients with ideal hard and soft tissue. This is particularly the case with patients who has vertical maxillary excess and gummy smile.
When the patient present with very compromised dentition, it is sometimes better to extract all remaining teeth so that the replacement prosthesis can be made without being constrained by the existing natural teeth that may be lost in the near future. However, reconstructive surgery of the jaw and dentition is a lot more complex because all anatomical references are gone and the restorative dentist need to be able to guess-estimate the ideal position of the implant to be placed.
- Limitation of time
Singapore is a regional medical hub and I see a lot of patients who fly in from the region. These medical tourists do not have a lot of time in Singapore and there is also a limit to the number of times that they can fly in. For this group, we need to maximize what we can do in each trip and to reduce the number of trips that the patient needs to make.
- Medically compromised
Modern Medicine can keep many patients who are afflicted with a debilitating condition relatively healthy. However, doing an invasive procedure on these patients may disturb this balance. For example, a patient who has certain heart conditions may require long term anti-clotting medication to prevent blood clots from forming and clogging up the arteries. However, dental implant surgery may result in excessive bleeding in this group of patients. Coordination with the patient’s cardiologist is needed to ensure safe surgery without compromising the patient’s pre-existing medical condition.
- Failed implant for redo
As more and more implants are placed, the absolute number of failure will rise even if the percentage failure remains the same. Patients who has had failed implants coming in for a redo are always at a higher risk of failure than the first time due to less favourable condition such as deficiency or irregularity of the tissue bed as well as the compromised healing ability due to scarring secondary to the earlier failure. Alternative treatment approaches may needed to improve the chances of success the second time round.