Dental Implant Singapore- complex "re-treatment"

In Singapore, the profile of the dental implant patient is changing. It used to be that only affluent people with a high dental awareness (what some dentists call dental IQ) have dental implants to replace their missing teeth. Today, it is no longer the case. Implant dentistry has become mainstream dentistry. 25 years ago, there was only one main implant brand in Singapore. They practically controlled the number of dentists providing that service because they only sell implants to those who have attended their courses, for which there was a waiting list. Today, there are more implant brands here than I care to count and they are always recruiting dentists to attend their courses and buy their products. Competition is a wonderful thing. It has made dental implants widely available to patients at a significantly lost cost than it use to be. But along with that, there are also more problems. We are now beginning to see the next phase of implant dentistry in Singapore.

In my practice, I begin to see more patients coming in for treatment of their implant complications. Some problems can be easily solved. For example, if a patient developed infection around an implant, then we simply remove it, let it heal and then place a new implant. Sometimes, a bit of bone grafting is needed to replace the lost bone structure. A bit tedious, but nothing too difficult.

However, some cases are a bit more complex. For example, a patient with an implant replacing the upper central incisor that has developed some bone resorption and exposing part of the implant. This is an aesthetic nightmare. It is a difficult problem to solve because the implant is well integrated into the bone and removal requires removing the bone around the implant. However, after the removal of the bone and implant, there will be not much bone left and replacement with another implant will be very challenging. Multiple surgeries will be needed. First, grafting with an autogenous bone graft is done to increase the bone mass. This will recreate the width of the bone but not the height. After the bone graft has consolidated, distraction osteogenesis is done to increase the bone height. Distraction osteogenesis is a process whereby bone is cut and then stretched bit by bit on a daily basis until the desire height is reached. A few months later, an implant can be placed. Some soft tissue grafting may be needed to improve the aesthetic outcome prior to completing the treatment with restoration with a crown. The whole re-treatment may take many visits over 6-12 months to complete. Even then, the prognosis is still guarded.

The other type of re-treatment cases that is a real challenge are the full arch implant cases. These are cases whereby the patient has six to ten implants placed in one jaw and a fixed prosthesis cemented onto them. When some of the implants develop problems, re-treatment is often an arduous task. The prosthesis needs to be cut out to remove the infected implants. Thereafter, bone grafting is again needed to rebuild the bone before replacing the failed implants. A temporary prosthesis is needed during the treatment period before re-doing a final prosthesis when the new implants have integrated. The process may take 6-12 months to complete.

Re-treatment is always more difficult than the first time. The hard and soft tissues are compromised by the first surgery, making handling more difficult and healing less efficient. As such, it is important to have a team of specialists to manage this. A prosthodontist is needed to design a new plan and to transition the patient through the treatment phase by using a provisional prosthesis. This provisional prosthesis is also a diagnostic prosthesis as it provides information to construct the final definitive prosthesis. An oral maxillofacial surgeon is needed to remove the implants, rebuild the bone and replace the new implants. A good laboratory technician is needed to fabricate the prosthesis based on the design of the prosthodontist.

Some of these problems are preventable, others are not. Treatment philosophies change with time based on the scientific studies that emerge. While we strive to practice based on scientific evidence, not everything can be scientifically proven. A large part of clinical practice is an art. Two different dentists doing the same treatment on similar patients can have very different outcomes. Dentists should continually update themselves on new proven scientific treatment approaches and collaborate as a team to deliver the best outcome. Patients should spend some time to research which dentist or team is best suited for their needs.