Treatment Planning and Modalities of Implant Placement
During our initial consultation, we assess the objectives of our patients and discuss the various treatment modalities for the restoration of the tooth/space in question.
If it is indicated that an implant is the preferred solution we start the treatment planning process, which occurs as follows:
- We take a CT scan on site using our XG3D cone beam Ct Scanner to assess 3 dimensionally the volume of bone, the position of adjacent teeth and any vital structures in the area
- We can virtually plan our implant placement and assess what is required to place the implant in the ideal position to support the crown or bridge
- We determine whether this is to be an immediate implant where the tooth is extracted and the implant is placed on the same day or whether the tooth requires extraction with a delayed placement of the implant. We adhere to strict clinical protocols in determining which is going to deliver the optimal result in the most time and cost efficient way
- We also can determine whether we want to do this as a precision surgical guide keyhole surgery, which does not involve any incisions or suturing, or whether a conventional approach is required.
Immediate Vs Delayed Placement
Where the situation allows we look to place implants the day the tooth is taken out.
We are able to do this in situations where the bone has not been destroyed by infection. Provided the implant is tight in the socket we are able to place a temporary crown on the implant the same day.
Done with precision and following strict clinical evidence based protocols the advantages of immediate implants are:
- Decrease in treatment time
- Maintenance of the soft tissue shape and height which is particularly important for the front teeth – see case study
- No need for other forms of temporisation such as removable dentures
- Clinical evidence shows that immediate implant is as predictable as the delayed implant placement
- No need for incisions, sutures and a quick fast procedure. Generally taking about 40 mins to an hour.
If a temporary crown is placed, it is important that no pressure is applied to it during the healing phase as this can cause the failure of the bony connection (osseointegration).
Case Study - Immediate implant
This lady has been a patient of Dr Barry Phelan since 2011. During the initial consultation it was noted that the patient was a bruxer (teeth grinder). A mouthguard was prescribed but declined by the patient…
When there is infection or the bone is not adequate to predictably place an implant, the tooth is extracted and generally a graft is done at this time to maintain bone volume. We use a product called Bio Oss as our bone grafting material. This has been shown to be totally safe and effective.
After healing for 3 months we take a new scan so we can use technology to virtually plan the implant prior to surgery. We then allow healing for a further 3 months prior to fabrication of the final crown. For front teeth we often have to fabricate a temporary crown to allow for the gum to grow around it to mimic a natural tooth so that we can predictably get an aesthetic result. This can take some months but in most cases we can recreate a similar gum shape as to what was there previously, prior to going to our final crown.
For people who have had a tooth missing for a long time getting an aesthetic result can be challenging as the bone shrinks both horizontally and vertically. We can predictably rebuild the bone horizontally but vertically this still presents as a very difficult challenge. This can result in a restoration that looks too long. For people with a moderate to low lip this tends not to be an issue. However for those with a high lip line or gummy smile this is a very difficult obstacle to overcome.
We therefore strongly advise people that early intervention with implant therapy is going to deliver a much more predictable, aesthetic and functional result and cost less!
Precision Guided Keyhole Surgery Vs Conventional Implant Surgery
Precision Guided Keyhole surgery
Here at Contemporary Smiles we have invested in the latest technology in the intra oral 3D scanner, The CEREC Omnicam and the XG3D cone beam CT xray scanner from Sirona, Germany.
Once an implant has been decided upon, we take a cone beam CT scan at our practice, which gives a 3D radiographic (xray) image of the jaws and teeth.
Provided that there is sufficient bone and soft tissue, we are able to take an intra oral 3D scan with our Cerec Omnicam. Using their advanced software we are able to design a virtual crown or bridge from this scan. We are then able to stitch this crown design onto the 3D CT image. This allows us to virtually place the implant where it is required to support the overlying crown. We send this information over to Germany via the internet and 2 weeks later we get a surgical guide back. www.sicat.com
With the accurate fitting of the mouthguard we are able to place the implant with pinpoint precision without the need for any incisions or stitches.
We regularly use guides for placement of implants where no grafting is required and often this is the case for back teeth. We like it as it has pinpoint accuracy and patients love it as it decreases treatment time and there is no need for incisions or sutures!
Conventional Implant Surgery
Conventional implant surgery involves the reflection of the gum from the underlying bone to allow for visualisation of the bone during implant placement and also when a graft is required. We tend to prefer this type of approach for delayed implant placement for the front teeth as generally these require bone grafting. As we need to expose the underlying bone to do this the advantage of keyhole surgery is lost and we therefore don’t avail of the guided surgery in this instance. The ability to visualise the area tends to be more predictable in our experience when working in the front of the mouth.
Bone Grafting is required when with the loss of the tooth, stimulation required for the maintenance of the bone height and width is lost and it therefore resorbs. This is a progressive process so the longer a tooth is missing the more likely it is, that a graft would be required to restore bone width and volume. This would happen either at the time of implant placement or in more extensive cases prior to implant placement.