10 min read

Allon4 Opinion: The "Mismatch" Between What The Patient Seeks and What the Dentist Offers

What are patients looking for?

The patient has an extremely unstable upper denture and is looking for a solution to his problem. What does he seek, what does he imagine, and what is offered to him? In short, he seeks a solution to his problem. He does not seek surgery. Just keep in mind he is not a surgeon, and, unlike us, he does not like to see blood, surgical procedures, or pictures of dental implants. If there were a non-surgical alternative that could solve his problem, he would certainly choose it. But he already knows that it doesn't exist. He has already changed prostheses several times and even started using denture fixing creams, and nothing solves the problem as he expects. As all patients nowadays search for solutions on the internet, he already knows that, in such circumstances, the only alternative is a dental implant treatment. He already imagines and understands in advance that a surgical procedure will be necessary. Despite the fear, he decides to face the treatment, after all, it's just one surgery and everything will be just fine. He'll have his life back. Then he gets ready to evaluate with his trusted dentist to face this surgery procedure right away and solve his troublesome problem at once. He has researched possibilities like immediate loading and knows that in just a few days, or even on the same day, everything can be done. After the clinical and tomographic examination comes to the diagnosis: There is not enough bone in your upper jaw for the immediate installation of dental implants. It is another case of atrophic maxilla. There is no doubt in the surgeon's mind and the treatment method is automatically selected. Just like 2 +2 = 4, atrophic maxilla = bone graft. What is offered to him? Bone grafting. Not just one surgery, but at least three surgeries until the end of the treatment and more than one year of treatment (if everything turns out fine). But don't worry, Mr. Patient, I have many titles, and I am a great surgeon. I will show you how I can reconstruct your entire jaw, I have a lot of experience in advanced bone grafting surgery, and we can remove a piece of bone from your pelvis under general anesthesia and screw several blocks of bone in your whole upper jaw. It will be an incredible surgery! After limping and unable to use your dentures for several weeks, we will schedule a second surgery to install the dental implants and, after a couple of months, we will schedule the third surgery to reopen these implants, and we will start making your dream fixed full-arch rehabilitation. At this point, what is going on in the patient's head? Fear, disappointment, and deception. The initial courage to perform a surgery is overwhelmed by the news about the necessity of a bone graft procedure and at least three surgeries. Here is the mismatch: The patient seeks a solution and imagines one quick and straightforward surgery. The surgeon offers three surgeries, bone graft, weeks without using the denture, more than one year of treatment. But Doctor, are there any alternatives? Yes, there are! We have several bone graft alternatives!

The problem of the "I have a hammer" approach

From a legal point of view, the patient has the right to choose among the different treatment options. The professional knows about it and the range of options is sometimes open to the patient. However, in the case of the atrophic maxilla, several treatment possibilities are not usually offered, but just several bone graft possibilities. Mr. Patient, we have several options. We have several types of bone grafts that we could use. We can choose autogenous, allogeneic, xenogenous, or alloplastic bone, but there is no doubt and no treatment method except the bone graft! We all know that the gold standard is the autogenous bone graft, but morbidity and availability is a limitation of this modality. Biomaterials work well in the maxillary sinus, but for block use, we still need more evidence. Allogeneic bone, available in some countries, is not without risks(1,2). The lyophilization process does not entirely eliminate the immunogenic potential and may bring future problems to the patient. Regardless of the type of graft, the patient will always need to undergo at least three surgeries and more than one year of treatment. We all know that the patient has the right to know about all treatment alternatives, but when it comes to the atrophic maxilla, it is different. The bone graft has been presented with the only option. Why? It is the traditional mindset. A type of conduct that we can say is to treat atrophic maxilla thinking inside the box, following common sense, and omitting important information about the possibility of treating atrophic maxilla WITHOUT bone graft.

For those who have a hammer in hand, every problem is a nail.

It is prevalent to have two classes of surgeons. Those who hate zygomatic implants and those who love them. It is rare to find a middle ground. How is it possible, on the one hand, some surgeons having incredible results with zygomatic implants, rehabilitating atrophic jaws without bone graft and with immediate loading, to the point of using this technique as a routine in their clinical practice and, at the same time, having another group of surgeons who just don't want to hear about this type of implant? Often they do not even consider this possibility of treatment with their patients. But after all, if both are talking about the same technique, is this technique feasible or not? Is it predictable or not? Why so much variance of opinion? From a scientific point of view, there is a scale of evidence levels, where the lowest possible evidence is the level of personal opinion, and the top of the pyramid is the results of randomized clinical trials or systematic reviews and meta-analyses of randomized clinical trials. Therefore, if our objective is to offer our patients an evidence-based clinical practice, these discussions and divergence of personal opinions have a very low level of scientific validity and should never be taken into account in our decision-making process.

When we go further to the top of the pyramid of evidence levels, we find that there are plenty of scientific studies corroborating with the high success rate of graftless rehabilitation techniques(3-15).

In summary: the zygomatic implant is a highly predictable technique and promotes a substantial decrease in treatment time and patient satisfaction. This is the scientific truth that we have up to date. However, if you or any other surgeon has not yet convinced yourself about this, know that this is your personal opinion, and it has no scientific validity.

In the recent past, the patient had only professional guidance regarding knowledge of all treatment possibilities, but this is not true today. The same scientific article available to you is also available to your patient. Nowadays, it is quite normal for patients coming to the dental office extremely well-oriented about treatment possibilities and with extremely advanced technical questions. In the case of atrophic jaws, it is increasingly common for patients to start looking for professionals focused on graftless rehabilitation.

Great surgeons, minimally invasive surgeries

There is a perception that at the beginning of an oral surgeon career, one learns basic implant dentistry. The dental implant is installed when there is a favorable availability of bone and soft tissues. At the level of basic implant dentistry, the focus is on acquiring basic knowledge, developing initial surgical skills; that is, the focus is on learning. However, this favorable condition does not always exist, and the professional begins to face more complex cases, such as, for example, cases of atrophic maxilla. He then sees himself in need to take advanced surgical training, that is, he needs to learn how also to perform bone graft procedures. At this stage, he feels superior in the hierarchy; he is at a high level; he is a surgeon who makes graft procedures. I remember my feeling at oral and maxillofacial surgical training when I did my first maxillary bone reconstruction using an iliac crest graft. I felt like a great surgeon. But for the patient, it was terrible. A large segment of the iliac crest was removed (much more than necessary for the maxilla graft).

bone graft dental — Iliac crest graft for dental implant

At hospital discharge, the patient could not even put his foot on the floor because of the pain he felt in his hip area. He had to go home in a wheelchair. Despite this, my ego as a great aspiring surgeon inflated, and I loved to tell other colleagues about the greatness of the surgery just performed. The ego only began to deflate when the patient, progressively, lost the implants one by one. Anyway, at this stage, it is common to focus on the surgeon, who, after all, wants to do big and complex surgeries. What we believe is that there is a stage above this level of the surgeon who performs bone graft. The highest level would be the surgeon who rehabilitates atrophic maxilla without bone graft.

The big change happens when our focus shifts from the surgeon and goes to focus on the patient. We start to seek solutions in more predictable and less traumatic ways. It truly is a high level. It's here where the game change and, once you've tried this type of approach and its results, it's impossible to go back. There is no way to ignore graftless methods.

Great surgeons, minimally invasive surgeries

Less is more. And that was a great lesson that I learned during my Masters in Implant Dentistry at the University of Sagrado Coração in Baurú-SP. I came to Professor Dr. Carlos Eduardo Francischone with a tomography of an atrophic maxilla to explain my treatment planning and convince him that we could offer the patient an iliac crest graft. Assertively, lovingly and elegantly, he replies: "-Let's just tilt two implants in the posterior region and place two implants in the anterior part and immediately solve the patient's problem in a simple and fast way, and, under local anesthesia." At that time, I was formally introduced to the concept that would radically change the path of my clinical practice - The Allon4 concept. We did rehabilitate the patient with immediate loading, and, from there, my view of the atrophic maxilla was never the same. To further consolidate this view, Dr. Paulo Maló was presenting his doctoral thesis at that institution, and I had the opportunity to attend in person the nearly 5 hours of presentation and arguments from the board. My practice surrendered to the simplicity and sophistication of rehabilitation of atrophic maxilla without bone graft, and today, I have this as my main professional activity. Knowing these treatment possibilities, would the patient choose for bone graft? Are the clinical results the same as bone graft in the long run? Long-term 9 to 14 years follow-up studies show us a 90% survival rate for autogenous bone graft reconstructed maxilla implants(16). Not bad, but let's think about the patient's point of view. If I told him that there is a possibility to solve his problem with immediate load and with a 95% or higher chance of success in the long run, what would he choose?

If Mother Nature presented us with a type of dense bone that provides us with an excellent anchorage, why look for them elsewhere using more invasive methods? Per-Ingvar Brånemark

The focus on the patient makes us invariably think of techniques without bone graft. In addition to the benefits mentioned, this treatment philosophy brings us another positive side effect in our practice: we have a huge differential from competitors.

Become a reference in your market

In the business world, there is a term called Unique Selling Proposition, or USP. It refers to a differentiator that you have from your competitors.

What would be a great USP? Focus on the patient!

Remember: the patient seeks a single surgery, seeks immediate loading, wants a technique with a high success rate, and aesthetic longevity. Can we offer it all? Yes! It's a win-win treatment.

The surgeon who learns how to rehabilitate atrophic jaws without bone graft quickly becomes a reference in his city and region. Over time, you will likely receive a patient from several states or even from other countries to be rehabilitated.

Understand that: every surgeon who dominates the zygomatic implants technique also dominates the bone graft procedures, but not everyone who dominates the bone graft procedure dominates the zygomatic implants technique. Which group do you want to be part of?

The first step in learning this treatment philosophy is to get rid of the old paradigms to which we have been exposed throughout our professional journey. That is what we will learn in this post.

REFERENCES

1 de Lacerda, P. E. et al. Homologous transplantation with fresh frozen bone for dental implant placement can induce HLA sensitization: a preliminary study. Cell Tissue Bank 17 , 465-472, doi:10.1007/s10561-016-9562-9 (2016).