VII: THE TREATMENT PROCESS: STEP BY STEP FOR CERAMIC (ZIRCONIA/METAL-FREE) IMPLANTS
A.PRE-SURGICAL CONSIDERATIONS
1.PRE-SURGICAL CLEARANCE
- Medications which affect blood coagulation: If you take blood thinners (even a daily aspirin), these must be stopped up to 5 days before surgery. Your medical doctor will need to be contacted and clear you for surgery.
- Medications which affect bone metabolism: certain medications in the Boniva class (bis-phosphonates for bone density) and chemotherapy may contra-indicate surgery. Some of these effects can be reversed and must be done before surgery.
2.ANETHESIA: LOCAL OR GENERAL?
- Local: That is, regular Novocain injections are sufficient for 95% of cases. It is important to eat a large meal with protein prior to surgery.
- General: If general anesthesia is required or requested, patients must consult with our anesthesiologist Dr. Atlas prior to surgery. Do not eat, or drink after midnight prior to the surgery and you must have a driver to drive you home.
3.GOALS OF SURGERY
- Bone Replacement vs. Bone Regeneration
Bone regeneration is the ability of your body to grow vital or live bone. Part or all the bone graft may die due to poor blood supply, ischemia (cut off blood supply), poor coagulation (blood clotting) and other reasons. This topic is covered in Bone Grafting.
- Placement of the Proper Size Implant
Although this seems obvious, this is not always achievable. In the molar (back teeth) region, more bone is needed to provide a larger implant in order to restore a larger tooth. A small tooth in the molar area is harder to chew on and has a greater failure rate. REMEMBER- the purpose of the implant is to support a crown which is healthy, cosmetic and functionable.
4.DAY OF THE SURGERY: DO’S AND DON’TS
- DO– get plenty of sleep and rest the previous night. Again, eat a large meal if getting local anesthesia to avoid a drop in your blood sugar.
- DON’T– Take any medications or supplements which interfere with the Novocain or thin your blood too much such as Vitamin C, Antioxidants, Fish oils and omega 3,6,9 oils. Coffee reduces one’s pain threshold and has a high level of vitamin K (induces clotting) so it is recommended to not drink if unless one will get a headache.
5.POST-OPERATIVE SELF CARE
- Natural pain and anti-inflammatory products can be recommended. Ozone and homeopathic products are given to the patient. Over 95% of our patients choose this approach.
- Pain killers and anti-biotics are available to patients if necessary.
- THE TOOTH EXTRACTION PROCESS
1.TREATMENT GOALS: ARE WE TREATING THE TOOTH OR YOUR WHOLE BODY (SYSTEMIC DENTISTRY)?
The concept of systemic dentistry is concerned with the role of teeth in regards to your systemic (or “whole” body) health. Once a tooth is infected (an infected tooth may be sensitive, painful or asymptomatic), the infection will spread into the bone around the tooth. Infections, bacteria and inflammatory cytokines (proteins which turn on and off your body’s inflammation), will concentrate in the bone and enter the bloodstream.
Once in the bloodstream, these factors can affect susceptible cells causing infection or inflammation somewhere else in the body (hence, oral-systemic infections or inflammation) possibly causing or contribution to a condition which can now worsen (as a result of a tooth condition). Our goal (and yours) should be to remove the entire dental foci, that is, the area of infection or inflammation causing a systemic problem:
SYSTEMIC-DENTAL CAUSAL PATHWAY:
Insert Graph called Systemic Oral Pathway
2.TREATMENT PHILOSOPY AND TECHNOLOGY:
HOW CAN I GET THE RESULTS I EXPECT?
There are two major treatment philosophies in dentistry today-traditional and integrative dentistry. Integrative dentistry is essentially the traditional model with holistic and biological modalities incorporated into the procedures.
Systemic Dentistry is a scientific concept which must be incorporated into one’s procedures. One reason it is not popular among integrative dentists is because of the difficulty of applying new techniques and in getting consistent, predictable results.
The oral-systemic causal pathway presents patients and dentists a step by step pathway which shows the root causes. The technique, in order to eliminate all the causes, must have a method to verify all the root causes have been eliminated. Once this is established, the procedure will now be verifiable and hence successful.
A new philosophy, called Bio-Energetic Dentistry, has been founded upon the concepts of systemic dentistry and employs bio-feedback energetic techniques such as Applied Kinesiology (which is essentially biofeedback therapy) as a novel verification system.
The central problem of all dental philosophies is the complete removal of infection or inflammation. Without full removal, although the tooth is removed, the body reacts as if the infections is still present and provides one with a false sense of security. To be fair, holistic dentistry maintains it cannot remove the entire infection and further surgeries, may be required. *Our goal is to remove the entire infection in one procedure to allow the patient to be confident that his or her mouth no longer has any chronic, or hidden infections. Under these conditions, the body will heal to the extent the oral cavity was the prevailing negative influence. of the disease process. Further, once the oral cavity has been completely healed, the patient can now look for other causes if the condition persists.
TOOTH EXTRACTION AND SYSTEMIC DENTISTRY
THE CAUSAL PATHWAY (Which must be successfully removed and be verifiable)
INSERT GRAPH Called: Tooth Extraction
3.THE TREATMENT PLAN: WHAT ARE MY OPTIONS FOR SAME DAY IMPLANTS AND SAME DAY TEETH?
- EXTRACTION AND SAME DAY BONE GRAFTING
Extracting of problematic teeth require a bone graft to prevent bone loss. This procedure is necessary for future implant placement and future bridge work where cosmetic and periodontal considerations require stable bone levels.
In many cases, bone grafts can be planned at the time of extraction. Bone grafts may require 3-4 months of healing in the lower jaw and 6-7 months in the upper jaw.
There are some circumstances which will contra-indicate a bone graft at the time of extraction which may be decided at the time of the surgery.
These include of the following factors:
High patient systemic inflammation
Extractions requiring extensive bone removal resulting in a high level of “inflammation” in the extraction site (ex. Root canaled teeth)
Extractions of infected and fractured teeth
Poor blood clotting
Likewise, there are circumstances in which multiple bone grafting appointments may be required. (Requiring another surgical procedure)
Some of these factors include:
Extensive bone loss
Loss of bone, plates’ (buccal and lingual)
Loss of vertical bone height
- SAME DAY (IMMEDIATE) IMPLANT PLACEMENT
There are occasions in which implants can be placed at the time the tooth is extracted.
The same day placement of an implant can speed up the treatment time and save 3-6 months because the two procedures are being performed together require only one healing phase.
Many times this can be determined beforehand or at the time of surgery. There are also times when it appears one is a good candidate for same day implant placement and certain events are revealed during the surgery which contra-indicate is such as:
Difficult extraction creating inflammation
Extensive bone loss not allowing implant stabilization
Poor clotting on the patient’s part
- SAME DAY TEETH
Full Arch or Full Mouth cases (upper and lower) almost always allow same day teeth to be placed on the implants because many implants allow equalization of pressure. A single implant has to resist all of the forces and, therefore, special consideration has to go into determining whether it is a candidate for a same day tooth.
A same day removable tooth, nicknamed a ‘flipper’, is generally made because it places less stress on the implant and is removed at night (clenching on the implant will cause implant failure). However, there are cases when a same day fixed (that is, cemented) temporary crown can be placed.
- BONE REGENERATION AND BONE GRAFTING: ARE THESE SIMILAR RESULTS?
A.DEFINITION AND CONCEPTS:
“BONE REGENERATION”
- Refers to the creation of new vital (alive) bone without infection, inflammation or dead bone.
- Vital bone conducts the acupuncture meridian energy through it. As a result, the tooth site and all the organs on that meridian remain healthy.
- As of now, there is no technique which creates regenerative bone.
“BONE REPLACEMENT”
1.Refers to bone which appears normal and healthy clinically and on Xray’s (even 3-D CT Scans) but can be up to 90% non-vital (‘dead’).
2.Non-vital bone does not conduct energy through the meridian. As a result, the body ‘acts’ as if the dead tooth or infection is still present and the organs/glands on that meridian remain affected.
3.As a result of the holistic dental techniques (a higher standard), the average meridian energy is around 20%.
Osteomyelitis-inflamed or infected bone.
Osteonecrosis-non-vital dead bone; most sites contain a combination of these.
- BONE GRAFTING PROCEDURES
- BONE PRESERVATION
Typically, after a tooth is pulled, a bone graft must be placed or bone loss will occur. This will decrease your chance to place an implant or require you to perform a more complicated bone graft if you later choose an implant. Bone preservation is also called ‘socket’ grafting because bone grafting materials are typically placed in tooth socket immediately (or shortly after) an extraction.
- BONE AUGMENTATION (REPLACEMENT)
Augmentation attempts to increase the amount of bone present (usually lost by not placing a bone graft) in order for implants to be placed.
- SINUS GRAFTING
Many patients have a ‘low’ sinus in the upper molar region. Implants need a critical width and length (height) in order to be successful. Frequently, as a result of a low sinus, this height is inadequate to support an implant and requires bone grafting. A sinus ‘lift’ is a more conservative approach which is successful if only 2-3 millimeters of bone is necessary, whereas the sinus augmentation graft is necessary for larger defects.
- BONE GRAFTING PROCEDURES
TYPES OF BONE GRAFT MATERIALS.
INSERT: Bone Grafting Procedures
E.BARRIER MEMBRANES (FOR BONE FORMATION); DOES ONE SIZE FIT ALL?
1.THE CONCEPT OF ‘CREATING’ BONE– Periodontal Disease, essentially loss of bone height around teeth, was traditionally treated surgically. Once bone loss and gum recession occurred, surgeons lifted the gum off the bone, removed calculus, added bone particles and placed the gum at a higher level to allow bone growth. Since gum heals faster than bone, the gum grew into the bone, displacing it, with the unintended effect of the gum healing at the same (pre-surgical) level.
The purpose of a barrier membrane is to block gum growth into the graft in order to give the bone space and time to grow. These vary from synthetic to natural products, which either resorb (dissolve) naturally or require a second surgery to remove them.
Many patients came in and demand a certain type of bone or membrane and get upset when these procedures fail. The choice of bone and membranes is partially (and sometimes fully) dependent upon the procedure or extent of the surgical site.
Part of the confusion lies in the fact that many dentists are not aware of limitations of grafting and membranes because manufacturers tell them “one size fits all” and their product can provide all membrane requirements. Further, there are some products (even natural ones) which are highly inflammatory thereby slowing or stopping the healing process. To make matters worse, an antibiotic may be prescribed which has little to no effect on inflammation. When failure occurs, it later becomes obvious the material was contra-indicated to enhance grafting.
2.BARRIER MEMBRANE PROCEDURES
- GUIDED TISSUE REGENERATION (GTR)- in this procedure, membranes are utilized to enhance soft tissue healing and bone healing for small sites (ex. Extractions)
B.GUIDED BONE REGENERATION (GBR)-When large bone grafts (such as augmentation) or multiple teeth extractions sites require grafting, GBR is utilized.
Note: As discussed, the term regenerations when used in dentistry does not denote vital (or ‘live’) bone. Most dental grafting, even with appropriate bone and membranes, still yields non-vital (dead) bone.
- PROTEIN RICH-FIBRIN (PRF) / PROTEIN-RICH PLASMA (PRP): CAN ONE SIZE FIT ALL?
PFR, which is the newest protocol amongst the protein-rich plasma procedures is being heavily marketed in the holistic world as not only natural, but being a ‘one size fits all’ procedure. As I stated earlier, each case is individual and requires a full examination of bone and membrane materials in order to obtain successful bone replacement.
The leading authority on PRF (listed below) summarizes the pros and cons of the technique as follows in his latest research:
- There are NO Stem Cells in PRF (Every patient inquiring on this procedure were told it contained their stem cells)
- PRF, as a barrier membrane, may be superior in enhancing soft tissue (gum and mucosa) healing.
- PRF, for bone grafting, at this time is inferior to traditional bone grafting:
- Socket Preservation (conservative sites): bone grafting is still indicated.
- Bone Augmentation (growing new bone) PRF is not indicated.
- Root Canal Extractions –PRF is contra-indicated; root canals are difficult extractions with extensive inflammation usually requiring bone removal therefore, routine grafting is indicated.
- PRF, for Third Molar Sites, is indicated as it shows a decrease in post-operative complications such as “dry sockets.” However, this does not correlate with improved bone replacement, that is bone healing and live bone growth.
4.BARRIER MEMBRANE -VS-PROCEDURE
INSERT CHART CALLED: Bone Grafting
- SURGICAL PLACEMENT OF THE IMPLANT
1.TECHNIQUES FOR IMPLANT PLACEMENT
-‘Standard’ Surgical Procedure
-Guided Implant Procedure (for complex and nerve proximity cases).
2.PROTOCOL: BASIC SURGICAL STEPS
Step 1: A Gum Flap is created to expose the underlying bone to determine it’s width and quality.
Step 2: Bone drilling is performed to establish the proper depth. The implant needs to be a certain length particularly in the back teeth where biting forces are stronger.
Step 3: Once the proper depth is established, the proper width is created. Another implant goal is to place an implant with a width similar to the extracted tooth. This allows the restored tooth to be similar in size, shape, strength and position of the previous tooth.
Step 4: The implant is now placed into the bone site and gently tapped in. In order for the implant to be successful, it must have ‘primary stability’. That is, the implant must be torqued to the point where it is stable. Otherwise, it may need to be removed and regrafted.
Step 5: Sutures are placed and Post-Operative Instructions (natural Protocol) are given.
Procedures to enhance healing, pain reduction and infection (reduction) are now performed:
Homeopathic Procedures
Ozone Injections
Neural Therapy
Acupuncture
3.HEALING PHASE AND HEALING TIME
Good nutrition with vitamin D3 and K2 are recommended. We recommend patients to avoid acidic and sugary drinks which may induce calcium loss and therefore affect bone metabolism. These include excess coffee, black teas, soda, fruit juices, commercial ice teas, alcohol etc.
Healing time for implants:
Upper Jaw: 6-7 months
Lower Jaw: 3-4 months
- TOOTH RESTORATION OF THE IMPLANTS
- FIRST APPOINTMENT
-A post or abutment may be inserted into the implant. The impression is then taken and sent to the lab.
–Type of Abutments:
“Standard” Abutment can be utilized depending upon the implant system and case factors.
“Custom” Abutment is generally used in more difficult cases or to get parallelism in bridge cases (allowing seating of the bridge)
2.SECOND APPOINTMENT
-For simple cases, the crown or the bridge may be tried in, adjusted and cemented. The case is done!
-For other cases, the implant components may be tried in, re-impressed and sent back for more work.
3.STABILIZATION: LONG-TERM IMPLANT HEALTH
HYGIENE MAINTENANCE– Hygiene appointments are necessary to control inflammation around the implants (ceramic has much less inflammation than metal implants). Inflammation can cause implant infection (“implantitis”) and loss of the implant.
STRESS REDUCTION-Clenching on the implant may cause it to loosen or fracture. A mouth guard could help preserve the implant.
Home Care– Flossing around and under the implant will extend its life by reducing inflammation. It is the amount of inflammation that determines the frequency of your hygiene appointments (that is, whether it is every 3, 4 or 6 months)
REFERENCES
OSSEOINTEGRATION: On Continuing Synergies In Surgery, Prosthodontics and Biomaterials;
Zarb et al, Quintessence 2008
(Note: The Dental Standard for bone healing and implant healing).
BONE AUGMENTATION IN IMPLANT DENTISTRY; Pikos: Quintessence 2019
(Note: Industry standard for Bone Grafting, Membranes and Implant Surgery)
IMMEDIATE DENTOALVEOLAR RESTORATION:
Da Rosa et al; Quintessence 2014
(Note: Another Industry Standard on the repair and augmentation of bone).
UNDERSTANDING PLATELET-RICH FIBRIN
Miron; Quintessence 2021
(Note: The latest science, not fiction, on PRF by the leading expert).
