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Episode 9 - Determining One or Two Stage Surgery Options on the Maxilla

Full-Arch Restoration - Mission Possible (Mini-Series)

Full arch restorations require additional considerations when surgical planning is undertaken for maxillary cases. In this episode of "Full Arch Restorations... Mission Possible" Dr. Frank and Dr. James LaMar describe the rationale behind treatment planning and selecting a one or two-stage surgical approach for patients.

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Episode 9 - Determining One or Two Stage Surgery Options on the Maxilla

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Watch the Hybridge Podcast Video: Episode 9 - Determining One or Two Stadge Surgery Options on the Maxilla


Randal: Joining me today are Dr. James LaMar and Dr. Frank LaMar, and we're going to discuss the differencee between single stage and two stage surgery in the upper maxilla. Dr. Frank, will you start us on this topic?

Dr. Frank: Sure. Actually let's just define the two different scenarios.

Maxillary Dentate start, either removing teeth and bone grafting and then waiting and then second stage placing the implants after initial healing. So we’ll call that the two stage approach. The one stage maxillary approach would be extracting the remaining teeth and placing implants the same day. So we’ll call that the one stage approach. The industry seems to be infatuated with this idea that maxillary teeth are extracted and immediate placement and immediate load, and so we’ll talk a little bit about the pros and cons of that.

Randal: Okay, Dr. James, from a surgical perspective.

Dr. Jim: Yes, as Dr. Frank said, it’s important for us surgically for us to be able to place those implants into good bone and to make sure they’re very stable when they go in. So sometimes when we’re removing teeth and trying to place implants at the same time, there really isn’t enough bone for that. So, in those cases there’s probably a small amount of times when we are able to actually remove teeth and place implants. But the majority of the time we’re removing teeth, bone grafting and then waiting and waiting about 10 or 11 weeks for that to heal so we can do the next stage to place the implants at the second stage.

Randal: So, what are the advantages to you Dr. Frank when you do the restorative piece related to what Dr. Jim just said.

Dr. Frank: So you know, when we look at these cases, and Dr. Jim and I treatment plan most of these cases together and every other Thursday morning we get together and go over these cases, and basically we put them into one of two buckets. One of them is the one stage approach and we find that we feel most comfortable about 30% of the time doing a one stage option. We’re being critical though, we just saw one the other day. Maxillary teeth. Severely compromised, no bone, but apical to the remaining teeth was this abundance of maxillary bone. So we know that if we take those teeth out, we have a foundation, and Dr. Jim can put those implants in in just the right position with great immediate fixation which key. And unfortunately, the 70% of the cases that we do site development on, those patients from the time of extraction to the time of definitive, they’re wearing a maxillary denture. So, really that’s about the patient experience I think. And the industry is sensitive to the fact that patients want to be finished, or at least inconvenienced, as little as possible.

Dr. Jim: But sometimes what happens is when you try to rush those cases, or maybe do cases that are not quite up to that parameter, then you find that you get in trouble, or you lose implants, or you end up with a prosthetic result that might not be exactly ideal. So, anytime that we are able to place the implants and do it, if there’s good available bone, we’re happy to do it. But, I’d say the majority of the time, we are doing it staged, a two-stage approach, where we’re removing the teeth, building up the bone, getting the site ideal. It also gives the prosthetic side some time to work on some of the fine prosthetic. So, when we’re done with the case, when the implants are in, basically the implants and the final prosthetics line up really nicely.

Randal: And that actually has the best long-term outcome.

Dr. Jim: It does.

Randal: So you don’t have a patient coming back with challenges.

Dr. Frank: Yeah, you know when we do the two-stage approach, when they’re done healing and we’re ready to move forward with implant placement, we now have the opportunity, as Jim said, to know exactly where the final prosthetic, the anterior tooth position is going to be, and we can do a guided surgery that is really accurate to the final restoration. And now, when Jim is putting the implants in, we not only put them exactly where they need to go, at the exact angulation, but you’d be surprised that many of the times that we do that planning, pre-implant, and you can use any one of these systems that are out there, but when we do virtual planning, we find that we have insufficient interarch space more than half the time. So, having that second opportunity to go back at the time of placement and get a little bit more interarch space and idealize that one more time, really creates the ultimate result. Even with this two-stage approach, it’s 11 weeks from extraction to implant placement, and then we can finish that case from implant placement to deliver in about 6 weeks. So, we go to definitive, 16, 17 weeks, we’re all done, and we get an ideal, or an optimal prosthetic result.

Randal: And if you were to not approach it that way, how long could a patient be inconvenienced?

Dr. Jim: It depends. If there’s complications, and there’s issues with implants and you’re waiting for re-do of surgical procedures, I mean it could take, you know, almost twice as long as that.

Dr. Frank: Yeah, if you’re placing 5 or 6 implants in the maxilla, and as you’re going, if you lose one or two implants and something doesn’t work out and you have to go back and resurgerize the area, you’re significantly changing, not only the patient’s experience, multiple surgeries, inconvenience, but you’re adding hours and hours of doctor time onto these cases, which really changes the dynamics of, as doctors, what can we charge a patient, what’s the least we can charge and still be very productive, and it’s all about predictability. So, the one stage approach, I think Jim and I both agree, is more unpredictable, potentially more hours, not less hours if it’s not done under the ideal circumstance.

Dr. Jim: Right. So, just to be clear, we’re talking about the upper arch. Obviously, it’s a lot different than the lower arch, and we definitely will treat the lower arch differently.

Dr. Frank: You know, that’s a great point because in the mandible, I’d say we’re as close to 100 percent one stage approach on the mandible, and we get the same, the ideal results in one-stage. So we always say, the maxilla and the mandible, two completely different animals, and two completely different situations. And, they need to be treated as such.

Randal: Thank you both for insight today. Thank you ladies and gentlemen for joining us today, on Full Arch Restoration: Mission Possible.

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