Recently I saw a patient who had undergone root canal therapy and was scheduled for a post-and-core buildup. The appointment began with a routine attempt to remove the provisional restoration placed by the endodontist; however, just touching the tooth evoked a strong pain sensation in it. Ruling out the usual suspects, perforation and/or undiagnosed/untreated canals, one is left with a likely diagnosis of root fracture, which just over 15 years ago would have presented a huge challenge in a patient whose adjacent teeth did not require dental attention.
Today, however, clinicians have the option of incorporating dental implants in the treatment plan for the partially edentulous patient, an outgrowth of their routine use in the completely edentulous patient. While an implant-retained or -supported prosthesis is a treatment modality that is likely to have a profound positive impact on the edentulous patientís quality of life, the significance of implant treatment in the partially edentulous patient should not be underestimated. The ability to replace missing teeth without the need to restore adjacent teeth results in tooth structure preservation that, in return, will ensure a better prognosis for those abutments.
However, the use of implants in the partially edentulous patient presents its own challenges. The traditional criteria for evaluating implant success are still relevant for the edentulous patient but are lacking other parameters in evaluating implant outcome in the partially edentulous patient. The integrity, appearance, and harmonious integration of the soft tissue around the dental implant and neighboring teeth are of paramount significance. (Those parameters, discounted as secondary and of minor importance by some clinicians, suddenly become more important when the patient is their own spouse or child.)
Understanding that a stable long-term esthetic outcome is not skin (or should I say, gingiva) deep, one should also understand that there is yet no predictable solution for some of the challenging clinical situations found in the partially edentulous patient. Missing adjacent teeth and/or significant hard and soft tissue deficiencies in the anterior zone remain a challenge for the clinician. When making a decision whether to restore those missing teeth and/or deficiencies with dental implants, it is clear that many unknown factors exist; the predictable esthetic outcome one expects from a single anterior implant restoration may not be as predictable for adjacent implants.
Considering the rapid pace at which our implant knowledge and techniques are evolving, it is reasonable to assume that 10 years from now we will be able to offer the same treatment with a higher level of predictability. However, not all patients can or are willing to wait for an undisclosed amount of time to have their challenging dental situation restored. The clinicianís honest presentation of the clinical challenge and the unknown factors is key here. Patients need to know that while we are able to guarantee osseintegration in many of those situations, the final appearance is a different issue. In certain situations, I will not shy away from restoring adjacent implants in the anterior zone; however, I would never give the patient the impression that this approach is a cakewalk. Providing the patient with clear information regarding our limitations and the treatment alternatives allows us to formulate a treatment plan that takes into consideration proper risk assessment, treatment alternatives, and patientsí desires and expectations.