The issue addressed in this blog post is cause for much confusion among patients that come to our Barcelona dental clinic: what do dental implants have to do with orthodontic treatment, when they are treatments and specialties that are completely different? Therefore I would like to shed light on this matter, as many patients go crazy when some professionals are telling them that they have to have their dental implants inserted after orthodontic treatment, some are saying that they should do it beforehand, and then others are saying that it should be done during the orthodontic treatment. How can there be so many opinions that are so different? Why is this?
Starting at the beginning, nowadays there are many adults looking for the solution to their dental problems, seeking to improve their oral aesthetics and health. In point of fact, at Friedländer Orthodontics Barcelona the majority of the patients we look after are adults. They tend to be patients who require treatment involving various different specialties: periodontics, orthodontics, implantology, prosthetics, aesthetics, etc. As of their first visit and the moment they begin their treatment with us these patients are assessed, studied and treated using a global approach, taking into account all of the disciplines involved in their treatment, because it is impossible to solve their dental problem properly with orthodontics alone, or just using implants. This type of treatment is called multidisciplinary or interdisciplinary treatment, as it involves a range of different dental disciplines in the same treatment, requiring correct sequencing and coordination. In this day and age you cannot treat adult patients without a clear multidisciplinary approach. What occurs very often is that the orthodontic treatment has to be supplemented with treatments from other disciplines.
Multidisciplinary treatments step by step
The steps that are typically taken in multidisciplinary dental treatments are as follows:
- Analysis and planning – in orthodontic treatments we always conduct an initial analysis; without fail this entails studying every single aspect of the treatment, planning the steps that will be taken and creating a plan or ‘syllabus’ that is shared between all of the professionals involved in the treatment.
- Hygiene stage – adult patients very often have periodontal (gum) problems and caries. Prior to orthodontic treatment the mouth must be ‘cleansed’ so that we can position the teeth correctly without loosing bone support. This stage usually includes a proper periodontal treatment, taking care of caries and extracting any teeth that cannot be saved or have to be removed for orthodontic reasons.
- ‘Corrector’ stage – this is the orthodontic treatment that corrects the dental malposition and prepares the mouth for rehabilitation. In this stage ALL of the aspects of rehabilitation – implants, prostheses, aesthetics, etc. – are already being taken into account.
- Rehabilitation stage – after the orthodontic treatment it is the turn of a rehabilitation dentist, who will prepare the prostheses needed to replace whatever teeth are missing. Unless the first orthodontist has done their work correctly, the rehabilitation dentist will not be able to do theirs.
As you can see, each professional depends upon others, as does each stage, and they sometime overlap. Unless all of the professionals are working on the same wavelength, the treatment will not give good results.
When are dental implants inserted, before or after orthodontic treatment?
Looking at these stages of the multidisciplinary treatment, patients may think: “Well it all seems clear now, the orthodontist can position my teeth and then I’ll have my implants put in wherever they need to go.” This is indeed so in cases that require one implant in a specific position, but it is not the case in the event of a complex rehabilitation, and I’m going to explain why.
The majority of general dental practitioners and rehabilitation dentists will say: ‘Do the orthodontics, and then we’ll put in the implants and the prostheses. This way these professionals can free themselves of the task and the need (and perhaps the responsibility) of sitting down to plan the treatment with all of the team (the type of planning that yields the best results). To be able to sit down to form a plan with a team, each of the professionals must have knowledge about the others’ specialties. In other words, they really must be very well trained; the implantologist has to have knowledge about orthodontics, the orthodontist has to have knowledge about periodontics, etc. In addition, all of this requires time (something which is often in short supply these days). There is a need to invest a lot of thought and the will to strive for the very best solution. Finally, all of these ideas and concepts must be communicated to the patient in a way that they can understand. The process as a whole is far from easy.
Many dentists ignore the fact that when the mouth is missing a lot of teeth, the orthodontist can have a terribly difficult time trying to manage the case properly. It becomes difficult or even impossible trying to manage all of the spaces correctly (having to achieve degrees of precision in tenths of millimeters); trying to give the correct shape to the arch complicates matters, the use of intermaxillary elastics complicates matters further, coordinating the width of the arches complicates matters further still… All of this means a lot of time lost on treatment and sometimes an impossibility of the orthodontist being able to achieve a precise result.
So, what is the solution?
The solution is ‘simply’ to insert the implants BEFORE the orthodontic treatment in cases where a lot of teeth are missing, when the orthodontist does not have teeth to use as anchorage points to move the other teeth. This means that when various molars are missing and only front teeth are left, the orthodontist will need some provisional implants with crowns to be able to create the necessary orthodontic movements.
Looking at an example, the following patient is missing several teeth, has another with caries, and has a class II malocclusion with an excessive overbite. This case will have to be planned very well. Some teeth will have to be extracted and some worked on, and implants will be needed as well as orthodontic treatment.
In this case, without the support given by the implants, the orthodontist will have great difficulties managing the spaces, performing certain movements (such as the molar intrusion), modifying the patient’s bite height, etc.
Taking an example that is even clearer, in the following case the orthodontist will have an extremely difficult task without being able to get support from implants. As a minimum at least one implant on each side is needed. Without this there is no way of correcting the center lines, correlating the shapes of the arches, or achieving the objectives of the orthodontic treatment. In the images on the right-hand side you can see that the implants were inserted (in accordance with the setup made previously). Now the orthodontist is able to work efficiently and can achieve the planned objectives.
The setup of the teeth
Now the rehabilitation dentist may nervously put their hands to their head thinking: “Well if the implant is permanent, what happens if we have to move the teeth towards where the implant is?” (This has happened to me several times working with other professionals.)
The answer is very simple. A ‘setup’ of the teeth must be made prior to the multidisciplinary treatment. The setup involves carrying out orthodontic movements of teeth in a model of the patient’s mouth so as to plan where they are going to go and where the implants will be inserted. This can be done with plaster models or with digital models.
- Multidisciplinary dental treatments – more than other types of treatment – require good planning and communication between the team of professionals involved.
- For the orthodontist (and for everyone) it is better to insert ALL of the implants that can be inserted BEFORE starting the orthodontic treatment, and to insert provisional crowns.
- Any implants that cannot be inserted before the orthodontic treatment should be inserted as soon as the case permits (opening of a space and preparation of a root before the implant).
I hope this information has made the sequencing in complex multidisciplinary cases clearer.
In my next post I will be talking about the use and advantages of the setup.
For further information please contact us by telephone (+34) 93 832 72 81.
For further information please contact us by telephone (+34) 93 832 72 81.