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.
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.
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.
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.
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!
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