“I am a surgeon, I do not do prosthetics” – statements of this kind are no rarity in implantology. In the second episode of the trilogy on computer-guided implantology in the podcast Queens & Sons of Dentistry an experienced oral surgeon clearly contradicts this stance: prosthetic understanding is, for the surgeon working in implantology, the most important guide and the most important topic in the entire operation. Anyone who has no idea about prosthetics and has never made a bridge themselves is quite simply working badly – such is his deliberately pointed assessment. At least a minimum of prosthetic work of one's own he regards as indispensable.
A look across the border: Germany and France
The guest, who does not himself come from Germany, first places the debate in a structural context. In Germany the position of the surgeon is very dominant – in practice structures as well as at the universities. Being able to place implants quickly freehand counts in this country as evidence of a good surgeon. That is precisely what he considers a fallacy. In France the starting position is a different one: there, implantologists too are initially dentists who gradually develop into implantologists. A specialist dentist for oral surgery does not exist, and oral and maxillofacial surgeons hardly orient themselves towards implantology – among other reasons because they lack the prosthetic training. It is quite simply a completely different arrangement of the specialist disciplines.
What the operator has to know about the prosthetic restoration
What prosthetic thinking means in concrete terms for the surgeon is described by the guest on the basis of the questions that must be answered before every implant placement: which abutment will later be used – a straight or an angled one? Can the screw channel in the aesthetic region be angulated far enough for vertical screw retention to be possible without problems? Or is an angled screw nevertheless acceptable in the specific case? The operator has to know and be able to do all of this before drilling – because the implant position determines which prosthetic options remain available at all later on.
The referrers' concern – and the opportunity of collaboration
The surgeon openly identifies a practical area of tension: a surgically active colleague who also offers prosthetics deters some referrers – the collaboration then goes preferably to the colleague who does not do prosthetics. Against this he sets the perspective of the referring practice when preparation has been successful: if the patient comes back with perfect occlusion, intact papillae and a precisely prepared abutment that can be fitted exactly, that is wonderful work and collaboration – without compromises. In the end everyone involved benefits: the patient, the referrer, the practitioner, the dental technician and also the implant manufacturer – in the case of his practice, Straumann. The guest describes this constellation as a genuine win-win situation for the entire treatment team.
The workflow: from photographic analysis to the implant position
What prosthetically oriented planning looks like in concrete terms is described by the surgeon on the basis of his standardised approach, which remains the same in all extensive cases – whether anterior region, bone augmentation or full-mouth restoration:
- At the beginning there is a photographic analysis of the patient with a complete intraoral and extraoral protocol.
- The occlusion is registered digitally, where required with appropriate devices for recording movement.
- There always follows a Smile Design – for the guest the central form of communication with the dental technician and the basis of the further work, beginning with the anterior aesthetics and the entire facial analysis.
- The team attaches great importance to function: to how the two jaws work together and how the wax-up reproduces the tooth contacts.
Only once this prosthetic target position has been established does the actual implantological work follow: the implant is planned and placed in the bone in accordance with this position – implemented either via a static guide, a navigated operation or, where available, a robotic system.
Conclusion
The message of the episode is unambiguous: good implant surgery begins not with the drill, but with the restoration. Anyone who knows the prosthetic target situation plans backwards from the crown to the implant – and thereby creates the basis for results in which, according to the guest, patient, referrer, laboratory and practitioner take equal pleasure.