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A Can of Worms Waiting to Be Opened…

I look at my schedule for the day and see a new patient listed for an “implant consultation.”  During our morning meeting, I ask my office manager for more information about her.

“Apparently she already had an implant placed and she wants to know how much it will cost to restore it,” says my office manager.

I’m already a bit concerned.  I’m wondering why this patient has an implant but no restorative dentist.  I’m wondering why the surgeon who placed the implant didn’t refer her to someone directly.  Where is the treatment plan?  Do I really want to inherit this responsibility?

I meet with the patient and discover that the implant was placed about a year ago.  In Turkey.

Now I certainly don’t have a problem with Turkish dentists.  I don’t have a problem with dentists from any country.  My problems are the following:

(1)    The patient had traveled to Turkey to save money on the procedure.  That means she probably just wants the cheapest approach to restoring her implant, not necessarily the best approach.

(2)    Not only have I never me the implant surgeon, I have no way of communicating with him to discuss the case.

My first concern was confirmed immediately.  She wanted to know how much it would cost to restore the implant before I even had an opportunity to examine her.

I explained to her that I can’t know the fee until I at least know the angulation of the implant.

“The surgeon told me the implant angle was perfect!” she said.

Of course he did… of course he did.  If I never had any follow up on any of my patients, I’d be convinced my work was perfect, too.

I explained about screw-retained versus cement-retained crowns and how the angulation requirements can be different.  I explained about the plane of occlusion and the potential need to adjust opposing dentition in the case of supraeruption.  I rattled off a half dozen other perfectly good reasons explaining why I needed to conduct a basic examination before I could give a fee.  We’re already off to a bad start.

So here’s the periapical radiograph:


Uh oh.  That’s some decent distal angulation we’ve got there.  That could leave unsupported porcelain on the mesial if we’re not careful.  But it’s not the end of the world just yet.  But it also gives me an idea about this other dentist’s definition of “perfect.”  I won’t be able to fully appreciate the buccal-lingual angulation until I fit an impression coping, which I don’t have available.

What do you do when a new patient already has implants placed without your input?  Here’s what I do:

(1)    I explain what my fees are for my diagnostics: exam, radiographs, and study models of the implant impression.  I will need all of this information to determine the fee since I wasn’t involved in the original treatment plan.  Once I know what will be involved in restoring the implant (abutment type, occlusal corrections, etc), I present my fee.  If the patient thinks my fee is too high, I’ll hand them the radiographs and the study models and wish them well.  They have the freedom to take the diagnostic information they paid for to another dentist.

(2)    If the patient is too demanding and unreasonable, I refuse to treat them.  Even if the case looks straight forward.  Even if the case could generate some nice revenue for the office.

Once we finished our conversation, she agreed to come back for another visit to take an implant impression.  Again, I haven’t agreed to restore the implant yet; I need to look at study models to figure out the appropriate implant fee and do a comprehensive exam to see what other needs exist.  For example, we can see from the radiograph that she needs a crown on # 29.

Before she got out of the chair, she asked me to look at one more thing.  She was having some pain on a bridge on the upper left.  Here’s the periapical radiograph:

Somebody call Guinness World Records.

For those of you keeping track, that’s a six-unit bridge cemented on a canine and a third molar.  Wow.

Who did that bridge?  The same Turkish dentist, of course.  She didn’t want a removable option and she didn’t want to pay for all the implants that would be necessary, so she finally found someone to make her the longest bridge I’ve ever seen.

Here’s a rule of thumb.  If the span between two abutments is so long that it can’t fit on a single radiograph: your bridge is too long.

Here’s a more popular rule of thumb: Ante’s Law.  This is the Anti-Ante’s Law.

Her mild pain was coming from the cuspid and was elicited during function.  She wanted me to take off the bridge and make a new one.

My reaction looked something like this:

"You want me to do WHAT?"

I refused.  I told her the only way I would take that bridge off is if we were treatment planning her for implants or for a removable partial denture.  She left and I never saw her again.


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