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Slow and Staged Dental Implants

Most of the time my preference is for immediate extraction, implant and bone grafting simultaneously.  In this case it is best to slowly stage each out into separate procedures with some time in between.  This is because the bone loss is so bad it is much more predictable for the bone to be rebuilt with bone grafting to have a solid foundation for long lasting dental implants.  This concept generally applies to smaller areas of the mouth.  Most of my full mouth, “teeth in 1 day “ procedures do not have substantial bone grafting and yield more immediate results. This last molar dental implant case has a lot of pearls.   This is a woman in her 70’s who has a loose, failing bridge in the upper right area.  The remaining teeth have severe gum disease (bone loss) making the teeth loose.  This is also created the gap underneath the bridge.  As the bone loss is affecting her roots on those teeth, it is spreading forward onto the canine tooth.  When you have one bad tooth, it can spread to the others  especially when the disease is advanced.

Xray bone loss bridge
Severe bone loss spreading onto other teeth
Old Loose Bridge with gaps
Old Loose Bridge with gaps

Slow Sequence Of Molar Bridge Replacement

Procedure 1: Extract the bad teeth and do socket preservation bone grafting.  You can see on the photo where it has healed for about a week.  There is a dense PTFE (polytetrafluoroethylene) membrane that is non-dissolvable to hold the bone in.  I left this in for about 4 weeks.  At a follow-up visit removing the stitches and the membrane is quite simple.  In this case I used a combination of allograft (bone from a cadaver) mixed with xenograft (cow bone) for the best maintenance of the bone volume.  Underneath the membrane is newly formed a gum tissue and of course the bone which is regenerating.  I allow this to heal for approximately 4 months before she was rescanned with a 3D x-ray to check healing. Bone graft/membrane in mouth

Bone graft/membrane

Procedure 2: Under intravenous moderate sedation, the gum was reopened for the bone to be prepared for 3 implants.  The implants are placed in such a way that expands the outer wall of bone and makes sure that there is at least 1-2 mm of bone on the outer wall.  The gap in the gums is filled with a special gel called L PRF that stimulates healing.  This is made from blood from your arm and reintroduced into the mouth.  I closed the area with dissolvable stitches.  Most importantly the implants are of appropriate length and they are spaced out in such a way that they will perfectly fit the final teeth.  The implants are placed in such a way so that each crown can be screw retained.  This requires precision for the implants to have screw channels coming through the center.  I allowed the implants to heal for an additional 4 months.

Dental implants open flap blood
Day of surgery- dental implants placed into healthy bone
Day of surgery-healing abutments

Keep in mind that speed is not always the answer.  Although I do a lot of immediate implants sometimes going slow is a much better option! Especially when there is significant bone grafting, it is best for the bone to heal slowly before doing anything else. Procedure 3:  After about another 4 months of healing, I could begin restoring the case.  In my office, the impressions are not done with traditional gagging impressions, but rather by trios computer impressions.  A new x-ray is taken to verify there is solid bone and the implants have integrated.  Sometimes I will need to use my carbon dioxide laser to contour the gum tissue to make the teeth look and feel natural.  This controls the proper “emergence” from the gums.  The digital impression is then uploaded to my personal lab technician where we will go through a lab design together to work out the details of each tooth.

Screw retained implant crowns
Digital dental model of teeth
Digital implant model

  Procedure 4:  Deliver the final dental implant crowns.   At the delivery appointment most patients should be numbed.  This is because the implants are deeper into the gum and sometimes I need to use the laser again to get even better contours.  The spacing between each crown is verified, the bite is evaluated/adjusted and of course they have to look great!  At this appointment I reviewed the oral hygiene for how to maintain the implants over time.  I also take a final x-ray to verify the fitting of all the parts and to get a baseline on the bone levels.  This x-ray should be repeated at the one year mark because that is typically milestone for success.  If there are problems it is a good time to intervene if there is early onset peri-implantitis which can cause loss of the implants!

Side view of dental implant crowns
Side view of dental implant crowns
X-ray dental implant crowns
Top view of dental implant screw crowns. Blue dots showing bite pattern
Final dental implant teeth are shown on the upper left part of the picture

I hope you can see that sometimes going slow will yield the best results.  I wish I could have done this all in one fell swoop but that would not be the right thing.  Although it may have worked in the short-term, these molars are best replaced slowly! Each case is very specific and your dentist’s skill, training, judgment and experience has a lot to do with the success of the procedure. Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

4 thoughts on “Slow and Staged Dental Implants

  1. Hello Dr Amin. First, YOU ARE AMAZING! and Thank You & Bless You for all you are doing professionally to help so many people. How you find the time in your beyond-busy practice to share your talents & wisdom like this with so many of us in America (indeed, the world), is truly remarkable! I, personally, have gained so much valuable information from your Blogs, Articles, Q&A’s, etc., and if we didn’t live in Texas, and/or if I didn’t have complex Stage IV extra-pelvic endometriosis (& all that comes with it), we would have moved mountains to be able to have you do my All on Xs! However, even though we couldn’t physically make that happen, your writing & sharing has been invaluable in helping us to guide & decide regarding my own strategy here. As a result, I ended up finding an advanced, all-on-X practice locally, and very slowly & carefully over the last 2 years (corona virus delays w final bridge stages, etc) have had miraculous results thus far!
    Second, as positive as my local experience has been…we still of course miss that we couldn’t come to you…and thats particularly true currently as I face what seems to be a pretty complex issue/question (or, very least, it seems like one there isnt at all a clear answer to):
    We understand steroids (eg, those in Dr. prescribed medication for an unrelated illness or condition, or those that may be involved in epidural/spinal block or ilioinguinal nerve block procedures) are not good for integrating dental implants, and may also be contraindicated for some period PRIOR to dental implants being placed. My questions is:
    Is this also true for AFTER the implants are placed AND integrated? (If so, we also wonder how long, if ever, after dental implants are placed, might steroids used for other parts of the body be safe or not dangerous for the dental implants? Does the type of steroid, method of intake/delivery/location/amount/frequency/ etc matter?)

    I may soon need to have an ilioinguinal nerve block related to my Endometriosis & prior endo-related surgeries (have had bowel resection, etc…the whole basket of Endo goodies!). Im not sure they can do it without the traditional steroid part, with just anesthetic injected, etc, though we will be asking when we meet w that injection specialist in a couple of weeks. If they cant, ie if steroid must be included in the nerve block injection, when, if ever, is that safe, risky, too risky, contraindicated or not….after dental implants have been placed?

    My current GI surgeon, urologist, spine docs, PTs, OBGYN surgeons, regular dentist, old dentist, nurses at current All on X docs office, etc were all unsure the answer re timing of steroids AFTER implant placement….We will be asking the all on X doc in a few weeks when I have my next appointment w he and his lab & team to place my last version of pre-final bridges (yeahhh!)…But, im not sure he will have the answer either perhaps bc no one does bc science doesn’t yet. But, we still have the question/issue nonetheless!
    FYI: My 6 upper jaw implants were done Sept 2018 and my 6 lower were done Sept 2019 (I have a teeny mouth that just wouldnt take anymore implants….absent major bone grafting beyond that already done…or something more…in way way back I imagine..And even w a sinus lift I had on upper right, my bridges go pretty much all the way back there {and lower jaw does as well} bc mouth is just so small!).
    As for pre surgery and ever since, Ive made sure not to have any meds, nerve block injections (even topical skin creams) w steroids in them for a good year+ BEFORE the implants were all placed and THROUGH TO today…But im afraid my medical needs will soon be calling for them, or for certain will some day in future given my medical history, etc….So, even if I can avoid steroids for now, I may not be able to in the future whether theyre in an eg nerve block or even given during surgery, medication, etc…Thus, I really should gain a better understanding of their risks to all this beautiful dental implant work…And we’ve been hard pressed to find answers through asking, researching, etc….Hence…we come to you; my husband and I figure/hope that if anyone has some insight or even just reasonable or experienced “guesses” here, it would be you…and as always, any input from you would be invaluable!

    Thanks so much! LA (& her Saint of a husband!)

    1. Thank you for your very kind words.

      Steroid to given after integration of dental implant should not cause a problem. It is only a problem beforehand if you have been on high doses for a long time.

      Long-term steroid doses such as prednisone can become a problem if he has been taking it for a long time before the implant procedures. Most patients that take steroids sometimes have other comorbidities that make things worse. If you only taking steroids by injection every once a while for joint problems and is not really an issue.

      During my surgeries I give steroids both intravenously and intramuscular to help with swelling and pain but that is only for those few days

      Your health comes first and your dental come second.

      I would also make sure that you are not suffering from osteoporosis. Some people who take steroids for a long time have soft bones. A DEXA scan would be useful but I am sure you have had that already.

      I have treated many many patients on high dose steroids. It sounds like you are in good hands and thank you for your kind words

  2. My husband had a root canal a few years back his cap had fallen out and he never went to get it fixed now he is in severe pain the tooth or should I say what’s left of the tooth or where the cap was is exposed and he can feel these wire like pieces all in the roof of his mouth he kept putting his finger where the cap was trying to move some of those wire like pieces or metal whatever they are he kept messing with the tooth what are these things in his roof of mouth

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