The patient, a 60-year-old male, attended the practice concerned about the condition of his teeth. He was recovering from oesophageal cancer and a combination of poor oral care and post operative acid reflux had caused a significant amount of wear.
The patient had undergone a major operation during his battle with cancer and having been given the all clear was keen to improve the condition of his teeth. He was generally anxious about dental treatment but at the same time also keen to maintain his natural dentition. His oesophageal cancer had affected him emotionally and he felt that loosing his teeth would detract further from his self-image.
Assessing at the patient’s teeth on an individual basis, the upper right canine could certainly be restored, whilst the incisors would need crown lengthening for definitive restorations. The upper left canine and premolar would need significant crown lengthening and were most likely un-restorable. The patient would also need 4-6 implants, and possibly also a sinus lift to provide some form of posterior support.
An alternative approach would be to remove the remaining upper teeth and provide the patient with an immediate implant supported bridge following the All-on-4 treatment protocol. Whilst this option is more aggressive and invasive, it provides the patient with a restored dentition in one surgical visit. Not only is this faster, but it is less expensive than restoring the teeth and replacing the posterior teeth with implants. At this stage, the patient was not 100 per cent sure which way to proceed – whether to have his teeth restored or to have his teeth extracted for a full-arch restoration.
Patient management in this situation is absolutely key to achieve clinical success and have a happy patient. There were many different psychological factors affecting the patient’s decision making, and he was not in a position to commit to surgery of any kind at this stage.
After discussion with the patient, we opted to place interim composite restorations to give him the time he needed to think about the best treatment option going forward. This approach gave the patient an immediate improvement to his aesthetic appearance and provided a much-needed boost to the patient’s self-confidence whilst establishing confidence in his dental treatment. From a clinical standpoint, the composite build-ups helped to re-establish an occlusal vertical dimension while the patient took his time to consider whether he would want his teeth restored.
After a year, the patient returned to the practice for another consultation. In that time the patient had come to terms with losing his teeth, and decided he would opt for a more rapid and cost-effective treatment. A major part of the patient’s decision-making process was that he didn’t want to go through multiple surgeries and sinus lifts. Nor did he want to invest in crowns, root canal treatments and crown lengthening, especially as the prognosis was guarded for several teeth and considering there was a potential to for a single treatment alternative.
Even though a year previously the patient was very keen to keep his teeth, once he’d had time to think things through he changed his mind. This was a vitally important aspect of the initial composite build-up phase, as if we had opted for the All-on-4 treatment concept straight away, we would have been pushing him into a treatment that he might have regretted post-operatively. Unlike many of our dental restorations, extractions are truly permanent.
The treatment process followed standard protocol. The patient’s teeth were removed and bone height was trimmed conservatively to create an even residual ridge, which helps with implant placement and allows more favourable prosthodontics. Four NobelSpeedy implants were placed, with the rear two implants placed at an angle to take advantage of the greater volume and density of bone at the front of the maxilla whilst extending the implants as distally as possible.
Conclusion
It’s always difficult as a dentist, when faced with the prospect of removing teeth that are potentially salvageable. However, sometimes one has to consider the rehabilitation as a whole and sacrifice potentially salvageable teeth in order to provide the patient with a treatment that is right for them individually. This must be done with careful consideration and in conjunction with the patient’s full understanding and consent.
It is important to stress here that ‘teeth in a day’ is not ‘teeth on the first day’. Even though we provided the patient with an immediately loaded restoration, this came at the end of a long and involved process of treatment planning and consent. The All-on-4 treatment protocol is well established with considerable research, however it should not be used as a default treatment option. The dental team and patient spent over a year thinking about his options and carefully considering the path that was best for him. He concluded that he would opt for a ‘same day’ option that was efficient from a financial and surgical perspective and most importantly gave the patient the confidence to enjoy his active lifestyle