There are mainly two aspects that can characterize an implant case as complex:

• When the lack of a bone prevents you from placing the implant.
• When the elements that need rehabilitation have relevant aesthetic implications.

Having to deal with both these elements at once can make a case particularly difficult.

If you just lack the bone, you can rely on some modern tricks, like short, narrow, tilted implants…that’s all stuff that works pretty well. In other cases, like with a maxillary posterior tooth, we can use some basic regenerative techniques that everyone should manage to perform, like sinus floor lifting.

But when you lack the necessary bone, and you are also working in a considerably visible area, then you’re in some serious shit. Either you are totally confident of what you are doing, or you’d better send your patient to someone else!

You need to have a specific procedure for each phase when you deal with these cases, and we’re going to discuss this in detail, further on; today I want to talk to you about what, for me, stands before every decision. I want to tell you about the principles that guide me in planning the management of these difficult cases.

PRINCIPLES guide PROCEDURES, and PROCEDURES guide DECISIONS. Without principles and procedures, we’d have to overthink for days each single complex case, still feeling uncertain in the moment in which we make our call on how to treat the case.

Wait: I don’t mean to imply that you mustn’t think carefully about what you’re doing. Instead, you have to REFLECT and STUDY very well to define principles and procedures and to update them, any time you realize that there is room for improvement. But then, once in the foxhole, you have to shoot, for fuck’s sake!! You cannot go on and on with mental masturbation over each single case you have. A case should be…a case, not a big mess! And when you have, or will have a successful practice (maybe also thanks to some of our tips?), you’ll be presented with dozens of new cases each month! In our practice, it’s dozens every week!

And you have to bring home these cases as soon as possible, because that’s what people, RIGHTFULLY, want.

 1) GIVE TIME TO BIOLOGY.

Since it is the first principle, it is definitely the most important one! Nowadays, everybody tends to cut down on the time required for every surgical procedure, and to a certain extent I agree with this trend, because it generally brings great benefits. For instance, think about the substitution of a front tooth affected by a cavity or external resorption…you take it out, place the implant, you do something to avoid a gingival collapse, you load quickly and there you go. Consider the advantage that this is for a patient, compared to the classic approach (besides the undeniable aesthetic advantage!). Or, consider the all-on-4 technique in failing dentition cases. You take it out…place it back…ant the patient goes back home with teeth in his mouth.

But in the cases that require TRUE bone reconstruction you cannot choose this approach. And the reason is simple.

You have to force your patient’s system to carry out an unnatural job! 

The system wants to reabsorb, but you force it to regenerate. So what happens down there is very complex and delicate and, in order for it to work, it must be well protected by healthy, resistant and uninflammed tissues.

I have seen dozens of regenerative procedures by my colleagues fail miserably because they had been carried out in a moment in which soft tissues weren’t ready!

So, if you want to do difficult things WAIT for your patient’s tissues to heal!

 2) DO NOT COMPROMISE IN

     HARD TISSUES RECONSTRUCTION

Taking two magic scraps that a smart salesman saddled you with, stitching them on the implant and putting a spare piece of paper on it is not a regenerative procedure..it’s bullshit.

If you decide to treat a complex case, you cannot start by a compromise right away, you have to lay at least the foundations as well as you can!

So, if you’re not able to reconstruct a bone properly, you have three possibilities:

• Forget about complex cases,
• Send your patient to someone who can restore the bone and then you deal with the rest of the procedure, or
• (and that’s the solution that I highly recommend) learn how to regenerate the bone correctly.

I am completely available to help you with the second and the third point!

 3) ALWAYS AUGMENT SOFT TISSUES

Peri-implant soft tissues must have two crucial functions:

• Allowing the patient to keep a good hygiene
• Provide a proper PINK AESTHETICS to rehabilitation.

Then, we will need good quality, thick tissues able to compensate the deficiency which might occur due to the hard tissue reconstruction.

So, grab the scalpel and tell the patient you need his palate, you cannot do without it!

 4) FREE YOUR PROSTHESIS FROM THE BURDEN OF METAL AND TRUST ADHESION

Ok, if everything had gone swimmingly so far, I am sure now I must have managed to piss someone off!

Let me put it this way.

For thousands of years we only commuted on foot. Then someone understood that wheels could spin and wood could float: from that moment onward we started traveling with wagons and ships for tens of thousands of years. Less than three hundred years ago the locomotive appeared, and less than a hundred years ago the combustion engine was invented; as far as the airplane is concerned, in 1923 Edgar Buckingham, from the US patent office, published a report that was pretty skeptical about the economic competitiveness of the new propulsion engines, if compared to propeller engines used at low altitude and speed back then: “at present there seems to be no prospect to reach some kind of practical value, with this kind of turbojet propulsion”.

Nowadays, metal-free materials have a complication occurrence comparable to metal-ceramic, and in addition they provide a MUCH HIGHER AESTHETIC VALUE, and a DRAMATICALLY MORE CONSERVATIVE APPROACH ON THE DENTAL ELEMENTS THAT NEED RESTORING.

YOU DON’T ALWAYS GO IN THE RIGHT DIRECTION IF YOU KEEP DOING WHAT YOU’VE ALWAYS BEEN DOING!!