Focus On: Treatment Planning for Success

Ara Nazarian, DDS


Ara Nazarian, DDS

Ara Nazarian, DDS, discusses necessary steps and technologies in treating fully edentulous patients with implants.

Q: An increasing number of patients are presenting to national dental offices requiring multiple extractions leading to full edentulation. With the progressing development of dental treatment and materials, why is this number still rising?
A: As people live longer, the wear on their dentition increases and function decreases. Also, teeth can become more brittle due to prior endodontic or prosthetic treatment from years past. Certain medications taken can cause the degradation of the dentition due to increased caries rate from dry mouth. Medical conditions that may impair proper oral hygiene may also increase the caries rate to the point that teeth are nonrestorable and require removal.

Although age may be related to tooth loss, we are seeing a younger generation necessitating full-mouth extractions. These individuals have either severe wear or severe decay due to drug use. A highly addictive drug that has received a lot of attention in the dental community because of its destructive nature to the dentition and health of the patient is methamphetamine, or meth. Meth mouth starts with overall bad breath, interproximal and facial cavities, and generalized bleeding gums. In later stages, the teeth are totally obliterated and destroyed requiring extractions.

Q: How do you present full-mouth implant reconstruction to patients so that they understand and accept the treatment?
A: As dentists, we tend to look at everything in our profession with finite measurements and scientific data. Because of this, we like to explain dental treatment with a lot of complexity—this creates a whole host of problems including wasting time, draining your energy, and confusing the patient. It is essential to present everything in the simplest possible language and form. One way I do this is by showing patients treatment options that relate to their dental conditions. I will highlight the problems they are presenting with, the consequences if these problems are not addressed, and then the solutions to these problems.

Superior case presentation involves more than just an explanation of the dental treatment. It requires the patient understanding how he or she will benefit from treatment, ie, a whiter smile, the elimination of pain, an even bite, or a healthier mouth.

Fees are often an obstacle to case acceptance. Patients need a simple and affordable way to pay for the care you prescribe. This is why we will recommend a third-party payment option that has low rates and high approvals with an easy online application.

Q: How do you decide what type of full-mouth implant restoration to provide for your patients?
A: There is no cookie cutter approach to providing full-mouth reconstruction with implants. Implant-based restorations can be either fixed or removable, depending on the patient’s desires, amount of available bone, and whether adequate support can be achieved by the implants alone or with soft-tissue support. The final prosthetic design must account for all the individual patient variables, taking into consideration the best available evidence regarding long-term prognosis while ideally meeting the patient’s expectations for aesthetics, function, and affordability.

Q: During the treatment planning stage, what are some of the materials or methods you utilize when gathering the information for these cases?
A: Computed tomography (CT) is a digital modality that has revolutionized radiographic imaging. The resultant CBCT data produced allows the dental provider to generate many different sections of interest that are clear and free of distortion. Lately, we see a variety of different CBCT equipment available that are more compact, have reduced radiation, and are easy to implement into the general practice. Any anatomical landmarks including sinus cavities, bone concavities, and nerve canals are easily identified using CBCT. More importantly, using this type of data allows the clinician to plan the most optimal areas for ideal implant placement.

Virtual wax-ups can be digitally created to facilitate ideal arch form, tooth shape, and plane of occlusion with a press of a button. Importing a quadrant or arch of teeth from a digital library and customizing it to the patient allows for dentist-lab technician communication about a reconstruction before any surgical procedure is even exercised. Once the virtual wax-up is accepted, a printed model may be fabricated to fully visualize the restorative needs in a traditional manner giving the patient, dentist, and lab technician an accurate preview of how the finished case will look.

Q: What are some new technologies that make the digital workflow efficient and effective for you?
A: Some of the most interesting and fascinating digital integration for dentistry has come in the form of digital impression technology. With a handheld intraoral scanner, the combination of 2-D and 3-D digital color pictures creates the final 3-D digital impression in the system I utilize in my office. Within seconds, the operator sees a real-time 3-D visualization of the impression being created during the scanning process on a touchscreen display as it is passed over the area. Not only is this process efficient and effective, it eliminates the pulling or tearing of sutures during an impression at the surgical phase.

Creating a photo-realistic 3-D digitalization of the patient’s face with a proprietary extraoral scanner is another piece of modern technology that assists dentists and lab technicians in creating the final restoration on the basis of the face (midline, incisal edge position, degree of tooth display, labial contour, etc). This way there is no guessing of whether or not the newly designed smile will complement and fit the patient’s facial features.

Q: The use of CAD/CAM in dentistry has grown exponentially in recent years. How has this been applied to implant placement and restoration?
A: CAD/CAM technology has had an expanded application in dental implant dentistry. Not only can it be used in the production of surgical guides but it also serves a big purpose in the planning and fabrication of the abutments, frame substructure, and final restoration.

CT-based CAD/CAM surgical guides are custom made for each patient’s clinical situation, allowing highly accurate drilling and implant placement according to the digital surgical treatment plan. The guides can be fabricated to fit onto existing teeth, over the tissue, or rest on the bone. These surgical guides provide the seamless link between implant planning and actual treatment ensuring predictable dental implant placement.

The use of CAD technology has also been used for the fabrication of custom abutments. Using specific designing software, the patient-specific abutments are individually designed from the final tooth shape to provide better margin placement and gingival tissue support whether the restoration is cement-, screw-, or attachment-retained. The benefit of CAD/CAM technology is that it allows the practitioner and dental laboratory the ability to produce aesthetic, well-fitting prosthetic dental restorations very predictably and cost effectively.

Dr. Nazarian maintains a private practice in Troy, Mich. He is a Diplomate in the International Congress of Oral Implantologists and is the director of the Reconstructive Dentistry Institute. He can be reached by calling (248) 457-0500 or via the website at