No–I will NOT be silent…
This week I attended a continuing education course at the dental association that was truly upsetting. The course took the form of a professionally designed video. As the course unfolded, I felt as though I was watching the last nail hammered into the coffin of my profession. There seems to be no standard for what is presented in courses.
My younger colleagues have no idea what standards were in place when I joined the dental profession, so they are totally oblivious to the trajectory of where it is going. From what I can see, continuing education seems to be more driven by corporate interests than in the past. Corporate entities only care about their bottom lines, not in actual patient outcomes. As a doctor, I am most concerned about outcomes because I truly care about my patients. I want to see them return year after year for the hygiene visits and watch my work last in health.
The course centered around the treatment of one patient. This patient presented with missing teeth, abnormal wear and broken down clinical crowns, an abnormal jaw position and loss of vertical dimension. The remaining teeth were actually in good shape, with good bone and adequate root length—an excellent foundation for restorative dentistry.
Restorative dentistry and appliance therapy to verify the correct jaw position would have been the ideal treatment choice–certainly the least invasive with the most predictable outcome. I have done many such cases over the course of my career. Typically, full coverage restorative dentistry patients go through a phase of wearing temporaries made to ideal architecture and plane of occlusion to verify the correct jaw position and occlusion. The patient is eased into major restorative changes to ensure comfort and proper function before any permanent dentistry is made. Attention to detail in this manner takes time but has a very predictable outcome.
Sadly, the patient was not offered this treatment option and this choice was not discussed. The course presenter just assumed that course attendees would agree that the teeth were unsalvageable. The patient’s case was worked up for invasive surgical treatment to extract all the teeth, place the implants (four in the upper arch and four in the lower arch), and insert new teeth made to a new occlusion in one day! Two full arches of teeth were designed and fabricated in advance of the surgery on the computer to fit on implants that would be placed by computer-generated stents. There are so many things that can go wrong with this overly invasive and drastic treatment that I don’t think the outcome can have predictable longevity. But many practitioners like this concept because treatment duration is short with minimal visits—and highly profitable.
The patient was sedated and anesthetized and all the teeth were extracted—upper and lower. The bone had to be shaved down further to accommodate the implants, which were going to be placed according to the “All-on-Four” protocol. The course did not include any discussion about the efficacy of this treatment nor did it offer any studies to demonstrate case longevity with this protocol. The protocol seemed largely experimental to me.
Many red flags popped in my head as the treatment was presented:
- The treatment was overly invasive and drastic. Such treatment has the potential to do great harm. In my opinion, this type of treatment is unkind and does not allow the patient to adapt gradually to major restorative changes. “First do no harm” is the oath doctors take for good reason.
- There was no consideration of biomechanical factors that can cause the entire case to fail. Dr. Carl Misch, one of the great researchers in the field of implant dentistry, explains that: “the most common causes for implant-related complications are centered on biomechanical stress. Thus, the overall treatment plan should (1) assess the greatest force factors in the system and (2) establish mechanisms to protect the overall implant-bone-prosthetic system.*”
- The implants were actually placed at odd angles and were of varying lengths. The angles were such that it was clear that the implants would be subjected to forces that were not aligned with their long axes. Dr. Misch says that
“Mobility of an implant…can develop under occlusal trauma. However, after the offending element is eliminated, an implant does not return to its original rigid condition. Instead, its health is compromised, and failure of the entire implant system is usually imminent.”
- The upper and lower arches were restored with an occlusion that was largely guesswork. There was no temporary phase to allow the musculature to relax and accommodate the new jaw position. Muscles do not relax immediately when the occlusion is changed. An analogy is that if a person has a tack in his shoe and develops a limp to avoid injuring his foot, the limp may not go away when the tack is removed. I have seen accident victims experience a change in occlusion from muscle spasm that does not revert back to normal by itself.
If the patient continues bruxing, which contributed to the wear of the original teeth, great damage to the restoration and the implants themselves is possible. Here’s what Carl Misch had to say about implants and bruxism:
“Forces from bruxism are often the most difficult forces to contend with on a long-term basis. These forces commonly lead to marginal implant bone loss, unretained abutments, and fatigue fractures of the implant fixtures or the prostheses. A bruxing patient is at higher risk in two ways. The magnitude of the force increases because (1) the muscles exert stronger forces and (2) the number of cycles on the prosthetic components is greater as a result of the parafunction. Eventually “something” must give if bruxism cannot be reduced in intensity or duration. No long-term implant system is without complications in patients with severe bruxism.”
- The full arch restorations formed large superstructures that not only replaced the missing teeth, but the missing bone and gingiva as well. It seemed to me that the implants might be overloaded and inadequate to support such large superstructures. Carl Misch explains that:
“When bone has ideal strain, the bone remains organized and load bearing. When the strain is greater, it may be in a pathologic overload zone, which causes bone loss. Therefore, the hypothesis that occlusal stresses beyond the physiologic limits of bone may result in strain in the bone significant enough to cause bone resorption is supported from a cellular biomechanics standpoint.”
- The superstructures were difficult to clean. There was no discussion about hygiene and how the patients would be able to clean under the superstructures, which were really dentures screwed into implant fixtures.
- The prostheses were made of zirconia, a hard metal that has no “give” to it. Breakage is a distinct possibility. It is very difficult to repair breakage on this type of prosthesis. Dr. Carl Misch notes that:
“The implant system receives greater force and is more at biomechanical risk than a natural tooth. The implant system includes the occlusal porcelain on the crown (which may fracture), the cement or screw which retains the prosthesis (which may debond or loosen), the abutment screw which contains the components (which may loosen), the crestal marginal bone (which may be lost from pathologic overload), the complete implant-bone interface (which may result in mobility and failure) and the implant and prosthetic components (which may result in fracture).”
- The implants were immediately loaded. The most predictable approach for implants is to allow them to fuse with the bone for 3-4 months before loading forces on them. There is some evidence that immediate loading can work, but this practice is largely experimental. Here’s what Carl Misch had to say about immediate loading after his extensive research:
“The surgical and initial healing phase for implants is primarily related to biological aspects of healing and is very predictable…Although the initial healing of the implant has very high success rates, an implant may fail shortly after it is loaded with the prosthesis. Before failure, the implant appears to have rigid fixation, and all clinical indicators are within normal limits. However, once the implant is loaded, the implant becomes mobile, most often within the first 18 months. This has been called early loading failure…Early loading failure is most often related to the amount of force applied to the prosthesis and/or the density of the bone around the implants, both biomechanical factors…It should be noted that biomechanical related causes of failure are more often influenced by the dentist than biological causes of failure.”
- There was no contingency plan in the event that one of the implants fails. If just one of the implants fails, the entire case is a failure and the patient is really screwed. It may not be possible to place additional implants if that happens. If too much of the ridge was lost when the bone was shaved down to accommodate the implants, it may be impossible for the patient to wear a denture. It is important to realize that it is not a given that implants are going to work or last a lifetime. I have seen implants cases fail after years of successful function for unknown reasons. The best treatment plans include a contingency in the event than an implant fails. All on Four plans offer no such contingency.
Carl Misch formulated a “Stress Treatment Theorem” from the extensive research he conducted on implant biomechanics. The theorem states that “treatment related to the science of implant dentistry should be centered around the biomechanical management of stress. Stress-related conditions that affect treatment planning in implant dentistry include the following:
(1) Bone volume lost after tooth loss (2) Bone quality decrease after tooth loss
(3) Complications of surgery (4) Implant positioning
(5) Initial implant interface healing (6) Initial loading of an implant
(7) Implant design (8) Occlusal arrangement
(9) Prosthesis fixation (10) Marginal bone loss
(11) Implant failure (12) Component fracture
(13) Prosthesis fracture, and (14) Implant fracture.
The course presenter did not even discuss any of these biomechanical factors that could result in case failure.
There is no question that the final result was quite esthetic and the outcome was a vast improvement over what the patient walked in with. However, there was no follow-up whatsoever. Course attendees had no idea if that case actually survived in function over time.
Esthetics alone is not enough to advocate for a particular technique. If the protocol has a high failure rate, is that a protocol practitioners should follow? I think not. What is the success rate for 100 such cases? We course attendees need to know this information! It is my opinion that any case presented should have at least 5-year follow-up X-Rays to verify that the treatment was successful.
It bothers me that most younger practitioners nonchalantly accept what is being presented without asking questions. When I voiced my objections during the course, I was met with cringing stares of disbelief. I could feel the daggers in my back: “Who are you to question the illustrious presenter?”
No, I will not be silent. I don’t like seeing my younger colleagues misled because they don’t have enough clinical experience to effectively evaluate what they are seeing. They are easily swayed by the prestige of the presenters and the lure of quick-fix lucrative dentistry. But they must understand that this type of treatment protocol could be a malpractice suit waiting to happen. The dental profession is doing a huge disservice by not insisting on strict standards for clinical presentations.
*Carl E. Misch, BS, DDS, MDS, PhD (hc), “The Key to Implant Treatment Plans: Stress Treatment Theorem for Implant Dentistry,” Implant Prosthodontics Monographs; Volume 1, No. 2; June 2017.
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