Implant Supported Restoration: What Should You Emphasize During the Tooth try in Appointment?

Over the years, I have learned from my own mistakes.  You can be delivering first-class dentistry and yet the patient may not appreciate your work to the same level.  Patient management is very important in my line of work and sometimes it takes more energy than doing the dentistry itself.

I want to share with you some of the lessons I have learned of what should be emphasized when planning and delivering implant supported restorations.  Patients are paying a lot of money for the work and they may or may not be aware of what they are getting.  Over the years, I had patients getting upset over things I didn’t think matter.  Or that the patients were upset with their dentist when the dental work to me was totally acceptable and the patients were just not aware of what the prosthesis should look like.  Sometimes patient management starts at the time of treatment planning and not at the tooth try in appointment or even at the insertion appointment.  So here are some of my pearls.  I will separate my discussion for single unit or short span anterior implant restoration from full arch implant restoration.

1/For Single Aesthetic or Short Span Implant Restoration:

Start managing their expectation before any treatment begins.

  • I look at the space available to see if it is proportionately balanced to the rest of the dentition. Recognizing the limitation of biology, I will inform the patient what the final restoration may look like in comparison to the patient’s original tooth.  Will it be more narrow, wider than the original tooth?  Will it be shorter or longer than the original tooth?  How likely will it have an interdental papilla?  This will depend on the surgical placement and I will tell the patient the worst case scenario and the best case scenario so he/she knows the range of possibility, including the use of pink prosthetics.   At this point, the patient may not fully understand what all this means but I plant this information now so I can revisit these issues at the time of restoration.
  • I also like to highlight the imperfections of the other teeth now so the patient can see how imperfect or how perfect their teeth are. Should they want to have additional treatment, I will start the conversation now.

Provisionalize the anterior implant restoration

  • When it’s time to restore the case, I always provide the anterior implant case with a temporary restoration. In this way, I can objectively discuss the issues previously addressed during the treatment planning stage with the patient.  I can also test out the patient’s acceptance and understanding of these issues.

Beware of the following:

  • Black triangle: I see patients who are not happy with their restoration even when the implant procedure is executed in the most perfect way.  Most of them will say they don’t like the shape of the crown when in fact they can’t accept the presence of the black triangle.  Due to the path of insertion, position of the implant or the location of interproximal bone, the presence of a black triangle may be inevitable.  They think the emergence profile can be altered to eliminate the black triangle.  Sometimes you can but sometimes you can’t.  If the patient has high aesthetic demand and high gummy smile, beware of this risk and inform before you start
  • Screw access hole: If you are restoring the mandibular teeth, depending on the location of the arch, the access hole of a screw retained crown can be considered unaesthetic.  Be sure to be addressing that at the time of treatment planning if that is an issue.  If the patients tells me they don’t like the access hole appearance, I may consider a cement retained restoration instead.

 

If I have a reasonable patient, my system of managing their expectations at the treatment planning stage, then again at the provisional stage, helps me tremendously that, at the time of final delivery, it goes a lot more smoothly.  The patient already has an idea what it should look like given the space available and understand the unavoidable imperfection that comes with respecting nature and biology.

 

2/Full arch implant case

In managing a full arch implant case, I have a very similar system of managing the patients’ expectation.  I start managing their expectation at the treatment planning stage, then again at the provisional stage and finally at the definitive stage.

At the treatment planning stage, I will review the following:

1/Will there be any pink prosthetics? How much?

2/What is the transition between the prosthesis to the gum line like? Will there be a space to facilitate cleaning? Or minimal space to improve phonetics and aesthetics

3/How will it be cleaned?

4/Will the implants be splinted or restored as single units?

5/What type of long term maintenance should be expected?

6/What type of provisional restoration will the patient have and how will that be different from the permanent restoration in terms of appearance, texture and cleansability.

7/What is the reparability of the definitive prosthesis?

Again, it can create information overload if you try to address all these issues at the first visit, along with all the other surgical, technical, logistic issues related to delivering full arch implant procedure.  But throughout the many phases of treatment, I will repeat the few important concepts so they hear it on multiple occasions.

Beware of the following:

Whether it is at the provisional stage or tooth try in stage:

1/Make the patient aware of the location of the dental midline.  Whether it will be matching the opposing arch, the facial midline or not.  Sometime these details don’t matter to the patient or they don’t notice it until at the very end.  Train their eyes so they know what to expect.  I have learned that the patient may appear not to care about these details until at the final insertion stage, which is often more costly to address than at the provisional stage or at the tooth try in stage.

2/The polished surface is important.  The patient does not know how well your implants are placed but they will feel the buccal and lingual contour of the prosthesis.  If it is very different from their own teeth, which it can be if there is significant resorption or that you are intentionally improving the occlusal relationship.   Patients gauge your work by how they can feel in their mouth; how their lips, cheeks and tongues drape over this surface.  Take the time to address this issue before they notice it themselves.  Explain to them the rationale for how this surface is developed.  Test that out in your provisional stage so you can discuss it more objectively with the patient

3/The intaglio surface is just as important.  I always get patients that just received their full arch treatment elsewhere how much they dislike the intaglio surface….how it is a food trap….how it is difficult to clean.  Well, all these problems come with the prosthesis they selected but they often tell me that they were not told about this problem.  So to avoid an unhappy patient, if you are treatment planning full arch implant restoration, take the time to address how the intaglio surface will affect their food impaction, their ability to clean and the long term maintenance that should go along with this type of prosthesis. And remember sometimes you have to repeat this information a few times before they actually understand it fully.

 

As a prosthodontist, I don’t see people within the normal distribution of the Bell curve.  I see the outliers: people requiring very difficult dentistry or they are just difficult to manage.  So sometimes, even with your best efforts, you just cannot win.  But I hope these little pearls can save some of you a few headaches if you learn to manage the patient well at the very beginning.  Thank you so much for reading!