Before dental implants were widely available, if you had any missing teeth your only options to replace them were a dental bridge, or a removable denture. While both are good options, they both come with limitations. Namely, the bridge requires the shaving down of the support teeth either side, and the denture requires removal after meals to clean, and removal overnight, and traps food and plaque underneath it. Additionally depending on the situation in the rest of your mouth, the denture or the bridge may not be possible.
Dental Implants can offer a great way to replace a single missing tooth, or several missing teeth. They are widely considered the gold standard to remove a single missing tooth.
Dr Carla has been putting the crowns on implants since 2011. She took the next step and began her implant surgery training at the Branemark Centre in Perth in 2017. She then completed the Master Clinician of Implantology program (GIDE) with Loma Linda University in California, USA in 2018. This course focused on bone and soft tissue grafting techniques. She is a strong believer in continuing education and continues to do training to refine her skills at every opportunity.
What is an implant?
An implant is a titanium screw, which acts as a replacement root! If only one tooth is being replaced, then a ceramic tooth (also known as the crown) is then fitted onto the titanium replacement root. If more than one tooth is missing there are different ways for the implants to support the missing teeth. These can be as a bridge, or an implant supported denture.
Titanium is a very special material because it is one of the only things in the world our bone will actually grow onto and attach to! This is very important.
Above, implant replacing a single missing back tooth next to natural teeth.
Like all things, a good outcome starts with a comprehensive plan. You will be directed to a radiology clinic to have a 3D x-ray of your jaws, known as a Cone Beam CT (CBCT).
Dr Carla will take moulds of your teeth and then using the CBCT digitally plan where your implants will go. This plan ensures the implant keeps away from important structures like nerves and your nasal sinuses, and also helps determine if any bone or gum grafting may be required. Then, depending on the situation and which is best, she will either place the implants fully guided with a printed stent that fits over the top of your other teeth, or she will place the implants free hand. Dr Carla and the team are sure to follow sterile surgical procedure at all times.
Depending on how tight the implant goes in to the bone will determine if a tooth can be placed on top straight away. Generally however the implant needs the bone to heal to it for three months before the tooth (crown) can go on top.
While your implant is healing and you are waiting for the tooth to be fitted to the implant, you can choose to have a removable denture made to replace the teeth that are missing. People replacing missing front teeth often choose the temporary partial denture, while people replacing missing back teeth often opt to go without the temporary denture.
Above, Dr Carla digitally planning an implant for a top back tooth
Great! Am I a good candidate for implants?
Implants are a surgical procedure and as such have surgical risks. If you are unwell or have medical conditions that put you at a high risk for surgery, implants may not be right for you.
While this is not an exhaustive list, below are listed some medical conditions that place you at a higher risk of implant complications or failure
gum (periodontal disease)
autoimmune diseases (particularly those treated with steroids)
if you have ever taken a class of drugs known as bisphosphonates (often used to treat osteoporosis and metastatic cancer)
If your gums are already thin and receding, then you may benefit from a gum graft.
If you don't have enough bone where your implant needs to be, you will most likely require a bone graft. This is why the CBCT (3D x-ray) is necessary to see how much bone is under your gums.
Other things that can make an implant more difficult are;
if your teeth are very triangular in shape
if you clench or grind your teeth
limited gap between other teeth to place your implant
you show a lot of gum when you smile/laugh etc
Timing of Implants (screw placement)
There are different options for when is the best time to place your implant. Some of the common options are listed below.
An 'Immediate' Implant means that your tooth is extracted and the implant (screw) is immediately placed. It does not necessarily mean that the tooth can be placed on the implant straight away. An immediate implant may be suitable in cases where there is no infection, and there is adequate bone around the tooth the place the screw. What determines if the tooth can go on top of the implant at the time the implant is placed largely depends on how tight the screw went in, and if you need any other gum or bone grafting at the same time.
Early placement is when the implant is placed 6-8 weeks after the tooth has been removed. The benefit of this technique is that it allows the gum tissue (which heals fast) to heal, and if there was any infection in the tooth prior to its removal, the body will have had a chance to completely remove any bugs left over. Usually at the time of implant placement, a bone graft is required. Early placement is suitable for front teeth that have infection present.
Delayed placement is when the implant is placed more than 3 months after the tooth has been extracted. At this time the bone would have had a chance to fill in where the root(s) of the tooth used to be. While this is beneficial in some ways, it has it's disadvantages as well. The reason for this is that once a tooth is removed, the bone that supported the tooth actually disappears over time because the tooth is what kept the bone there. If you require a tooth to be extracted, and are considering an implant in the future (i.e. longer than three months) it may be beneficial to have a socket preservation procedure (small bone grafting) to keep more bone there longer.
Timing of final crown (tooth on top)
The timing of when the tooth goes on top of your implant depends on when the bone has healed. Bone is quite slow to heal. Our natural bone heals faster than the material from a bone graft (which acts as a scaffold for our natural bone to grow into).
No bone graft
If you have not required a bone graft, and if you are fit and healthy (i.e. no systemic medical conditions), then usually the crown (tooth) can go on top of your implant 3 months after the implant was placed.
If you required a bone graft to have your implant placed, then this bone takes a bit longer to heal. Usually we need to wait 6-9 months after the bone graft procedure before placing the tooth on top.
A gum graft usually requires 2 months of healing before the tooth can be placed on top.
What is my final crown crown made of?
Your final crown will be made from Zirconia and may be layered with ceramic to enhance the translucency, which is important for front teeth. Zirconia is a very strong material that is white. The base that screws into the implant is made from Titanum.
Above, Zirconia Implant crowns with Titanium bases
What are my temporary teeth options?
If waiting up to 9 months without a tooth is not going to work for you, then there are several temporary options. Some times you will b given a combination of the temporary options.
1. Suspension Bridge
A suspension bridge 'suspends' the replacement teeth in a rigid clear plastic tray which is held up by covering your other teeth. Because the replacement teeth are held up by your other teeth, there is nothing making contact with your gum. This is very very beneficial because after your implant and any bone or gum grafting surgery you do not want to have fake teeth touching or rubbing on the delicate gum area. For this reason, the suspension bridge is usually to go-to temporary for a month or two immediately after your surgery.
Caring for your suspension bridge: This type of temporary is prone to wear and tear, especially if you chew food while wearing it. It is important to remove the suspension bridge after you eat and drink to rinse it and rinse your teeth to remove any food or drink residue. Rinsing your mouth and suspension bridge helps keep it clear longer, and reduces the chance of damage to your other teeth. As the clear tray is made of plastic, is is likely to stain. Avoid eating and drinking things that would stain a white T-shirt (e.g. beetroot, turmeric, coffee, tea, etc). The plastic can change shape if it gets too hot, so avoid putting very hot things like hot drinks and soup in your mouth, or using boiling water to clean. The clean, use liquid soap and a soft tooth brush twice a day. Every couple of days you can soak it in denture cleaning tablets for a few minutes. DO not use harsh chemicals or bleach.
Above, Suspension bridge replacing 4 top front teeth and gum. Two implants will support a new 4 unit implant bridge
A denture is a removable plate that rests on your gums, and hooks onto your teeth with metal clasps. Because it rests on your gums, it is best avoided to use for a couple of months after any implant, bone or gum grafting surgery.
The benefits of the denture over the suspension bridge are that because it does not cover the biting surfaces of your teeth, it is more comfortable to chew your food. It is also made from a much stronger acrylic which makes it is more durable. It is also more stain resistant, and can last several years.
Caring for your denture: The denture is more robust than the suspension bridge. Remove after eating to rinse your mouth and the denture. Clean twice a day with a soft brush and liquid soap. Do not use harsh chemicals, toothpaste, or bleach. A couple of times a week soak for a few minutes in denture cleaner.
Above, acrylic partial denture on stone model replacing four top teeth
3. Immediate Temporary Implant Crown
If you don't require any bone or gum grafting, and when your implant is placed into your bone it is nice and tight there is the option to have an immediate temporary crown fitted to your implant. The temporary crown is made from composite resin (white filling material). It is screwed into the implant the same way your final ceramic crown is. The temporary implant crown is only for fashion, not function. It will have the shape and colour of a tooth, however it should not be used for biting or chewing. Any pressure placed on the tooth will travel down to the implant. Just like a broken arm or leg, the implant needs to be very still to heal properly. After the 3 months of healing of the bone to your implant screw, a mould is taken and your temporary composite crown is swapped for a new ceramic crown.
Caring for your immediate temporary implant crown: The area needs to be kept very clean with gentle tooth brushing and mouth rinsing for a couple of weeks after it is placed.
4. Long Term Temporary Implant Crowns
You may benefit from a long term temporary crown if your implants have been placed in an 'aesthetic area', for example your front teeth. This is because sometimes it can take the gums several months to settle, and having a long term screwed in temporary crown (or bridge) means that you have a more comfortable temporary than a denture and your gums have an opportunity to stabilise before your final crown in ceramic is made. The temporary crown is screwed into your implant. It is made of plastic. The colour will not be as beautiful as the ceramic, and it won't be as strong. Normally the long term temporary crowns can be made once your implant has finished healing (see above). You may wear the long term temporary crown for several months.
Caring for your long term temporary implant crown: The area needs to be kept very clean with gentle tooth brushing. You can use small interproximal brushes to clean around your temporary implant crowns.
What about maintenance?
Implants need to be closely maintained and monitored by a dentist for the rest of their life! The seal of the gum to an implant is no where near as strong as the seal of your gum to your natural teeth. This means that the gum around the implant is vulnerable to getting damaged and infected. This can lead to bone loss around your implant! Bone loss is the nemesis of implants, and is very hard to treat!
Above, the connection of gum to an implant is much weaker than gum to a natural tooth. Notice a deeper gum gap ('pocket') which allows plaque and food to sneak in, and fewer connecting fibers
At home maintenance
Cleaning around your implant at home is super important!
You want to brush gently and thoroughly (we recommend an electric tooth brush). Do not do any sort of scrubbing as this can damage your gum.
Cleaning between or around your implants:
To clean between implants we recommend ditching the floss! This is because studies have shown that the tiny fibers of floss can get stuck under the delicate gum around your implant and lead to bone loss. We want to avoid bone loss at all costs! So, to clean between your implants we recommend the small interdental brushes. You can still use floss around your natural teeth if floss works well for you.
Above, interdental brushes
Above, electric toothbrushes
You should have your implants reviewed by the dentist every six months at least. There, the health of the gum can be checked and x-rays can be taken to check the bone levels. As described above the attachment of the gum to the implant is very delicate. Additionally the implant titanium is actually very delicate as well and prone to being scratched. To avoid any accidental damage to your implant, make sure you only have it cleaned with the AirFlow Master. If there is tartar build up on your implant (hard white stuff that doesn't come off with the Airflow powder), the Airflow Master actually comes with coated tips to gently remove the tartar from your implant screw without scratching it.
What are the Risks and Complications of Implant treatment?
Implant treatment is a surgical procedure and carries risks. Some risks associated with implant surgery include bleeding, swelling, infection, damage to near by teeth, damage to near by nerves or structures such as the nasal sinuses, and failure of the bone to attach properly to the implant and the implant failing and requiring removal. If you have a bone graft or a gum graft there is also a risk that they may fail and require removal and replacement. The medical conditions listed above increase your risk of complications.
There are also risks you get bone loss or infection around your implant (this may happen years after the implant is placed). This is called peri-implantitis, and requires treatment. If there is too much bone loss the implant may require removal.
The crown and screw attached to your implant may also chip and require replacement.
Regular maintenance helps to catch any complications early.