Preparation for Implants
Implant treatment is generally very straightforward. Careful planning before we start in conjunction with Dawood and Tanner will make sure that treatment proceeds smoothly and predictably.
Where one or just a few teeth are to be replaced in an otherwise intact dentition planning is usually straightforward. However, in circumstances where there is little bone available, or few teeth remain to guide the surgeon in his choice of implant positions, planning may begin by ‘designing’ the appearance of the new teeth, focusing on the shape and appearance of the teeth, as well as the support for the lip, and the amount of teeth or gum that is visible when smiling or speaking – this is particularly important for patients who have little remaining bone, or have been wearing dentures for a long time.
In situations where there has been bone loss, we would often ask our patients to have a Cone Beam CT scan. These scans are special radiographic (X-ray) procedures, which allow us to create an accurate three-dimensional computer simulation of the jaws. This extraordinary technology means that we can examine the intended implant site in 3D, to get a clear understanding of the anatomy of the region and pre-select the types of implant which will be used.
We use the resources of Cavendish Imaging (www.cavendishimaging.com). This centre has some of the latest scanners available, as well as facilities to produce 3D jaw replicas from the scan, and scientists to help with planning and diagnosis.
In some situations this scan may be used for planning computer guided implant surgery, or minimally invasive surgery, where implant positions are planned in software, and treatment is carried out using specially made rapid prototype drill guides. (see: Guided Surgery)
To complete the planning process we may also prefabricate temporary bridgework or prototype bridgework which will allow us to deliver temporary teeth at the same time as the surgery, Immediate Implant Teeth, All-on-4.
If you feel anxious about the procedure you may request or be offered treatment under oral sedation in conjunction with Dawood and Tanner with a mild sedative; you would then need to be picked up from the practice, and escorted home.
Intravenous sedation is also available, by prior arrangement. Intravenous sedation puts you into a drowsy state and makes the whole experience as comfortable as it can possibly be.
You will be able to leave the clinic approximately one hour after treatment, and you should make arrangements to be accompanied by an escort and taken home by car or taxi, where somebody should remain with you for the rest of the day. After the procedure you must not drive or operate machinery, or sign any legal documents for 24 hours. Please note that it is advisable that you rest for at least 48 hours after surgery.
In order to support dental implants we sometimes need to augment or “graft” the jaw to provide sufficient anchorage. There are many ways to achieve this, using a variety of different materials.
Before grafting we will generally take three-dimensional scans of the jaws to visualise the bony defect, and if bone is being taken from elsewhere in the mouth to map out the “donor” area.
We often prefer to carry out surgery under sedation for larger grafts. Sedation puts the patient into a dreamy comfortable state and makes the whole process as pleasant as it can be.
Typically, after surgery, there is little pain, but sometimes there is quite significant swelling or bruising particularly if bone has been collected from the chin or side of the jaw.
Grafts usually work well as a way to gain more bulk to anchor implants, e.g. at the back of the upper jaw in relation to the sinus. However, building up bone height at the front of the mouth can be difficult where there is a large visible defect. Under these circumstances, further grafting with gum tissue, or alternatively using pink porcelain or resin to simulate gum may be necessary to make up the difference.
Sometimes grafts are placed along with special membranes, which stop the gum tissue from growing into the bone, and encourage the grafted bone to bond with the local bone. Bone grafting can take place with your own bone or with bone substitutes.
Using your own bone
In the process of preparations that we may anyway make for implant treatment elsewhere in the mouth, we sometimes also generate fragments of bony debris. This bone ‘dust’ can be collected and used to build up areas that are deficient in other parts of the jaw. Sometimes we use special collectors that fit onto our suction system that allow even the very small particles of dust to be collected. This approach works well for small defects, where multiple implant sites are being prepared around the mouth.
Where there is a large defect, pieces of bone may be taken from the side of the jaw in the wisdom tooth region, or from the chin, and used to graft the deficiency. When taking bone from the chin, a small nerve that runs to the surface of the skin can be damaged leaving a small patch of numbness. This is rarely a problem, but can be irritating for a few months. Generally, we now prefer to use substitutes in order to avoid a second surgical procedure.
For very large defects, bone may be taken from the hip or knee – but nowadays we often have other solutions for these sorts of problems – see ‘zygomatic’ implants.
The advantage of using synthetic bone is that no other surgical sites need to be used to gather bone to graft. Synthetic bone works well in small amounts and can be used to good effect in small defects. The biomaterial is generally delivered in small vials and either takes the form of a calcium type mineral or a bio-glass. We try not to rely entirely on grafts of this material, so we tend to use it when the implant can be at least partly stabilised in existing bone.
Bovine Bone Mineral
Where larger grafts are needed it is now common practice to use bone mineral derived from a bovine source. This material is prepared from a very carefully controlled source and has been processed to remove all organic material leaving only the mineral structure behind.
This material is particularly useful for a ‘sinus lift’ surgery where the sinus membrane and floor is lifted to create a pocket into which the bone mineral fragments are inserted.
In all cases, where bone grafts have been carried out there is a need to allow for prolonged healing of the region before the implants are placed. Typical healing periods are 2-3 months for your own bone and 3-6 months for synthetic or bovine mineral.
Patients who smoke are very much more susceptible to problems with their teeth and gums in general; bone grafting should not take place in someone who is smoking heavily – even light smoking can cause small problems with healing. We would also usually need to delay treatment if a patient had a cold.
Careful cleaning of the grafted site is important. You will be given antibiotics and an antiseptic mouthwash for the first few days, and later on gentle brushing will be encouraged as directed. Occasionally granules of bony material may appear in the mouth or in the wound. This is not a concern as the region is usually ‘over’ -filled.
Pain would usually be controlled well with the painkillers that we will provide you with, and is not usually a problem. Do, however, let us know if there is significant discomfort.
Smoking & Implants
The adverse effects of smoking on health are well documented. Cigarette smoking is considered the single most important preventable environmental factor contributing to illness, disability and death. The mouth acts as a primary target for tobacco smoke, as well as being affected by tobacco products in the blood stream.
Smoking affects wound healing and tissue turnover: not surprisingly this means that people who smoke, age faster with deterioration of their skin, hair, bones, and gums. Interestingly, by way of example, older people who smoke are three times more likely to fracture their hip as a result of the affect of smoking on bone density.
Unfortunately, not so many people are aware of the hugely significant effect that smoking has on their teeth and gums.
People who smoke have fewer teeth, more gum disease and more complicated patterns of healing. This is particularly troublesome after surgery. Smoking will reduce the success rate of gum surgery and implant surgery, and will for some people cause failure of implants.
In the short term, smoking before surgery or just after surgery may prevent proper healing and the implant may never ‘take’. In the longer term once the implant has set in place smoking may cause bone loss around the head of the implant and shrinkage of the gum – these are chronic problems and in a way rather similar to the effects on teeth and their supporting bone. However, eventually if bone loss continues the implants can be lost.
We know how difficult it can be for some people to stop smoking. However, our advice has to be to stop smoking altogether if you are having implant treatment. Not only will this help to make sure that your treatment is problem-free and long lasting, but it will also help to keep you healthy enough to enjoy the new teeth.
We are always happy to assist our patients with advice on smoking cessation.