Therapeutic strategies and the concept of informed consent in implant treatment
- Introduction
The therapeutic strategy, in other words the choice of different surgical protocols and different prosthetic concepts, must have as their final objective the creation of a functional and aesthetic prosthesis.
- Surgical procedures or protocols .
Therapeutic strategies and the concept of informed consent in implant treatment
A number of surgical imperatives must be taken into account:
2. 1.Tissue planning protocol (see “tissue planning” course)
2.2. Implant placement techniques
2.2.1. Conventional techniques
- Flap elevation and measurement of vestibulolingual bone thickness
- Drilling through the static surgical guide to optimize implant position
- Marking the impact point with a ball end mill or a pointer drill bit
- Drilling under continuous irrigation (The drilling sequences are adapted to different bone qualities/densities)
- Implant placement
- Two-stage surgical technique (buried implant)
The buried technique (two-stage technique) recommended by Branemark is generally recommended by most designers. It has the advantage of placing the implant in a wet nurse during the osteointegration period, protected from: the external environment, functional or parafunctional constraints and in particular the temporary prosthesis.
Protocol A cover screw corresponding to the diameter of the implant is placed on the day of insertion. The flap is sutured edge to edge, without tension, using an X-shaped stitch or a running suture depending on the size of the surgical site. After the wet nurse phase, which lasts two to four months, the implant is removed.
- Non-buried technique: one-step technique
The one-stage surgical approach is always preferable to the two-stage approach in partially edentulous patients because it avoids a second intervention, shortens the treatment duration and reduces its cost.
Protocol A healing pillar corresponding to the diameter of the implant and the thickness of the soft tissues is aimed at the implant, whose vertical positioning is supra-cretal, the flap is then adapted around the pillars and sutured without tension by vertical mattress stitches in order to obtain a stable positioning of the soft tissues.
- Advanced techniques
- Immediate extraction and implantation
- Flapless: is a non-invasive flapless technique. The goal is to place implants without incision or detachment of soft tissue. Among the disadvantages; the non-direct visualization of the underlying bone tissue.
- Rules for three-dimensional implant positioning
- Mesio-distal direction
A minimum of 1.5 mm between a tooth and an implant and a minimum of 03 mm between implants
- Apico-coronal direction: The implant neck must be located between 01 and 03 mm from the necks of the adjacent teeth.
- Vestibulo-palatal direction: Preserve a minimum of 02mm of cortex vestibular to the implant
3. Prosthetic strategies
- Single prosthesis
- Bridge
- A removable partial prosthesis can be accepted by the patient on the condition that it is perfectly stabilized by sufficient implants on which attachment systems allow a removable prosthesis to be stabilized (stellite, total, etc.). The available bone volume, the occlusion, the prosthetic requirements and the aesthetic request of the patient guide the prosthetic choice.
- Screwed prosthesis
Therapeutic strategies and the concept of informed consent in implant treatment
Indications
- a reduced inter-arch space < 7mm
- Implant emergence profile must be compatible with the crown (screw access)
Benefits
- Very easy disassembly of the prosthesis;
- Connections via machined pillars ;
- The absence of use of a sealing cement.
Disadvantages:
- Altered occlusal anatomy.
- Anatomical emergence profile sometimes difficult to achieve
- Emergence of screws on occlusal surfaces.
- Sealed prosthesis
Indications : compatible with an interarch space > 7 mm
Advantage:
- Respect for the anatomy of prosthetic occlusal surfaces.
- Anatomical emergence profile.
- The grouting cement facilitates passive adaptation of the reinforcement.
- High fracture resistance of screws;
- Facilitated occlusal equilibration.
Disadvantages:
- Difficulty in disassembly.
- Risk of overflow of sealing cement subgingivally)
4. Implant maintenance
Objective:
- Maintain the aesthetic and functional results obtained in the long term ;
- Prevent the occurrence of both biological and biomechanical complications;
- Intercept potential problems by dealing with them as early as possible
Maintenance consists of:
- observation of peri-implant tissues. It allows to highlight the existence of inflammation of the tissues, recessions (appearance of pillars, or even coils), and sometimes a fistula.
- Palpation of the external and internal bony tables sometimes reveals vestibular and/or palatal dehiscences , but can also cause suppuration and/or pain.
- Probing: allows the depth of the pocket to be determined, but can especially cause bleeding which reveals the presence of an active site of peri-implant disease.
- Radiographic examination: allows the presence or absence of bone loss to be demonstrated and, in most cases, a differential diagnosis to be made between mucositis and peri-implantitis.
- Examination of the prosthetic suprastructure is necessary to control screwing/unscrewing, occlusal overloads
The frequency of maintenance sessions must be individualized according to each individual’s risk of developing a peri-implant complication. It is therefore necessary to distinguish:
- Patient-related risks : smoking, history of periodontal disease, cleaning dexterity, systemic disease, etc.
- Risks related to the implant : three-dimensional position, implant proximity, prosthetic anatomy, surface condition, etc.
- Risks related to the implant site : quantity and quality of peri-implant tissues, periodontal health
Informed consent
Therapeutic strategies and the concept of informed consent in implant treatment
“This is a medico-legal obligation. The intervention can then be scheduled.”
- Historical
Origin of the patient’s right to consent .
After the horrors of the Second World War, the philosophical and religious concept of human dignity took a prominent place in the law of Nations.
The dignity of the human person constitutes the foundation of human rights. Thus, the Universal Declaration of Human Rights (UDHR) adopted on 10 December 1948 by the General Assembly of the United Nations proclaims that all members of the human family possess “inherent dignity” (Preamble) and provides that “all human beings are born free and equal in dignity and rights”
Fifty years ago, doctors did not hesitate to impose on patients, sometimes without explanation, what they considered to be good for them, and this attitude was socially accepted.
In the 1960s, medical research violating individual freedoms and the integrity of people called into question the idea of leaving them to be the sole judges of the actions to be undertaken on patients or research subjects,
The requirement to obtain consent from subjects before subjecting them to research procedures and consent from patients before undertaking interventions on their bodies has become the means of restoring the delicate balance between the imperative of respect for persons on the one hand, and the imperatives of techno-scientific progress and medical power on the other.
Currently, the concern to inform patients and obtain their support for the research care offered to them has become the norm.
“Free and informed consent takes place between the professional and the patient and commits them both”
- Fundamental Qualities of Informed Consent (IC)
To be valid, consent must possess three fundamental qualities: it must be free, informed and continuous.
- Essentially, consent must be given freely by the participant, that is, voluntarily and without medical, family or social pressure,
- It must also be given in an informed manner, meaning that the participant has a reasonably complete understanding of the purpose of the research, its risks and potential benefits and has all the information necessary to make a fully informed decision.
- Finally, consent must be continuous, meaning that the researcher must ensure that it is maintained throughout the research.
Therapeutic strategies and the concept of informed consent in implant treatment
How ?
According to the medical code of ethics, “clear” information means “intelligible” information. It must be simplified compared to a specialist presentation, avoiding overly technical language and superfluous details.
The practitioner often has an educational role (doctor comes from the Latin verb docere which means to teach, to instruct) which involves simplification, repetition, exchange
It can be difficult to make a complex situation understood, it may be necessary to simplify it without distorting reality, it is necessary to ensure that the patient understands what is being explained to him, to let him ask additional questions, to suggest that he reformulate what he has understood.
- How to obtain consent
Written consent
- Consent is generally ORAL because the medical contract is traditionally a
Oral contract.
- “Consent must be evidenced either by a signature on a form or by other appropriate means, recorded by the researcher.”
- The purpose of written consent is to protect the patient. It is written proof that the patient has been informed and has freely consented. This form of consent is only mandatory in certain circumstances (organ removal, biomedical research, dental implants, etc.)
Before giving consent to treatment, the patient must receive fair, clear information adapted to their level of understanding from the care and medical teams while being free from any pressure or constraint.
Giving informed consent involves knowing the possible therapeutic alternatives, that is to say the other means of treating the health problem(s) encountered with their advantages and disadvantages…
It is on the basis of this exchange that the patient will be able to accept or refuse what the health professionals recommend. The latter must respect the patient’s wishes.
- Special cases of consent expressed by a third party
In some cases, it is difficult, if not impossible, to ask a patient to personally express their consent before an act of care:
- minor patients , particularly young children: it is then the parents or legal representatives who give consent,
- adult patients under guardianship : the expression of informed consent falls to the guardian if the judge has so decided when placing the person under guardianship or later, depending on the evolution of the patient’s state of health. Apart from such a decision by the judge, the principle of autonomy applies to a protected adult who cannot be represented in the expression of his or her consent.
- patients whose state of health does not allow them to express themselves at the time when care is necessary. In this case, the doctor or the care team must obtain informed consent, either from relatives or from the trusted person if the patient has designated them.
In any case, faced with a serious and urgent health situation and incapacitated
expression of the patient and their possible representatives, doctors and teams
Caregivers must provide the necessary care under their sole responsibility.
- Health Code and Law
- Algerian Code of Medical Ethics
Article 43:
The doctor, the dental surgeon must strive to enlighten his patient with intelligible and fair information on the reasons for any medical act Article
Article 44:
Any medical act, when it presents a serious risk to the patient, is subject to the free and informed consent of the patient or that of persons authorized by him or by law. If the patient is in danger or unable to express his consent, the doctor or dental surgeon must provide the necessary care.
- New health law (2018)
Article 343
- No medical act, no treatment can be carried out without the free and informed consent of the patient.
- The doctor must respect the patient’s wishes, after informing him of the consequences.
of his choices.
- This information relates to the various investigations, treatments or actions of
prevention measures offered to him, their usefulness, their possible urgency, their consequences, the frequent or serious risks normally foreseeable that they involve as well as on the other possible solutions and on the foreseeable consequences in the event of refusal.
- The information is provided by any healthcare professional as part of their
skills and in compliance with the ethical and professional rules applicable to them. The rights of minors or incapacitated persons are exercised, as the case may be, by the parents or by the legal representative.
Article 344.
- In the event of refusal of medical care, a written statement may be required from the patient.
or his legal representative.
- However, in case of emergency, serious or contagious illness or if the patient’s life
would be seriously threatened, the healthcare professional must provide care and, where appropriate, override consent.
- In the event of refusal of treatment, the doctor must respect the patient’s wishes.
but he must do everything possible to convince him to accept the essential care.
- Essential in implantology
Obligation of means (preoperative consultation)
- health check-up, clinical examination, radiological examinations, etc.):
- It is always necessary to establish a patient medical record, which chronologically traces the
various treatments; keep the fundamental documents, namely, the health assessment, the treatment plan-ESTIMATE and the informed consent,
Obligation of monitoring and follow-up.
7. Prosecution in the event of lack of consent:
1) – On the criminal level:
Any medical act performed without obtaining the patient’s consent is a defective medical act, just as experimentation on a human being without his consent is a fault Against humanism; as a result, the doctor cannot benefit from the protection of the law and any medical act performed under conditions is considered as intentional assault and battery on his patient,
2 — On the civil level;
Failure to consent primarily incurs the civil liability of the doctor because it constitutes a breach of the doctor’s contractual obligations.
Therapeutic strategies and the concept of informed consent in implant treatment
