Drs. Burton and Jeffrey Melton advocate a relationship with the edentulous patient based on co-treatment planning and communication. The doctor and patient should conduct a "dual interview" to discuss needs, desires and expectations. This approach will ensure a superior result, they argue. The patient consultation video you'll find here demonstrates this approach. In addition, an animation illustrates the unique bone resorption issues facing the edentulous patient and his or her clinician.
Dr. Burton Melton has practiced dentistry in Albuquerque and Santa Fe, N.M., since 1972. He received his undergraduate degree from Brigham Young University, his DDS from Baylor College of Dentistry and his Diploma in Prosthodontics from the University of Missouri School of Dentistry. He has lectured in the U.S., Japan, Korea, Mexico, Taiwan and England. He has also appeared as a guest lecturer at dental schools across the U.S.
Dr. Jeffrey Melton graduated from Baylor College of Dentistry in 2003. He received graduate diplomas in periodontics and prosthodontics as well as a master's degree from the University of Texas Health Science Center at San Antonio. Dr. Melton recently completed his board certification in periodontics and is preparing for completion of his board certification examination in prosthodontics. He practices in Albuquerque and Santa Fe, N.M., and lectures extensively.
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Once the teeth are lost the jaw bones resorb over time. The amount of this resorption can be divided into four stages. The amount of bone resorption and, therefore, the amount of hard and soft tissue that will need to to be replaced will impact the prosthetic options available to fully restore the edentulous patient into function.
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One of the most critical and life-altering services we provide as clinicians is caring for the edentulous patient. The functional and esthetic concerns the edentulous patient confronts are unique and challenging. A traditional approach to treatment frequently provides only an acceptable outcome, rather than a superior result. This article will address a better way to go about patient care. A future article will expand on providing treatment for the edentulous patient once a treatment plan has been developed.
When a patient's teeth are removed, alveolar bone immediately begins to resorb and continues to do so over the lifetime of the patient. The degree of resorption has everything to do with the difficulty and, sometimes, marked limitations of what a clinician can do to restore a patient to function with good support and satisfactory appearance. Clinically, there are two ways to go about providing patient care. Typically, the clinician describes the problem(s) to the patient, gains case acceptance, makes financial arrangements and then starts treatment. "Starting" treatment involves applying the techniques or "tricks" the clinician has learned to produce a result: prosthesis, denture or "plate." The clinician hopes the new result will be better fitting and more attractive than — or at least as good as — the patient's previous prosthesis or dentition.
However, there is another, better way to go about this process. Decades ago, during an epochal time in dentistry, Dr. Robert F. Barkley, the "father" of preventive dentistry, revolutionized the dental profession with his innovative approach. Redefining the doctor-patient relationship, he stressed the need for doctor-patient co-diagnosis and co-treatment planning.
Building on Dr. Barkley's philosophy, we advocate that proper patient care must
begin with a thorough "dual interview," during which the doctor interviews the new patient, and vice versa, to gain a better understanding of the patient's needs, desires and expectations. During this interview, the doctor and patient should discuss the patient's health and life circumstances (i.e., limited time, limited finances, inadequate health).
This initial interview is used to create provisional and definitive treatment plans, offering the patient levels, or "layers," of care. Price ranges for these treatment plans should also be discussed, in order to help the patient select the appropriate layer of care. These layers of care enable the patient to accept treatment beyond what is acceptable or satisfactory. Instead, an appropriate, definitive treatment will be achieved that will include excellent esthetics, a secure and truly functional prosthesis or restoration, clear speech and an enhanced quality of life. The selected treatment plan should marry the patient's wants and wishes to what is clinically possible and affordable. Working within these layers of care allows the patient to decide, level by level, whether they need or want a more advanced layer of care.
This more comprehensive approach enables the patient to fully understand his or her current dental health and what he or she can achieve. Under this model, the doctor and lab work together to fulfill the patient's expectations in a way that is affordable for the patient. This allows everyone involved — the patient, the doctor and the laboratory technician, who have been charged with making the impossible or improbable a clinical reality — to achieve the desired result.
How It All Begins: Data Gathering and Analysis There is an axiom in dentistry: "Never treat a stranger." The idea is the doctor should spend time talking to the patient to understand his or her desired result and decide whether he or she is going to be able to help the patient.
The patient interview should, at the very least, cover the patient's wants, needs and expectations, followed by the doctor asking the patient, "Have you thought of a budget for your dental care?"
The patient should also undergo an orofacial examination as well as a review of his or her health history. Photographs with and without the prosthesis should be taken and impressions made for diagnostic casts.
A well-made maxillary denture is the perfect diagnostic tool for a subsequent implant-supported overdenture, implant-supported fixed prosthesis or hybrid prosthesis that is fixed as well as removable. This diagnostic denture is the architectural model for the final result and a stepping stone to the patient's next layer of care.
At the time of the esthetic trial denture, both the patient and the doctor should be satisfied with the prosthesis in terms of esthetics, phonetics and occlusal function. If the doctor has done his job well, the initial prosthesis is the practice of fine dentistry, allowing evolution to the highest level of technicality and facilitating a better quality of life. (Note: Several protocols are acceptable to make a trial/diagnostic denture and/or a definitive denture. This will be the subject of a future article.)
After the trial denture is made, the patient and the doctor each have the opportunity to terminate treatment, if either or both believe the continuation of treatment will not lead to patient success. (Dr. Earl Pound was a leading proponent of the trial denture before the definitive or "best" treatment plan is provided.)
There is always a "terminal point" in care, at which the clinician has done the best he or she can to please the patient.
Anything beyond this only frustrates all parties, sometimes causing anger or, in extreme cases, litigation brought by the unhappy patient. To avoid this, the doctor and the patient should agree on an acceptable midtreatment termination fee before treatment begins.
Once the patient and the clinician accept the trial denture, it can be processed into a Scan Appliance. The type of Scan Appliance should be based on the type of radiology to be utilized. In the past, a panoramic film was standard. Now we can use Cone Beam Computerized Tomography (CBCT) to create 3-D images. The CT data is imported into implant planning software and the case virtually designed.
The information gathered can then be utilized to develop a treatment plan for the patient. The case illustrated here will be used to demonstrate fixed and fixed-removable prosthetic options.
Case Study The patient in this case is a young, attractive female. She is edentulous in the maxilla, with a full complement of mandibular teeth. She desires a fixed ceramic restoration, if possible.
After the initial patient interview, the patient's records are reviewed and photos are taken. These images plus the digital plan and diagnostic casts are used to determine the limitations of treatment.
The doctor can do his own treatment planning using a
CBCT scan and planning software.
The doctor can send the scan of the patient to a third party, who will do the treatment planning and the surgical guides. (This frequently leaves the doctor out of the loop.)
The scan can be sent to a planning center, where the planning experts schedule a Web conference with the doctor to co-diagnose and co-treatment plan the case. (The clinician doesn't need his own software in this scenario.)
Treatment Options The first treatment option is eight implants for a segmented restoration (eight implants supporting four 3-unit bridges) (Fig. 1a, Fig. 1b). It is best for Stage I and Stage II ridge resorption patterns. This option does not present any restrictions to the clinician or the laboratory, but its high cost can be restrictive to the patient.
A second treatment option is six or more implants broken into one to three fixed-bridge segments. The positions of the implants are based on the arch form, the anterior-posterior spread and available bone. For a square arch form, the most anterior implants are placed in the canine positions (Fig. 2a, Fig. 2b). For a tapering or U-shaped arch, the anterior implants are placed in the incisor region. This option offers increased stability, especially where vertical bone loss exists. Permanent or removable bridgework can be used, and hard or soft tissue grafting may be required. Splinting dramatically increases stability in all three planes (X, Y and Z axes). With this option, porcelain fracture can be catastrophic, unless there is an element of retrievability so the units can be repaired versus having to be replaced.
The third option is "All-on-4/6" (fixed bridgework on four to six implants) (Fig. 3a, Fig 3b, Fig. 3c). This option is a splinted but removable restoration, usually screw-retained, that requires four implants — maybe more, if space allows. It has a titanium framework with denture teeth and pink acrylic. No bone grafting is required. Often implants are immediately loaded with a fixed provisional followed, after adequate healing time, by a one-piece fixed restoration.
A variation of the third option is a Premium Hybrid (sophisticated fixed-removable; titanium framework with individual all-ceramic crowns) (Fig. 4a). This is the same as the first option listed, but all implants are connected by a CAD/CAM titanium framework that has a gingival mask (pink composite) and individual ceramic crowns. More extreme bone loss requires creating the appearance of the patient's original hard and soft tissue. This option provides a high level of esthetics, but due to the advanced technology required, it is considerably higher in cost for the laboratory, doctor and patient. Typically, eight implants would be required to support this type of prosthesis (Fig. 4b).
Conclusion The doctor-patient relationship is critical. Doctor-patient co-diagnosis and co-treatment planning provide a method to determine the appropriate layers of care. Through proper case set-up, treatment options can be developed to match the patient's wants and wishes to what is clinically possible and affordable to the patient.
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