Avoiding mistakes

In part 1 of a series, Dr. Diyari Abdah looks for ways to rise above dental implant complications

Despite the predictability of dental implants in today’s dentistry as a treatment modality instead of dental bridges or dentures, it can present many problems if not planned, executed, and maintained correctly.

The best policy is to know when to do something and when to refer — before it is too late.

There is no doubt that we have come a long way from the early days of placing an implant and waiting nearly a year before restoring it. Today, implants can be placed predictably straight after extractions. Some even restore the implant — with varying degrees of success — immediately after placement with a provisional or final restoration.

But what is the rationale for immediately placing an implant after extracting a tooth and restoring it sometimes on the same day? Why do people want everything done so fast — and do they always work, or are we just pushing the envelope? Worse is when we do this without any in-depth knowledge or consideration to the biological and mechanical factors that determine the prognosis of the case.

In reality, there is enough evidence in the literature to support the idea of immediate placement of an implant to maintain bone and soft tissue architecture as long as the case is planned properly; this treatment modality is not for every case.

Surprisingly, implants are one of the most widely researched areas of dentistry, yet people can still get it wrong at times, and the results can be short of acceptable. While there are dental practices that thrive on rectifying mistakes, we have to ask why this is happening.

Clinicians just need to listen to some experienced colleagues who lecture around the world, showing cases that had to be rectified after someone mismanaged a case at some point, and the results were not exactly as the patient desired. Even companies are pouring millions into research. Implant dentistry is a very exciting and rewarding topic for researchers and dentists alike, but who are the real winners?

The winners should ultimately be the patients, as they are the end receivers of these products; they put all their trust in them (and us). The dentist is, of course, the end user. Both dentist and patient are on the receiving end of the production line and the research around it.

The question is, Do implant companies do enough to reduce the risks of implants being mismanaged by certain “dentists”? Well, respectfully, some do. They are committed to providing good and solid education and do not allow their implants to end up in the wrong hands. But most of the education is understandably about the company’s implant range and the protocols it suggests.

Statistically, the majority of manufacturers don’t believe it’s their job to check on the operators’ surgical and restorative backgrounds before they sell their products. So who needs to make sure that the dentists possess the right skills to place implants in practice?

Without a doubt, it is the dentist’s sole responsibility to acquire the right knowledge and skills for managing these cases predictably — and making sure that they remain successful even after a long period of time.

To make cases more predictable and to achieve the desired results take many hours of study, attending hands-on courses, and critically reading and researching the available papers. What’s more, remaining at the forefront of the latest advances means exchanging ideas and attending forums. Some research results are groundbreaking, and they have certainly been used as benchmarks for many aspects of implant surgery. However, a lot of money and resources are wasted doing the same studies time and time again.

Learning to critically read these research papers is paramount if we want to filter out the
best information.

Blame game
When things do go wrong, whose fault is it? Is it always the surgeon’s fault for not following the right protocols or not paying enough attention to all the anatomical variations in relation to the restorative outcomes? Or does blame lie with the restorative and planning dentist who fails to communicate correctly with the surgeon? We have all seen cases where integrated implants have had to be removed because they could not be restored correctly. This is devastating for everyone and especially the patient.

Implant dentistry is a multidisciplinary treatment modality. Sometimes the same dentist with the right skills can provide all the solutions. Ideally, we want the best people with the best skills to do their parts in order to achieve the desired results. This is why the best policy is to know when to do something and when to refer —  before it is too late. That will be called correcting mismanagement.

Implant treatment, especially in large cases, can be tricky without a doubt, but the trick is to orchestrate the whole case correctly in a timely manner so that every step is done correctly and skillfully in the right sequence.

Whose responsibility is it to make a case successful?
More and more companies are offering lifetime guarantees on their implants with a “no matter what” return policy. Does this mean that their implants are so good that they have very few returns? Otherwise, why would they offer a lifetime guarantee? And what about the patients? Do they also play a part in making an implant successful and prolonging its lifespan? Or is it entirely the responsibility of the surgeon and the restorative dentist to make sure that they choose the right implant for the right site, under the right conditions, and using the correct protocols laid out by the respective implant manufacturer? Should these practitioners never mix these protocols with other forms of dentistry they have been doing for years or with other manufacturers’ protocols in case of multi-system users?

Problems and solutions
In this article I will touch upon some of the factors that can make or break a case.

We are all in the improving and restoring business — so the more we know, the better we become, and the more we can help our patients. Because of this, we need to constantly improve and polish our skills through lifelong learning and by being very observant, critical, and open to receiving new information.

It is not possible to cover all implant problems and solutions in this article, nor is it my intention. However, it will hopefully trigger a curiosity among some to review their protocols and do an audit to see what has or hasn’t worked, and what could be done about it. Some of the most common problems will be covered in part 2 of this series.

Avoiding mistakes and mishaps
The nature of implant dentistry is that there will be a lot of variations to bear in mind: surgical site variations, patients’ health variations, implant design and surface morphology variations, dentists’ skills variations, and so on.

The fact is that “things” will happen from time to time. As long as we follow the right indications, respect the surgical and restorative protocols and the workflow, combined with the patient’s needs, then ideally very little — or nothing — should go wrong.

It’s our sole responsibility to acquire the right knowledge and skills for doing and managing cases predictably.

But things sometimes still go wrong whether we like it or not. So why is that?

Implant dentistry is not easy. Yes, it is manageable and sometimes very predictable, but it takes skill and effort to achieve a successful end result.

The question is how we recognize the signs when something is wrong, what we do about it, and very importantly, what we learn from it, so it doesn’t happen again.

For some, one problem is enough to make the clinician anxious for a long time and avoid a situation in future.  This is understandable, but the real answer is to study more, acquire more knowledge to fill the gaps, and maybe get a trusted mentor that the dentist can work closely with. Thankfully, the majority will learn from the experience and will never allow it to happen again.

Sometimes the same problem has to happen several times before we realize that something is wrong, and a change has to be made, either to our protocol, choice of cases, or even the system used. Remember that not all systems are created equal.

Following protocol
In my years of mentoring and observing, I have found that one of the main issues people have is not following the protocol recommended by the implant manufacturer. This can obviously lead to all sorts of shortcomings and subsequent problems that could have been simply avoided by following the protocol.

This is how it goes: The dentist has been using a particular system for years, maybe placing hundreds of that particular implant, so is well experienced through practice. One day, a friendly dental rep pays him a visit to show him a new system that has all the bells and whistles. He decides the new system will make his life easier and orders 10, 20, or 30 implants with a “free” kit, maybe — all looking good so far.

Now, instead of following the new implant’s surgical protocol accurately, he becomes rather “creative” with it! So he invents his own set of protocols. While I am not against creativity per se — we dentists are creative people by nature — certain things have been laid out in a certain pattern for a reason.

It happens to most of us, and that’s fine, as long as we don’t do any harm. But a protocol is there to be followed and if, for any reason, there is an improvement to be made, I am sure any sensible manufacturer will be more than happy to listen to our suggestions.

We notice implants 2 mm above bone level when there is enough bone in the opposite direction (apically). You get the picture.

Solution follows the protocol to measure and re-measure between surgical sequences. When an implant comes out of its protective sleeve, ideally you want to use it once and not keep trying it several times because the site wasn’t prepared accurately. Guide pins are there to be used. For most implants, the site has to be prepared accurately in order for the implant to sit exactly where it’s meant to.

Some implants through their design allow the implant to create its own path, which can be a good feature. But in inexperienced hands, it could be dangerous, as there is no “bottom” to the site! In that case, the simplest thing to do is unscrew gradually, and if no vital anatomical structure has been touched, the implant could be left at a desired depth, i.e., at or just below the marginal bone level as the system dictates.

It is the “little big things” that make or break a case. But the real problem comes when they happen, and nothing is done about it — this is what leads to potential problems.

Remember, while the site is open, you can rectify anything that needs correcting. Once the flap is repositioned and closed, you need a very good reason and argument to persuade the patient to allow you in again. Just remember root canal therapy! You can correct most things while still working on it. Sometimes one simple and easily avoidable mistake can lead to partial or total failure of an otherwise successful placement.

One example is poor suturing, allowing bacteria to invade the site and leading to a less than desirable result.

Suturing is an art, and it has to be mastered. The secret is simple: Practice, practice, practice! Chose the right indication for the right suturing method, and you will have very few problems. Understanding why we suture in a certain way, using certain materials, is crucial for the overall success of the implant.

Understanding the biology behind implant placement and the subsequent treatment sequences is paramount — and how to help restore the biology by suturing is crucial. There are many good books and courses that cater for this obvious but overlooked stage in implant surgery.

Adequate healing
Fully understanding the biology and tissue behavior in the implant site is paramount for successful implant therapy. Once we understand how the hard and soft tissues behave, we can choose the right-flap repositioning technique and suturing to aid the overall healing process.

Inadequate repositioning and suturing can result in flaps not healing correctly or esthetically — or worse, allowing the hard tissue or grafting materials to be exposed, leading to partial or complete implant failure.

Implant angulation is also one of those problem areas that we can sometimes find out about too late — namely, at impression or restorative stage.

The obvious step (while still inexperienced) seems to be the use of a surgical guide, even for simpler cases. Usually there are plenty of reference areas in the mouth that could be used for aligning the surgical drills, but if in doubt, take control radiographs (although these must kept to a minimum), and use the neighboring teeth (being mindful of anatomical root variations), the occlusion table, and other anatomical features as a guide. Until then, a correctly made surgical guide is the best solution.

It is no surprise that every once in a while on the lecture circuit dentists see presentations of implants that could not be restored because of angulation problems or malpositioning.

Next time
The second part of this series, to be published in the next issue of Implant Practice US, will detail some of the most common problems in implant dentistry.