Richard Winter comments:
This post evokes a lot of emotions and perhaps the wording could have been less supercilious. Whether someone is a specialist that received training years ago or a generalist that excels at surgical and prosthetic rehabilitation there should be a collegial atmosphere where ego is not front and center. There are obviously many problems with this case but we don't see the CBCT pre-operatively, nor photos immediately post delivery. Yes there is a problem with lack of inter-occlusal space, Yes there is a problem with prosthesis design, yes there was a built in plaque trap but I have seen many failures that were done by teams. Simply stating that one should "stay in their lane" is demeaning and wrong. I believe every person should be able to discuss all aspects of the case that is involved. Simply allocating responsibility for an aspect of the case does not ameliorate failure nor assign guilt. This could have been an opportunity to discuss ways this could have been improved so that this failure may have been avoided. Instead the opportunity was used to try and persuade many very educated colleagues that your way is the only way. I am a GP that does both surgical and prosthetic rehabilitation. I also have written articles on General Dentistry As a Specialty as we all must be specialists in all aspects of what we provide. I do agree that not every dentist is qualified to do complex implant treatment. I am a strong advocate for the FAAID, DICOI, and especially the DABOI/ID training, testing and documentation (all of which I have pursued and attained.) That being said, a weekend course is certainly not what this doctor took but their failure is all of our failure. Lets use our pedestal to further the profession. As Carl Misch, my mentor and teacher taught me, "shut up and fix it." We all could learn more by being more a mentor and less judgmental. Just my opinion.Michael McClure comments:
Like Neil Bryson, I started placing implants many, many years ago because of poorly placed implants by so called “specialist’s”. But in reality who’s really an implant specialist? Is a periodontist an implant specialist, no. Neither is an oral surgeon. Both have good surgical training but they aren’t implant specialists because specializing in implants REQUIRES an exceptional knowledge of not only surgery, but restorative and laboratory procedures as well. Taking a weekend restorative course is not good enough as taking a weekend course for surgery is also not good enough. People should stay within their skills for sure whether a specialist or not.Riyaz Gangji comments:
i think a super dentist in my definition is a credentialed, for example , ( AAID / /ICOI) GP who has educated himself with evidence based training in the fabricating of implant retained prosthesis and as in my case surgical training as well . However , to broadly label all GP’s in this manner is not appropriate as i can post several cases performed by specialists with similar results. i consider myself to be a GP who is well trained and comfortable in using implants to treat most cases , however , i know my limitations and i will always refer difficult cases to a specialist who are better trained in complex implant cases . Ask the GP how many screws we used to get from Oral Surgeons-not in the correct position and ask a periodontist if oral surgeons ever pay attention to soft tissue quality around their placements . So let’s not point at or limit our evaluation to failures to just one group. It’s simple , lack of training , apathy in real care for people and failure to seek help when someone more learned can help , and unfortunately greed too plays a part. However , most clinicians are not like this as we care for our patients . Should i post a 23-26 lower implant retained bridge , where two narrow fixtures were placed by a seasoned surgeon and restored by a GP that i had to improve where threads were exposed simply because of lack of kertinized tissue , and poorly placed trejectory of 23 and 26. i polished the exposed threads and placed free gingival graft to stabilize case and increase band of attached tissue and improve the saddle prosthetic design to a sanitary convex. it happens all the time. Just my thoughts and obviously the specialist in most cases are always more trained in surgery but A trained GP / perio/ pros too , is the one managing the outcome for the lifetime of the case.Timothy Carter comments:
Perhaps my original post was taken out of context. My reason for singling out the intaglio is because it demonstrates the lack of vertical. A “Team” of trained clinicians and laboratory technicians would have most likely identified this, preferably prior to surgery, in the provisional phase and prevented it from proceeding to final restoration. I apologize for the confusion.Faisal Moeen comments:
How long did this prosthesis last? If it had given reasonable service for over 10 to 12 years, why didn’t the dentist intervene a few years before point of failure. There isn’t enough case related or technical information in this post to give a definitive judgement call. Besides, does it really matter who did what wrong here? Shouldn’t we focus more on why it failed and how we can proceed next? Were the implants loose when you removed them? If not, (and since there is no CBCT attached) I’m assuming they weren’t placed that badly and your point of “ a specialist should have placed implants here” goes out the window. Besides, patients don’t walk in our clinics asking for well placed implants, they want replacements to their missing teeth and are more focused on the prosthesis. The plan could have been okay to begin with, what I think went wrong was the delay in changing that plan in between.Timothy Carter comments:
It was in function for less than 2 years and implant placement had nothing to do with why I posted this case. It failed due to poor planning. The prosthesis identifies the critical error of inadequate restorative space. This should have been identified in the records phase while mounted on an articulator. When I see these patients for surgery consult I do a face bow and mount each case on a Denar Mark 320…. I do this as part of my surgical plan and it provide useful info to the restorative doc. This is how a “Team” works… we all share knowledge for the patients benefit. I have never criticized the implant placement or the fact that a GP placed them only the fact that the failed restoration tells the story of lack of restorative spaceDr Yassen Dimitrov comments:
I also disagree about the problem for this case is, because it was treated by a single specialist, instead a team of two, three, etc. Coleagues above were wright- we do not know how long the prosthesis has been in function, has the patient attended the regular visits for prophylactics (mandatory AT LEAST twice a year). In my modest oppinion: 1. If preventive efforts were applied from both dentist and patient (severe plaque control for prevention of mucosistis, spreading to periimplantitis), most probably the life span of this treatment would be increased. 2. Choice of material for prosthetics is of significant importance for the ease of at home maintenance of such large restorations. Clearly resin based bridges are not the primary choice when long term function is targeted. Zirconia (according to many publications) is beyound doubt a surface, easier to maintain free from bacteria. (not good news for the supporters of resin bridges- Malo & Co.) 3. Treatment planning should not be done by the principle ( Oh, there`s a tiny bone peak I can screw my implant in), but instead categorizing the case in the appropriate atrophic category, hence- the measures and procedures, needed to rebuild the necessary missing bome ( some C. Misch desribed this more than 20 years ago, remember :grinning: ? It`s not the implant doing the job, it`s the bone surrounding it! When the bone is weak or thin, and the bone-implant surface is small-the bone resorbs, and the case fails). Maybe if the case was better planned from the beginning, properly regenerated, cleaner materials were used and patient was more compliant, the outcome could have been better.John comments:
I dont think having a dental team has anything to do with this case. Its a very lame thought. If you cant restore your own implants and need a full team to do your work thats just sad.Michael Lefkove comments:
No doubt, this case failed spectacularly. But when these cases do fail, they fail in a big way. Has no one else ever had one of these cases come unglued like this? Just asking for a friend.DeeR GeeSin comments:
For me, these cases arent about the number of people involved. Its about the people involved being competent. If the restoring doctor is knowledgeable, he will guide the laboratory and the surgeon as to what he needs, IF those two entities lack the restorative knowledge. Treatment should be restorative based. If the restoring Dr isnt proficient, then yes, he needs the opinions and "eyes" of others for success.Greg Kammeyer, DDS, MS comments:
What would be interesting on this thread would be if we focused solely on the 1) problems, 2) diagnosis, and 3) treatment choices and 4) causes of failure. Sadly a lot of mud slinging when it's all about what is or is not done, rather than whom does it.G Kammeyer DDS MS DABOI comments:
As a GP I found I couldn't be excellent at everything. As I started working with specialists, I found they more consistently got the endo right, the children taken care of etc. I also found my self going to more classes and Reading Research Papers, limiting the scope of my practice all to avoid the weekend training limitations and the ongoing challenge of more and more information to sort through. As time went on I realized I wanted to focus on dental implant cases only and went to Loma Linda U's 3 year, full time Advanced education in Implant Training. However during that training I realized "None of us is as smart as all of us", and that truly keeping up on implant and related surgery was more than enough: by that I mean going to AO, AAID, ASDA etc meetings regularly and continually taking specialty training courses to refine my skills. In this day and age, it's near impossible to keep current with all the research that is published even as it relates to implant dentistry. I do know each dentist has a different take on variety of treatments that they can do well. I too straighten out my share of others problems as I am sure my other area specialists do on some of my cases. I believe why specialists get a bad rap is some specialist get arrogant because 1) we read specialty journals (several!! not just one in each discipline), 2) we devote a chunk of our life to learn to do things well, 3) we try to pass that information onto the GP (who has the challenge of doing far fewer cases of the work we do daily) and 4) we go to multiple meetings/year devoted to our limited role. All too often, the GP's failures wind up on specialists door steps, which yes can be frustrating especially when the GP isn't invested in learning how to avoid the problems. Yes, specialists make mistakes too. Some GPS and specialists make more mistakes than others. I do believe in credentialing: If you are serious about implant dentistry, why not get Board Certified? These certifications are by our true "peers", and at the end of the day we are all people serving others with well meaning intent.