Thank you for coming for a consultation on the 5th of October.

It was a pleasure
to be able to discuss your problems you have had since your recent dental
treatment. As we discussed your case is complex, and I feel that a careful logical
thought out treatment plan is essential if we are to succeed in the long run.
From what I gather you have had implant placement with a sinus graft on the
upper right hand side done previously in Bristol.
Your main concerns are the function and appearance of your teeth. You have
also indicated that your gums occasionally bleed when you brush your teeth. I
had referred you to Kings College Hospital for treatment, as I felt your bite
(occlusion) was not stable. After your appointment at Kings they have informed
us they will not be able to undertake any treatment.
Following your appointment with us today, and looking at the photos/models and
x-rays taken today I have written below what problems I feel you currently have.
Problem List
Teeth: there is severe wear of your lower front teeth. I believe this has been
caused as you have lost many back teeth, meaning youre now eating on the
front teeth, putting excess pressure here, and wearing the front teeth away.
There is no decay on any of your teeth. You have indicated that you would also
like whiter teeth and are not fully happy with the colour of your teeth.
Gums: You do have bleeding areas on your gums as well as areas of bone loss
and gum disease. This will have to be addressed before any restorative
treatment is carried out. There is also associated recession of your gums
Oral Health: your general oral heath is good. You have no evidence of oral soft
tissue problems (e.g. cancer/precancerous lesions). Examination of your muscles
and teeth indicate you probably have a very heavy bite and may be grinding/
clenching your teeth. This will have to be investigated/ managed before, during
and after your restorative treatment.
Bite (occlusion): You currently have a complex bite called a Class 3 bite, this
means your lower teeth lie in front of your upper teeth. This bite is more
complicated to manage than other bite patterns. Looking at your bite and jaw, I
believe we can get you to bite in a better position when we change and manage
the way your teeth meet. It is important we get this right, as we can cause
overload and subsequent failure of any work we carry out, or the implants that

have been previously placed. You will almost certainly need a time of provisional/
trial work to manage and test drive your bite.
As mentioned above you have lost a lot of your back (posterior) teeth. I believe
this is putting undue pressure and force on the front teeth. We will need to
replace or redistribute this excessive force more evenly to get a stable bite.
Restorations on the implants: The implants and the restorations on top of the
implants have been made to conform to your existing bite. However in light of the
above problems, the restorations can not be adjusted or added to in order to
correct the above problems. This means that whilst the existing implants may be
useable the restoration work on the top of the implants will have to be replaced if
you decide to take up this treatment.
The placement of the implant looks to be good, though there is a suggestion on
the x-ray that one of the implants may be touching a natural tooth under the bone
level. This may not be the case as x-rays are 2 dimensional images of 3
dimensional objects. However, this will have to be investigated (with 3D scans) to
confirm that the implants are ok.
Health: Whilst you are taking medication for your blood pressure and cholesterol,
this should not propose a significant problem in your treatment. However, blood
pressure medication can exacerbate and worsen gum problems. Whilst there is
no indication that your medication is currently having this effect, if your GP
decides to change your blood pressure medicine or alter the doses it may worsen
your gum health.
With this in mind it is important to inform us of any changes in your general
health at any point during the treatment.
I should also inform you that if you decide to take up smoking again (even though
you have been smoke free for a long time!) it may influence both your gum health
as well as the proposed work.
Proposed Treatment
In light of the above problems I am going to make a few suggestions about the
work I believe you will need to get you into a healthy, comfortable, aesthetically
pleasing, and stable condition.
Stabilisation (and investigation) Phase 1: There are elements of your oral
health (as detailed above) that need to be stabilised before we proceed to make
changes to your mouth.

1. Gum Disease treatment (periodontal treatment). This is designed to

ensure that the foundations on which we would like to build the
restorations on will be stable. This includes the teeth you currently
have as well as being able to maintain them.
I have enclosed a leaflet detailing gum treatment, what is involved and
why people get gum disease.
I would advise appointments to stabilise your gums. This will be done
by me and the practice hygienist (Jaye Hibbins). Looking at the x-rays
we currently have it is unlikely that you be losing any further teeth in
the short to medium term, though we may need to take 1 or 2 further xrays to see the health of your bone around the lower front teeth.
Jaye will also be providing you will all the tools and kit and knowhow to
be able to clean your teeth as effectively as possible, both now and in
the future. The cleaning and maintaining of the work and teeth you
currently have as well as the work you will receive is PARAMOUNT.
2. Investigation of the implant upper right side, I would like to take a 3D
scan of the implant on the upper right side. This is done with a CT
scanner at the practice. This is taken to ensure the existing implant will
not or has not affected the adjacent teeth.
3. I would also provide you with whitening to improve the colour of your
natural teeth. This will give us a good base colour to build the rest of
your restoration on.
Diagnostic Phase 2: this is designed to ensure stability, comfort, health and
aesthetics of your proposed treatment
4. We will need to take further (more accurate) moulds of your teeth as
well as very accurate measurements of your bite and jaw joint. We will
use this to replicate your jaw on an articulator. This is a mechanical
representation of your bite, teeth and jaw, which we can work on at the
lab (and surgery) to plan and assess your treatment (very accurately)
before we do any work inside your mouth.
From this representation we will have to decide how to replace some of
the other missing spaces you currently have. This can be done with
implants or dentures.
Once we decide on which method you would like to replace the
missing back teeth our lab will then mock up a new bite in wax which
we feel would be suitable. You will have the opportunity to see this and
review the shape and size and position of the teeth before having them
place inside your mouth.
This part of the treatment is essential to ensure you have an evenly

comfortable bite which will not affect your jaw joints or existing
implants.
5. From the mock up of your teeth we will then use a strong temporary
(composite) material to build up the existing teeth to this new bite, as
well as using prosthesis (dentures) and possibly other materials to test
drive the new bite. This part is essentially and engineering check to
ensure the bite works as predicted and is comfortable to you, as well
as proving you with a chance to test the look of the proposed
restorations and make any changes you feel you would like.
If you decide to have some additional implant work (which will take a
minimum of 6 months healing time) this work can be done whist the
healing phase is underway.
Provisional restoration Phase 3:
6. Once we have achieved a stable and comfortable bite, we will remove
the existing work and restorations from the implants and replace them
with a durable acrylic/plastic to allow any further adjustments. At this
stage it may also be necessary to have some minor gum surgery to
help protect some of the teeth and implants.
Permanent restoration Phase 4:
7. Once both I and you are happy with the bite and appearance and
stability of your new bite we will replace all the temporary work with
permanent restorations.
Review and maintenance Phase 5: Clearly it is important that after all this
proposed work you are able to look after it all. Cleaning flossing and brushing is
essential to making your restoration look as good as possible for as long as
possible. Think of this phase as an MOT or a service you would do for a car. This
is designed to ensure the work is maintained and kept in good working order.
8. We will have to have a period of review and maintenance to ensure the
work is functioning correctly and you are able to clean and maintain the
work we will carry out. This will once again involve the practice
hygienist.
We may also have to make a splint for night time wear to protect the
new work.
Consequences of doing nothing

Whilst you are not experiencing any pain or much discomfort the consequences
of doing nothing may be great with time. With your current bite and existing lack
of support on your back teeth I predict there could be a few problems that may
arise.
1) The stress of your bite is distributed on your front teeth, which with time is
very likely to cause your front teeth to wear further still. This can lead to
loss of tooth surface and weakening of the teeth followed by them
breaking. In some cases these broken teeth can get infected especially if
the nerve and blood supply is exposed.
2) The excessive force is distributed onto the implants. Excessive force on
implants can cause the implants to fail, and the surrounding bone around
the implants to resorb (erode away). If this bone does erode away, it can
be very difficult to get back. Failure of implants in this way will almost
certainly result in losing the restorative work placed on top of the implants.
Time Frames + Costs
I cannot emphasise enough that resolving the level of problems that you have is
not something that can be done overnight. In order to achieve something that is
comfortable, aesthetic, stable and healthy we must follow a logical sequence as
detailed above. The treatment time is predicted to be anything from 18months to
3 years. I hope you realise that it is impossible to accelerate or rush through any
of these stages. If this is unacceptable it would perhaps be better to not start the
treatment at all.
As you can appreciate it is difficult to price the above proposed work to the
penny. This is because the costing relies on your choices of materials used as
well as which treatments you would like to undertake. As the costs are difficult to
work out to the penny I will provide you with definitive costs for phase 1 of your
treatment and ballpark figures for phases 2, 3 and 4.
Phase1: I would expect this phase to take approximately 3-4 weeks and will
require 4 appointments, followed by a period of 2-3 months for healing (during
this healing phase we could also start phase 2) the cost of Phase 1 of the
treatment will be X
Phase 2: With dentures this will probably take around 3-4 months to
complete and will cost approximately x-x to complete. This cost is

assuming that you decide NOT to proceed with any further implant treatment and
would prefer a removable denture.
With Implants: If you would prefer implant treatment the time
required will be 6-9months and the cost will be approximately x-x
Phase 3: The approximate time frame for phase 3 of the treatment will be 23months
and will cost approximately x-x
Phase 4: The approximate time frame for phase 4 of the treatment will be about
2-4months and will cost approximately x-x (if no extra implants are
used) or approximately x-x(if implants are used)
Phase 5: you will need to see me every 3 months for the first year following
completion of the treatment, and the hygienist 2-4 times a year. Normal practice
fees will apply for hygienist and dental checkups. The splint, if needed, will cost
approximately x.
Financing
I understand the costs are significantly large. In order to make the treatment
more affordable we are able to offer both low cost (7.9% APR) and 0% financing
options over 6month to 4 years duration. I have enclosed an information leaflet
for you if you wish to take up this option.
In Conclusion
I understand and appreciate that I have given you a considerable amount of
information to take in, and as you are no expert it can be complicated and difficult
to understand. Please do take time to consider what I have proposed here. I
hope I have explained everything clearly; however I would expect you to have at
least a few questions about the proposed treatment. Please feel free to come into
the surgery, or call me at the surgery and I welcome any questions or comments
you may have.
Wishing you the best of health,