Navigating the private practice world of referrals can be a significant challenge for the full-arch surgeon. From speaking with OMFS colleagues, I know that there can be a lot of frustration and stress surrounding AOX referral relationships.
Part of this dilemma is that, as a private practice surgeon, you want and need full-arch referrals. However, how do you handle these patients when they come from a referral who knows little about the surgery or restorative aspects, and sometimes wants little to do with the process at all?
Who manages the restoration? Who handles the restorative complications? How do you best work with an inexperienced provider?
While I do not operate in a traditional referral-based practice, I have worked with over 20 restorative doctors to date in the world of full-arch surgery. As a result, I want to share a few key pieces of wisdom on how to select a referral that will create a strong full-arch relationship and make your life easier, instead of harder.
Please note that since I perform only the surgical aspect as an OMFS, and many of the colleagues that I know are OMFS, I am writing this article from that viewpoint. I want to be very clear, though, that you can and should employ this exact same thought process in reverse. A referring restorative provider should exercise the same caution and due diligence in choosing a surgical provider with whom to work as well.
5 Keys to a Successful Full-Arch Referral Relationship
1. Don’t underestimate the value of the restorative provider’s skill.
There is a rampant and unwarranted thought process in full-arch surgery that 95% of the success of the procedure has to do with the surgery itself. This is simply not true. The prosthetic portion is incredibly important and should be highly valued.
Don’t believe me? Track your implant failures on your referral cases with a restorative provider that has little to no experience and those in cases you’ve done with a highly trained full-arch restorative doctor that understands occlusion and cantilever management, amongst many other prosthetic skills.
Very often, you will see a stark contrast in implant success even though your surgery is done the same way. This highlights both the positive and negative effect that prosthetic management can have on the outcome of the case.
Don’t underestimate the value of partnering with skilled practitioners and tread cautiously when working with referrals who do not understand the procedure, or worse, have no desire to learn. Everyone has to start somewhere (myself included). There is a difference, though, between someone new and eager to learn, and someone who just doesn’t care.
I know that I am “a better surgeon” when I have the opportunity to work with talented restorative providers. The truth is, they simply make my work better. There’s no denying it.
2. What training do they have in occlusion?
Occlusion is so, so, so critical to full-arch success. This matters in both the short-term 4-month integration period and the long-term success of the prosthetic (i.e., delayed failures).
Selecting referrals to work with that have a solid understanding of occlusion, and specifically full-arch occlusion, is critical to consistent success.
Remember that no matter how well a surgery is performed, it cannot overcome poor occlusion.
3. Do they understand cantilever mechanics and the power they have to positively or negatively influence a case through cantilever management?
AP spread is the job of the surgeon. Cantilever length is the responsibility of the restorative practitioner. Yes, they go hand in hand and are a team effort. But there is a subtle distinction between the two.
Partnering with someone who understands full-arch biomechanics, actively looks for ways in which they can affect/alter the cantilever to improve force distribution, and knows when it’s necessary to do so will drastically impact your failure/re-do rate.
Occlusion (discussed in point #2) and cantilever length are, in fact, so powerful and impactful on full-arch outcomes that a skilled restorative provider can turn even a mediocre or poorly performed surgery into a successful case by controlling and optimizing these factors. On the other hand, a skilled surgeon has far less success trying to “overcome” a poorly done occlusion or a less-than-ideal cantilever length.
4. Case-specific selection (i.e., high smile lines, skeletal jaw discrepancies, significantly collapsed bites, VDO management, etc.).
Not all cases are created equal. Cases with high smiles, skeletal jaw discrepancies, significantly collapsed bites, those requiring VDO changes, and/or severely atrophic patients are going to be more difficult surgically and prosthetically.
If you are the more experienced provider in your full-arch referral team, you may need to decide if you are, in fact, comfortable completing these cases with a “new or inexperienced” restorative referral (again, the same can and should be said in reverse from the restorative provider’s viewpoint as well).
While it’s tempting to just assess whether you can do the surgery, you have to remember that these cases have a difficult restorative component that must be performed optimally for a successful outcome. Difficult cases that aren’t done well on the restorative end may often manifest down the line as secondary surgical issues.
While it may be a difficult decision for your practice’s revenue, it may save you a lot of headaches in the long run to be somewhat case-selective when working with a new referral.
5. Do you trust them? What’s being said when you’re not there? Will they do what they said in terms of prosthetic management?
This last point seems obvious. But sadly, it’s not. You have to trust the restorative provider you are working with.
This is, first and foremost, from a clinical standpoint to ensure that they can and will deliver on what they have indicated they can perform clinically. Also, that you trust they are willing to adapt or change plans as necessary to improve patient outcomes.
Furthermore, since the prosthetic and surgical aspects of this procedure are so closely intertwined, you have to be certain that your restorative colleague knows how to handle complications chairside from a patient management standpoint and that they will speak positively about you even when you’re not in the room.
I understand that the “private practice” world has a very different referral dynamic than the single-surgeon/prosthodontist environment I am used to. However, as a result, I feel that these dynamics are even more important in the private practice world, as you have a real “choice” in who you work with and who you don’t.
My hope is for you to have endless referrals and a busy practice. That being said, I have spoken with many a frustrated colleague (both on the surgical and restorative side), where the practitioner’s only wish is to go back in time and not work with “that referral” or not take “that case” on…
Remember that who you work with can have a major impact not only on the outcome of a surgery of this magnitude but also on your happiness and peace of mind in your practice.
P.S.
While there are many practice models out there today, one thing that I have learned over and over again in the full-arch style center is the immense respect I have for my prosthodontic and restorative colleagues.
I am very fortunate to get to work with practitioners every day who have done hundreds and thousands of arches restoratively. They bring immense skill and knowledge to the surgeries I perform. I have learned so much from them and have been fortunate to see firsthand the incredible value they bring to a successful full-arch procedure.