What Is Your Backup Plan For Your Anterior Implant Restoration?
I had two interesting cases in the past two months which made me rethink how I should manage my anterior implant cases. One case involved two implant crowns 11 21 that I restored a few years ago. The patient is a very busy health care professional who does a lot of public speaking and a lot of travelling. I saw his name on my schedule and the note left by my staff was “chipped implant crown”. Immediately, I had a sinking feeling that it means there is porcelain chipping on these crowns and the only way I can repair porcelain predictably is to redo the porcelain in its entirety. Then I started thinking what my temporary solution would be while the implant crowns are being repaired or redone in the lab. I started panicking because I know this patient would not want to go back to wearing a temporary denture. The day the appointment came, it was everything I had imagined. There was porcelain chipping and I started discussing the logistics of how this needs to be done. Then he told me he had this model with him and wondered if I can do anything with it. It was a working model I must have given to him when I delivered the two implant crowns few years ago. Inside, it had the previous set of screw retained implant crowns that were done by the previous dentist. When I saw that, there was an instant relief because I told him that I can remove his current implant crowns and re-insert the old ones while we discussed the logistics of how this repair can be done. In this case, the patient had time to think about his options. Even though the aesthetics of the old implant crowns were not ideal, they would be much more comfortable then to give him an acrylic partial denture while we wait for the crowns to be made or to be repaired.
The other case I saw was very similar. A very busy professional lawyer has an anterior implant crown where the abutment screw has fractured. This was a referral from a neighboring dentist. Again, immediately I have to do a lot of digging: what type of implant it was, what treatment options are available, what type of components do I need to order and what type of temporary solution I have for him. In this case, I have to provide a temporary acrylic denture for him because there was no model of any sort or any type of screw-retained restoration ready for him. He was not very happy knowing that he had to go back to wearing a temporary denture.
These two cases were similar in that the front implant crowns had to be redone in one way or another. The difference is that the first case had a backup plan already and the other didn’t. So I started thinking that all anterior implant cases should have a backup plan. I see enough anterior implant cases that I recognize there is a certain level of emotional attachment for the patient to be losing their front teeth. No one wants to walk around with a missing front tooth. No one wants to walk around with a flipper in their month. Almost everyone wants their front tooth restored as soon as possible.
Few years ago, I made it my standard protocol that all my implant anterior cases be restored with a set of temporary restorations prior to any definitive restorations. Even if the patient had an acrylic partial denture, by the time the implants are ready to be restored, I always plan for a set of temporary implant restoration in my treatment plan. At the time, I plan it like that not to intentionally have a backup solution but rather for me to have something tangible to evaluate the esthetics with the patient and to manage or condition the soft tissue after second stage surgery or soft tissue grafting surgery. It also allowed me to evaluate my patients’ expectation so I can deliver a more predictable definitive implant restoration for my patient. And whenever the case was finished with a permanent definitive restoration, I routinely give my temporary implant restoration back to my patient to keep it as a backup. Now that I think about it, all my patients with anterior implant restorations have a backup plan set up already. But to take a step further, I should give my patient the working model I had with the implant analogs and impression copings used. This arrangement will immediately save the future treating dentist and the patient the effort and time from finding out the information should there be a prosthetic complication requiring treatment from these implant restorations.
In recent years, there are many ways to manage a failing front tooth with an implant restoration. Traditionally, restoring a failing front tooth may mean staged treatment involving extraction, bone grafting, soft tissue grafting, implant placement and implant restoration involving several months of healing in between these stages. Currently, there is also an approach with immediate extraction, immediate bone grafting and immediate implant placement and provisionalization. Both methods have their place in practice and it is a matter of knowing what works better in the patients’ mouth based on their clinical condition.
No matter what approach is applied to your patient, when the treatment is finished, there may be follow up treatment required years later on these implant restorations. The patient may have moved or the implants may be discontinued and the prosthetic components may not be as readily available. In any case, I think all patients with anterior implant restorations should have a backup plan available. For me, from now on, I would provide my patient a temporary implant supported restoration ready along with the working model containing the implant analog and impression coping used. I would tell my patient to put this in a safe place and guard it like a piece of expensive jewelry. I think this will provide the patient a peace of mind and facilitate any future treatment should it be required at any time in the future.
I see enough prosthetic complications in my practice that perhaps some of you may think this is not necessary. But to me, it really is a reasonable service we should all provide for our patients. With the advance of CAD/CAM technology, this becomes even easier to be storing digital files of the case and to provide a copy for the patient as well. As a treating dentist of prosthetic complications, I always appreciate my referring dentists who take the time to provide me the relevant information of the case. It simply saves the patient so much time and money so I can provide a more predictable solution in a timely fashion.
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