With four treatment options, the patient must undergo a thorough consultation with the clinician, covering each restoration type. Each treatment presentation will include the benefits and drawbacks the that particular method, risks and/or impediments associated with placement, complications that can arise after placement and daily maintenance protocols. The presentations must be clear and concise and devoid of scientific terminology that may not be recognized by the patient. To enhance understanding, it is recommended that the presentations utilize models, photographs and/or drawings representing the final product; images of previous cases can be used if they comply with all patient confidentiality regulations.
It is important for the patient to choose the most appropriate treatment method, based on their individual preferences and lifestyle. In order to achieve this ideal outcome, an open dialog between the patient and clinician must occur. This conversation should provide the patient with the necessary information to make an informed decision; the clinician’s goal is to advise the patient of their options without professional bias.
The following are the patient’s treatment options for restoration:
Root extraction, replaced by a dental implant and implant retained crown.
Tooth extraction, replaced by a full contour double sided conventional bridge.
Tooth extraction, replaced by an adhesive bridge.
Tooth extraction, replaced by a removable prosthesis. The prosthesis will be constructed of acrylic, flexible acrylic (Valplast, Sunflex) or Crome-Cobalt alloy.
Dental implant and implant retained crown
A number of research studies have confirmed the high success rates of dental implants; they are the most probable restoration method in the majority of circumstances. A 2006 study by Lekholm et al. seventeen patients that had received dental implants between the years of 1983 and 1985. Lekholm et al. (2006) analysed the survival rates, prosthesis permanency, peripheral loss of bone, complications and overall patient satisfaction. The researchers concluded that successfully fitting titanium dental implants in a partially edentulous jaw provides a strong foundation for a fixed short-span bridge. Overall, patient satisfaction was high; several patients stated that they considered the structure a piece of their body.
In 2007, Pjetursson et al. produced a study comparing the survival rates of both tooth-supported or implant-supported fixed dental prosthesis and single crowns; the study included 5- and 10-year survival rates. Five years after implantation, the study showed a 95.2% rate of survival for fixed dental prosthesis and a 94.5% rate of survival for single crowns. Ten years after implantation, the study showed an 86.7% rate of survival for fixed dental prosthesis and an 89.4% rate of survival for single crowns (Pjeturrsson et al., 2007). Therefore, implant-supported single crowns have a slightly improved long-term survival rate. The study also identified a high frequency of the following complications: (1) veneer material fracturing, (2) loosening of abutment or screw, and (3) retention loss.
1,162 patients with one absent posterior tooth, for a total of 1,377 external hex titanium implants, were monitored over a 1- to 10-year time frame in 2008 by Misch et al.; the researchers again aimed to evaluate the long-term survival rate of these implants. Overall, Misch et al. determined that single-tooth posterior implants are a viable long-term restoration method. They noted a 98.9% survival rate after 61-months of monitoring.
Another noteworthy study, conducted by Torabinejad et al. in 2015, determined a 97% rate of survival for implant-supported crowns; the research was conducted using literature reviews that allowed researchers to calculate the durability of replanted teeth and implant-supported single crowns. Compared to a long-span bridge, it has been determined that dental implants are the paramount permanent restoration option (Jivraj and Chee, 2006). Compared to a root canal, dental implants have proven to have a higher survival rate spanning four to six years (Setzer and Kim, 2014).
Mordohai et al. (2007) concluded that, “Heroic attempts to maintain teeth with poor prognosis should be questioned. Implants should not be ‘the last resort’ and only used when all conventional therapies have failed.” In other words, implants should be considered long before the teeth are beyond repair. Instead, the following considerations should be made:
Local environment,
Site-specific elements, and
Patient preferences and/or requirements (Zitzman et al., 2009).
Dental implants constructed of zirconia were analysed by Depprich et al. in 2014; the study aimed to utilize clinical data to determine survival and success rates. The researchers identified seventeen clinical studies that matched their requirements; combined, the studies involved 1,675 zirconia dental implants. Depprich et al. observed numerous complications within the individual studies, providing unreliable evidence to support their findings. As such, their study ascertained a range of 74% to 98% implant survival covering a time period of 12 – 56 months. Additional studies have suggested that dental implants constructed of zirconia are more likely to fracture in the anterior maxilla (Gahlert et al., 2012). For these reasons, a zirconia dental implant is not recommended.
Successful implantation depends on many factors. Several risks factors have been identified; patients with the following conditions can be affected:
Smoking,
Unregulated diabetes,
Periodontitis,
Bisphosphonate use,
Consumption of high levels of alcohol,
Inadequate oral hygiene,
Defects within the hard or soft tissue, and
Certain immune disorders.
The aforementioned patient does not fall in any of these categories.
Full contour double sided conventional bridge
The advantages of conventional bridges are unparalleled; this includes both double-sided and single-sided cantilevered bridge configurations. Foremost is the simple manufacturing process. With this option, the patient requires fewer preparatory appointments, sometimes limited to two, before dental surgery. Hochman et al. (2003) concluded that this fixed restoration method is preferred by patients due to better-quality outcomes and shorter recovery times; during this procedure the patient will retain the unique features of their face and smile.
The survival rates of conventional bridges, as determined by numerous studies, are good. Lindquist and Karlsson (1998) examined 164 patients twenty years after their prosthodontic procedures. The study revealed a greater than 65% survival rate for fixed partial dentures. In these cases, the most common reasons for removal were loss of retention and periodontal complications. In addition, some patients elected to remove the apparatus due to aesthetic complaints, including general wear and tear and veneer discoloration. The majority of the apparatuses that were removed were immediately replaced with the same restoration system (Lindquist and Karlsson, 1998).
Two reviews were conducted of metal-ceramic fixed partial dentures; the study included a total of 515 partial dentures (Walton, 2002 & 2003). The researcher determined that tooth-supported fixed partial dentures have an 85% rate of survival 15 years after placement; these rates are achieved when specific clinical and laboratory protocols are followed consistently. Walton also discovered high rates of failure for cantilevered fixed partial dentures, non-vital abutments and anterior abutments.
Apparatus loss due to tooth dacay, 2.6%,
Periodontitis due to tooth decay, 0.7%,
Loss retention, 6.4%,
Abutment fracture, 2.1%, and
Material fracture, 3.2% (Tan et al., 2004).
In 2005, Chai et al. investigated several 3-unit double-sided restorations and 2-unit single-sided restorations and determined their overall survival rates; the designs studied were:
3-unit fixed-fixed fixed partial dentures,
2-unit cantilevered fixed partial dentures,
3-unit fixed-fixed resin-bonded fixed partial dentures, and
2-unit cantilevered resin-bonded fixed partial dentures.
The researchers concluded that replacing a single tooth with the 3-unit fixed-fixed fixed partial denture high the highest success rates after 48-months; however, the difference was negligible.
A plethora of studies have been conducted recently that have reached similar conclusions. Following up after 13 years, Zalkind et al. (2003) monitored 51 resin-bonded fixed partial dentures. Rehmann et al. (2015) evaluated the long-term consequences of cantilevered fixed partial dentures. Finally, Creugers et al. (1994) performed a meta-analysis of dental literature from 1970 through the present day, including the clinical data associated with conventional bridges. Altogether, these researchers determined that resin-bonded or conventional fixed partial dentures are appropriate for semi-permanent restoration and may have long-term success.
Patient dialog review
The patient in question prefers to avoid full contour fixed restoration and adhesive bridge restoration; the patient expressed discomfort with the idea of reducing abutment teeth and tissues. The patient prefers to not intervene with neighbouring teeth.
Conversely, the patient considers dental implants to be a more “natural” solution for the absent teeth. Due to this, every attempt should be made to mimic the natural design of the human mouth and jaw.
When discussing the cost of each restoration procedure, the patient recognized the increased expense of dental implants. However, they consider the added expense worth the increased long-term survival and success rates provided by dental implants opposed to the other options.
The patient opted for a fixed dental implant, verses a removed restoration. The decision was based on the patients uncompromising refusal to wear a temporary apparatus, despite the wide range of options regarding materials and construction.
Overall, the patient seemed content with the decisions made concerning the chosen restoration procedures, specifically a fixed dental implant. The patient appreciated the benefits of the process and is willing to compromise concerning the risks involved. Concerning the costs associated with the procedure, the patient welcomed a lower than expected total expense.
Treatment and recovery plans were reviewed with the patient, concluding with verbal and written consent. The choice of surgeon was satisfactory and approved by the patient as well.
References
CHAI, J., CHU, F.C., NEWSOME, P.R., CHOW, T.W., (2005) Retrospective Survival analysis of 3-unit fixed-fixed and 2-unit cantilevered fixed partial dentures. Journal of Oral Rehabilitation. Volume 32(10), pages 759-765.
CREUGERS, N.H., KÄYSER, A.F., HOF, M.A., (1994) A meta-analysis of durability data on conventional fixed bridges. Community Dentistry and Oral Epidemiology. Volume 22(6), pages 448-452.
DEPPRICH, R., NAUJOKS, C., OMMERBORN, M., SCHWARZ, F., KÜBLER, N.R., HANDSCHEL, J., (2014) Current Findings Regarding Zirconia Implants. Clinical Implant Dentistry and Related Research. Volume 16(1), pages 124-137.
GAHLERT, M., BURTSCHER, D., GRUNERT, I., KNIHA, H., STEINHAUSER, E., (2012) Failure analysis of fractured dental zirconia implants. Clinical Oral Implants Research. Volume 23(3), pages 287-293.
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