Implantology is one of the fastest growing fields in dentistry, expected to expand at a rate of 20% annually over the next two years alone. Only about 10 and 8 percent of prosthodontists and general dentists respectively place implants, indicating that the vast majority of dental implants are placed by surgical dentists (oral & maxillofacial surgeons or periodontists) while the ensuing prosthetic treatment is performed by restorative dentists. This situation obviates the need for precise communication between the surgeon and generalist or prosthodontist, if satisfactory outcomes in this process are to be achieved.
There are three main parts to this communication: referral by the restorative dentist (with patient education); subsequently providing the information needed for the case to the surgical dentist; and pre- as well as post-operative reports from the implantologist to the restorative dentist. Each step is critical to the overall success of this type of treatment and must be carried out with foresight and diligence.
Referrals
After a comprehensive examination has lead to a treatment plan in which the need for dental implants has been diagnosed, the restorative dentist’s referral to the surgical dentist follows. A conscientious referral entails much more than filling out an oral surgeon’s or periodontist’s pad and handing it to the patient. The restorative dentist must also educate his or her patient as to the need for implant placement and why this treatment modality is the best option for that patient. Understanding by the patient breeds ownership of the problem to be treated and ultimately case acceptance. Patient education software is an excellent way to arrive at this awareness and helps give the patient confidence in his or her eventual choice. This education should include a review of the possible need for bone grafting, sinus lift, distraction osteogenesis and more implants than originally planned for should the surgical dentist find conditions where bone morphology dictates the occurrence of any or all of these contingencies.
It has been my experience that it is most gratifying to both the patient and the surgeon when their consultation together yields no undue surprises. To this end, I refrain from quoting my patients any fees for implant restoration until the implantologist and I have arrived at an agreement on what the final scheme for this phase of treatment will look like. Under no circumstances do I attempt to quote surgical fees.
Information
Along with preparing the patient for the surgical consultation, the restorative dentist will need to give the surgeon certain information before and after this consultation to facilitate a thorough evaluation and accurate placement procedure. I have a standard form that I use to convey this information that includes tentative implant numbers as well as locations, the final prosthesis or prostheses to be used and the system I would prefer to employ. The surgical dentists I work with require a preoperative panoramic view of my patients and in some cases (at the surgeon’s discretion), 3D cone beam imaging also will be needed. If the restorative dentists has a panorex machine in his or her office and is using a digital radiography system, these images can be emailed to the implantologist’s office on referral. If the referred-to specialist is also using a digital system, phone conferences between the two dentists can occur with each manipulating the image on their own systems for parameters such as value or contrast to enhance the image and allow for an improved visualization of the clinical situation.
Fabrication of a surgical stent by the restorative dentist should be standard operating procedure in all implant cases, period. I do not work with surgeons who do not use stents, even in the instance of a single implant between two natural teeth. While it is the surgical dentist who is responsible for proper placement and osseointegration of the implant, it is the restorative dentist who should be in control of its orientation because this directly affects the restorative process thereafter. The restorative treatment plan dictates implant orientation and the surgical stent guides orientation. For this reason, there may be occasions where the specialist may want to see a stent in the mouth before finalizing his or her surgical approach. If he or she sees that the orientation denoted by the stent is incompatible with existing alveolar topography, pretreatment augmentation or a change in the restorative protocol may be in order. As the oral surgeon who places the majority of my implants says, “If the bone isn’t there to place the implant where the restorative treatment plan prescribes, then you make it there.”
Communication
After the surgical consult, it is imperative for this doctor to communicate his or her findings to the restorative dentist. In this way the conditional restorative plan already arrived at can be confirmed or modified in terms of prosthetic considerations, implant number and system type. For example, can the single-tooth case be done immediately or not? If so, what system will work best? If healing is needed post extraction prior to placement, what type of provisionalization will be needed? If the site in question has been long edentulous, is there a system that is more efficient than others in this situation? All these questions should be answered before surgery takes place so that both dentists are on the same page with the case and the surgical doctor can proceed with confidence knowing he will be giving the restorative doctor just what is needed.
After the surgery, the surgeon also must provide the restorative dentist with a summary of the procedure and its prognosis, including the quality of bone actually found on entry (which can some times differ from what is anticipated according to the pre-surgical workup), the number of implants in fact placed, estimated healing times as well as the loading sequence. Armed with this information, the restorative doctor can finalize his or her overall treatment plan, make appropriate appointment schedules and order needed implant components. Finishing restorative treatment thereafter can then carry on smoothly. I also like to provide my surgical doctors with a report when restorative treatment is completed, even though they will see the results in most cases at their normal postoperative follow-up visits with these patients.
When a team approach is used to perform tooth replacement using dental implants, accurate and effective communication between the restorative and surgical doctors is imperative. Without it, the surgeon may not be fully aware of what to deliver and in turn the restorative doctor may not have what is necessary to achieve the intended result. This will lead to a less than optimal final outcome, frustration on the part of both dentists and a loss of confidence from the patient. When such communication does take place, a superior end result can be realized that is a win-win-win situation for everyone involved. And isn’t that what we are all looking for in working with our colleagues and treating our patients?