Ceramic (Zirconia/Metal-Free) Implants

CERAMIC IMPLANTS ARE POSSIBLY SAFER AND MORE AESTHETIC THAN METAL IMPLANTS.

  1. Ceramic Implants are non-metal implants made from Zirconia. Success rare are similar to metal or Titanium implants ranging from 92-98%. A Recent European survey showed 65% of respondents prefer ceramic over metal implants. The major reasons for the preference were biocompatibility, (health tolerance) and strength.

ALL CERAMIC IMPLANTS ARE NOT EQUALLY BIO-COMPATIBLE

Although ceramic implants are inert, there is still a chance a patient may not be biocompatible to all brands. We are all unique, a concept called ‘biochemical individuality’. Despite the safety of ceramics, additional added materials can render them non-compatible to susceptible individuals. We have most brands of the ceramic implants and will test you prior to placement to ensure the brand we use is safe for you!

ceramic Zirconia Metal Free Implants

I: WHAT IS A CERAMIC (ZIRCONIA METAL-FREE IMPLANT)?

  1. A. Implant (itself)
  2. B. Abutment
  3. C. Restoration

II: AM I A CANDIDATE FOR DENTAL IMPLANTS? YES, IF YOU ARE…

  1. Missing teeth
  2. Problem teeth (painful, cracked or loose teeth)

III: WHAT IS INVOLVED IN DENTAL IMPLANTATION?

A. DIAGNOSIS

Missing teeth:

a)Tooth diagnosis (adequate space for tooth)

b)Bone diagnosis (amount of bone/sinus/nerves)

Problem Teeth:

a)Tooth diagnosis (the dental nerve dead or alive?)

b)Bone diagnosis (bone preservation or bone defects?)

B. PROGNOSIS (concept=fore-seeable)

  1. Prognosis of problem teeth; will they last?
  2. Prognosis of proposed treatment plan; will it be successful?

C. TREATMENT PLAN AND OPTIONS

  1. Single Implant Cases (70-80% of cases)
  2. 2.Multiple implants with bridges cases
  3. 3. All on 4 cases/ All on 8 cases, Same day teeth, Full arch (upper or lower teeth) or Full mouth (upper and lower teeth)

IV: FREQUENTLY ASKED QUESTIONS /FAQS

  1. Are Ceramic (Zirconia/Metal-Free) Implants Successful?
  2. Are Ceramic (Zirconia/Metal-Free) Implants Strong?
  3. Are Ceramic (Zirconia/Metal-Free) Implants Safe?

V: CERAMIC (ZIRCONIA/METAL-FREE) VERSUS TITANIUM (METAL) IMPLANTS: WHICH IS THE BETTER IMPLANT?

A. MAJOR FACTORS RELATED TO IMPLANT PERFORMANCE (CHART)

  1. Bio-compatibility: Systemic (General) health and safety
  2. Implant Success and Reactivity: Health of surrounding gum and bone tissue
  3. Cosmetic Appearance: Final crown and implant esthetics
  4. Bio-mechanics: Performance of the implant and crown
  5. Treatment Options; Preferred implant choice for type of restoration

B. DISCUSSION OF PERFORMANCE FACTORS

  1. Bio-compatibility factors: Autoimmunity; Titanium tolerance; nickel allergenicity, Implant reactivity; Galvanism (battery effect in the mouth);
  1. Implant Corrosion. Effect of fluoride on metal implants; peri-implantitus (infected implants)
  1. Cosmetic appearance: Bluish or gray appearance of the gum line; Need to place metal implants deeper to avoid discoloration (can cause more inflammation)
  1. Bio-mechanics: Superiority of ceramic implants in the front teeth; Superiority of metal implants in the back
  1. Treatment Options: Single crowns (best option); Bridges; Complex Full Arch and Full Mouth Cases

VI: THE EXAMINATION APPOINTMENT

A. IMPLANT GOALS AND HISTORY

1.Goals

2.Medical History

3.Dental History: Problematic and missing teeth

4.Dietary and Social History

B. DENTAL EXAM

1.The Comprehensive Exam (Whole Mouth) Xray

2.The Implant Site Exam

C. DENTAL XRAYS AND CT SCANS

1.Traditional 2-D Xray Indications

2.3-D CT Scans Indications

3.Bone Assessment and Implant Placement Rule

D. DIAGNOSIS OF THE IMPLANT CASE

1.Teeth Case Type: Fixed vs. Removable?

2.Bone Determination: Is there enough bone?

3.Sinus Determination: Is it too close? (Upper Back Molars)

4.Nerve Determination: Is it too close? (Lower Back Teeth)

5.Bite Determination: Is it creating too much pressure or stress?

6.Hygiene Factors:  Can poor oral hygiene cause implant failure?

7.Systemic Factors: Can implants adversely affect your health?

E. TREATMENT OPTIONS

1.Single Crown on Implant

2.Bridge / Multiple crowns on implants

3.Full Arch or Full Mouth / “All on 4” cases / “All on 8” Ceramic Cases

VII: THE TREATMENT PROCESS:  STEP BY STEP FOR CERAMIC (ZIRCONIA / METAL -FREE) IMPLANTS

A.PRE-SURGICAL CONSIDERATIONS

1.Pre-Surgical Clearance: Am I a Surgical Candidate?

2.Anesthesia: Local or General?

3.Goals of Surgery:  Live Bone and Proper Implant Size

4.Day of Surgery: Do’s and Don’ts

B.THE TOOTH EXTRACTION PROCESS

1.Treatment Goals: Are we treating the tooth or the whole body (Systemic Dentistry)

2.Systemic-Dental Causal Pathway: Tooth to organ connection

3.Treatment Philosophy and Technology: How can I get the results I expect?

4.Tooth Extraction: Systemic-Dental Protocol: Steps 1-4

C.THE TREATMENT PLAN:  WHAT ARE MY OPTIONS

1. Extraction and Same Day Grafting

2.Same Day (Immediate) Implant Placement

3.Same Day Teeth

D.BONE REGENERATION AND BONE GRAFTING:  ARE THESE SIMILAR RESULTS?

1.Definition and concepts: Bone Regenerations vs. Bone Replacement

2.Bone Grafting Procedures:

~Bone Preservation (Socket Graft)

~Bone Augmentations (Replacement)

~Sinus Grafting (Sinus lift and Augmentation)

3.Chart: Bone Grafting Procedures vs. Bone Graft Materials

E.BARRIER MEMBRANES (FOR BONE FORMATIONS): DOES ONE SIZE FIT ALL?

1. The Concept of ‘Creating Bone’

2. Barrier Membrane Procedures (to enhance grafting)

~Guided Tissue Regeneration

~Guided Bone Regeneration

3.Protein Rich Fibrin:  Can One Size Fit All?

4.Barrier Membrane vs Procedure (chart)

F.SURGICAL PLACEMENT OF THE IMPLANT

1. Techniques for Implant Placement

~Standard Surgical Procedure

~Guided Implant Procedure

2. Protocol: Basic Surgical Steps

3. Healing Phase and Healing Time

G. TOOTH RESTORATION OF THE IMPLANTS

1. The First Appointment

~Type of Abutments; Impressions

2. The Second Appointment

~Crown Fitting and Cementation: Insertion

3.Stabilization: Long-term Implant Health

~Hygiene Maintenance

~Stress Reduction: Mouth Guard

~Home Care

~References

THE FACTS ON CERAMIC DENTAL IMPLANTS (otherwise known as Zirconia or Metal-Free)

I: WHAT IS A CERAMIC DENTAL IMPLANT?

The dental implant consists of 3 parts:

A.The Implant itself, which is placed into the bone at the gum line. Some refer to all three components as the “Implant”, but the Implant proper is the component, which allows a restorative structure (crown, bridge or denture) to be placed.

B.The Abutment (also known as the post or retainer), which screws directly into the Implant, allowing a restorative structure to be attached to the Implant.

C.The Prosthesis (or Restoration), which is anchored by the Implant. It may take the form of a crown (in the case of a single tooth), a bridge (when several teeth or an entire upper or lower set is involved), or a denture.

II: AM I A CANDIDATE FOR DENTAL IMPLANTS?

Either those with missing teeth, or with painful cracked or loose teeth (that are otherwise considered to be unsalvageable)

A.MISSING TEETH CASES:

There are several good reasons for wanting to replace missing teeth. Among the considerations are:

1-The Facial Profile~ the loss of several teeth can cause “bite collapse”, which can seriously impact the facial profile.

2-Function~ a healthy set of teeth is necessary for proper chewing and speech. Certain verbal sounds cannot be formed without the assistance of the teeth.

3-Cranial-Sacral Considerations~ missing teeth can, by their impact upon the jaw, neck and spine lead to headaches, neck and back pains as well as sleeping and breathing disorders.

B- PAINFUL, CRACKED OR LOOSE TEETH CASES:

These present a more complicated scenario, involving the possibility of nerve degeneration (or nerve death), bone loss, or factors such as fractures, thereby compromising dental integrity.

III: WHAT IS INVOLVED IN DENTAL IMPLANTATION?

There are 3 steps involved: Diagnosis, Prognosis and a Discussion of

Treatment Options.

A-DIAGONOSIS:

1.First, in the case of missing teeth, the patient may present with various scenarios.

Best-case scenario: in this case a tooth was extracted without complication, and a bone graft was performed in order to preserve the bone. This would be especially ideal if the implantation is then performed within a year following extraction.

Worst –case scenario:  in this case you had a difficult extraction with infection, and no bone graft was performed. These are generally considered candidates for root canal. The problem for a dental implant is that, without the graft there may be inadequate bone present. However, another procedure known as Bone Augmentation may restore loss bone as a preparation for dental implantation.

Middle ground scenario: somewhere between these two extremes you may encounter a patient who got the bone graft, but waited too long to start the implantation procedure or, you might have a case where no bone graft was performed but the patient otherwise led a healthy lifestyle with a clean diet.  Here, there is still hope for good bone growth, and hence, a favorable outcome from the implantation procedure.

2.In the case of painful, cracked or loose teeth, there are several questions to be asked that can be answered through thorough diagnosis. Among the key questions are:

Is the tooth under consideration dead or alive? The diagnosis will then determine whether, a) the nerve is dead or dying; or c) the tooth is in a compromised state, due either to pain or sensitivity.

What is the structural condition of the tooth, gums and bone? Is the tooth fully intact, compromised or fractured? Do the gums present a “hermetic seal” so as to prevent infections from occurring? Are they inflamed or infected? Is the bone healthy and of adequate mass?

How much stress is being placed on the tooth or set of teeth from biting or clenching? It’s to be noted that 70% of all dental treatments are the result of excessive dental stress, and studies have found 90% of severe “clenchers” aren’t even aware that they’re clenching.

B-PROGNOSIS:

Once a thorough diagnosis has been performed, and accurate prognosis can be rendered. There are essentially two kinds of prognosis, good and bad. With a good prognosis the decision has been made that the tooth can be saved- although this is still up to the discretion of the patient whether he/she feels it’s worth it to save that tooth. With a bad prognosis there is really only one option, and that’s to pull a tooth that is deemed unsalvageable.

C-TREATMENT OPTIONS:

Once a patient has been designated as a suitable candidate for a dental implant, the following types of Prostheses or Implant Restorations become possible.

Single Implant –Abutment –Crown; almost 80% of implant cases involve a single tooth that is crowned. Again, 80% of these cases are considered “simple” in terms of implant placement.  Complications such as inadequate bone, sinus position, or position of the nerve may require additional bone grafting.

Multiple Implant –Abutment-Bridge: a bridge is simply a set of connected crowns that sit on top of the implants. For example, if three teeth are missing, two implants can usually support a three-tooth bridge. What makes the procedure more complex would once again be the position of the bone, sinus and nerves

All on 4/ all on 8/ Full Arch teeth (same day teeth): when an entire arch- meaning, the whole set of upper or lower teeth needs replacement by a Prosthesis, we use the terms “All on 4” or “All on 8” to refer to the number of Implants needed to hold and stabilize the teeth. Ceramic Implants generally require more Implants than those made of metal for reasons that will be explained later. But the cost for either type will be similar. Before this procedure can be done, an Implant assessment will need to be performed just to make sure one is a good candidate for a full-arch prosthesis.

All on 4 / All on 8/ Full Mouth Teeth (same day teeth): A full mouth is similar to a single arch, except here both upper and lower teeth are being replaced.

IV: FREQUENTLY ASKED QUESTIONS (FAQS) REGARDING CERAMIC IMPLANTS:

A.ARE THEY SUCCESSFUL

Yes, as a matter of fact the success rate is around 95%, which is comparable to Titanium Metal Implants.

Ceramic Implants were introduced to the American market in 2004 after proven success in Europe.

More Titanium-based implant companies are now designing ceramic implants to complement their metal systems, having realized the growing demand for Metal-Free.

Ceramic hip replacement has been in use for over 20 years, likewise, after having undergone extensive research and development. This is replacing titanium metal.

Ceramic material has proven success rate in other fields such as the aerospace industry, where NASA has performed extensive research and development

Many ceramic implant systems are now utilizing Titanium designs, thus incorporating the best of both worlds, building on over 30 years of dental implant research.

  1. ARE THEY STRONG ENOUGH?

First, we must establish that strength has two aspects: compressive strength, which resists the type of stress involved in chewing, and flexural strength, which involves resistance to fracturing under stress.

In general, we can say that Ceramic Implants have a similar success rate to Metal Implants in both of these categories with a few caveats.

Severe clenching can cause an Implant in the back of the mouth, where stress is at its highest to fail. In this instance, the ceramic may end up fracturing whereas the Metal Implant will simple become loose in the bone. In either case, a mouth guard may be required to prevent failure. (As a preventative measure)

Stress is generally lowest in the front teeth where Ceramic Implants enjoy a 97% success rate. This makes Ceramic Implants the preferred choice for frontal teeth replacements, with their combined strength and cosmetic benefits.

  1. ARE THEY SAFE?

The health and safety of dental materials is usually defined under the scientific heading of “bio-compatibility” (a term meaning, literally, “compatible with life”). What’s important to realize is that this is an individualized concept, meaning what’s safe or toxic for one person won’t necessarily be the same of another person. Traditional dentists claiming that all metals and plastics are safe in the mouth, as well as holistic dentists claiming that ceramic are 100% safe for all people are equally misleading. The materials must be tested individually to determine true bio-compatibility even for ceramic implants. This is part of our standard practice and we maintain all the different types of ceramics in order to make sure that we have a match for your needs.

So, with this in mind, we offer the following safety considerations:

1.Metal Implants contain not only Titanium, but also Aluminum, Vanadium and Nickel. Metals can be highly reactive! Thus, up to 1/3 of all patients may react negatively to Titanium. The other metals may likewise cause inflammatory or allergic reactions, or even incite auto immune responses. Nickel, for example is a metal to which many people are allergic and the toxic effects of Aluminum are well known.

2.Ceramic Implants contain the elements of Zirconia, Alumina and Yttria. While ceramics are by and large inert meaning non-reactive, some slight reactions may occur at the molecular level. Energetic testing is unique to our practice. It is necessary to access if you’re a candidate for a ceramic implant. This is the only way to determine the precise ceramic implant that is the best match for you. Unlike other practices that offer one type of ceramic implants we have all four, and we take the additional steps to ensure the right one. This is the best practice for the patient as it alleviates problems in the future.

As for the elements Alumina and Yttria: both are ceramic oxides of metals, meaning they exist in a glass phase-and therefore, there is no trace of metal present in the ceramic. That’s why they are referred to as “Metal-Free”. The Alumina form of the element is different from the metallic Aluminum. It exists in nature as a natural, safe component of earth and clays, as well as constituent of our bones. In fact, it’s responsible for the strength and elasticity (our ability to bend) of our skeletal structure.

V: Ceramic (Zirconia/Metal –Free) Versus Titanium (Metal) Implants

A: FACTORS RELATED TO IMPLANT PERFORMANCE

(In order of most to least important)

B.DISCUSSION OF FACTORS:

1.Systemic/General Healing and Safety

The concept of bio-compatibility, by definition, means that which is tolerable to life.

Bio-compatibility must be understood in terms of short-term healing. Most medical and dental studies assess short -term bio-capability and hence, systemic issues may arise 5, 10 or 20 years later and the Dental Implants may never be considered as a probable immune system risk.

The Immune System is one of the primary systems affected:

1-Titanium tolerance-up to 30% of the population may react to Titanium

2-Nickel Allergenicity- Nickel is one of the most allergic metals

3-Autoimmune- Implants can create or exacerbate an existing condition. However, it will be worse with metals. The truth of it is ceramic and metals can exacerbate autoimmune. But the ceramic is the better choice and we take the extra steps by doing Energetic Testing that can determine which out of the four ceramic implants  are the safest and least to cause any immune system risk.

The Detoxification System may also be affected:

1.Maxim:

All materials are safe if the detox system can remove them from the body and are toxic if the body cannot remove them and cells are affected.

2.HEALTH OF SURROUNDING GUM AND BONE TISSUE

Implant Success=Osseointegration

Osseointegration is the success with which the implant adheres to the bone. For the most part, from the traditional standpoint most dentists think that if the implant successfully if it adheres to the bone. However, we take it a step further by not only believing that the success is the implant adhering to the bone but also a healthy system for our patient. (Systemic)

Implant Reactivity: will the Implant react with the surrounding bone and gums? Implant reactivity is the effect of the implant on the gum and bones. Metal implants are re-active while ceramic are inert / non-reactive.  In essence Metal is highly re-active which is why many lean towards the ceramic Implants.

New studies are finding the release of Immune System Inflammatory factors (cytokine such as IL-6 and TNFa)

Medical Implants may corrode in the mouth and the corrosion molecules may cause a reaction.

Fluoride may increase the corrosion rate of metal implants

Other metals present in the mouth such as mercury (‘silver’) filling and crowns may result in a galvanic reaction thereby significantly increasing the release of metal ions into the body. This reaction occurs with mixed metals in the mouth whether or not Metal Implants are present.

A Metal Implant placed in a mouth with mixed (2 varieties of) metals will cause galvanism (2 galvanic cell).

Peri-implantitis is an infection area around an implant and is more common with metal implants.

  1. Cosmetic Appearance

Ceramic Implants are white or tooth color and will not cause a grey or black line around the gums like Metal Implants.

In order to avoid the dark line, the Metal Implants are placed deeper into the gum nearer to the bone (called bone level implants. This increases the risk for implant infection.

  1. Implant Performance (Bio-mechanics)

Maxim: Ceramic Implants are more cosmetic, while Metal Implants are stronger

General Rule:

Ceramic Implants are best in the front teeth where cosmetics is most important and strength secondary. Metal Implants may be best in the back teeth and in patients who grind their teeth (however, ceramic implants with a protective mouth guard can equalize or negate less dental stress). Under proper conditions, Ceramic Implants can be used successfully in any part of the mouth.

  1. 5. Treatment options

A.Single Crown-Implant Case

The Ceramic Implant is clearly the indicated choice. An Exception may be a back tooth in a patient who is a severe grinder/clencher.

B.Multiple Crowns/Bridges

The Ceramic Implant is also the indicated choice except in a few complex cases.

C.Full Arch (Upper or Lower) and Full Mouth

All on 4”/ 4 Ceramic Implants per bridge

Metal Implants can perform better with less implants and in more complex cases (sinus problems / extensive bone loss)

All on 8” (6 or 8 Ceramic Implants per bridge)

Ceramic Implants can be indicated and compensated for by placing additional implants. Each case must be thoroughly diagnosed and treatment planned by a skilled doctor.

VI: THE IMPLANT EXAMINATION APPOINTMENT

A. IMPLANT GOALS AND HISTORY

1.Goals

2.Medical History

3.Dental History: Problematic and missing teeth

4.Dietary and Social History

B. DENTAL EXAM

1.The Comprehensive Exam (Whole Mouth) Xray

2.The Implant Site Exam

C. DENTAL XRAYS AND CT SCANS

1.Traditional 2-D Xray Indications

2.3-D CT Scans Indications

3.Bone Assessment and Implant Placement Rule

D. DIAGNOSIS OF THE IMPLANT CASE

1.Teeth Case Type: Fixed vs. Removable?

2.Bone Determination: Is there enough bone?

3.Sinus Determination: Is it too close? (Upper Back Molars)

4.Nerve Determination: Is it too close? (Lower Back Teeth)

5.Bite Determination: Is it creating too much pressure or stress?

6.Hygiene Factors:  Can poor oral hygiene cause implant failure?

7.Systemic Factors: Can implants adversely affect your health?

E. TREATMENT OPTIONS

1.Single Crown on Implant

2.Bridge / Multiple crowns on implants

3.Full Arch or Full Mouth / “All on 4” cases / “All on 8” Ceramic Cases

A. YOUR IMPLANT GOALS AND HISTORY

1.Goals – Doctors rarely ask patients their goals, rather, they ask what problems they are having. This is because the emphasis is on treating symptoms rather than establishing health.

Some Goals Would Include:

-I want a safe implant (implants are invasive and can impact your systemic health)

-I want it to be cosmetic, comfortable and be able to chew on it.

-I do not want anything which is removable

-Post-op management: Do you want a natural approach to pain and swelling management? In most cases (over 90%), this is totally possible.

-A minimally invasive surgical procedure-less traumatic protocols means less post-operative pain. Many report discomfort instead of pain.

-If it is a visible tooth, I want an immediate tooth placed.

2.MEDICAL HISTORY

Are you healthy?

Are you taking medications which will affect the surgery or bone healing?

How is your immune system? Do you have systemic (whole-body) inflammation, chronic (non- painful) infection, autoimmune?

Do you have Diabetes which can affect healing?

3.DENTAL HISTORY

What is the current or pressing problem?

Typically, there are two events which draw patients to implants:

1.The Problematic Tooth that is, a tooth which is sensitive, painful or fractured and requires a diagnosis to determine.

2.The Missing Tooth (or teeth) can implants be placed here to support new teeth?

How is your dental health?

1.Do you get regular dental preventative care (regular cleanings)? Is your condition stable or do you have periodontal disease receding gums, tooth wear and decay?

2.How is your home care? Many brush, but do you floss daily?

4.DIETARY AND SOCIAL HISTORY

Dietary Questions

Carnivore, omnivore or vegetarian diet?

Adequate protein and nutrient intake?

Ability to properly chew food?

Water Intake

A survey in Toronto found 90% of the population did not consume straight water but received their water through coffee, soda and fruit juices. Coffee, considered by some to be essential (ie. Habitual), affects clotting, healing, vitamin K levels, and lowers one’s pain threshold (meaning increase the amount of pain you will feel).

Sugar Intake

Sugar causes blood sugar imbalance, kills immune cells, lowers your pain threshold and impairs your healing process. I advise patients to only shop at the ‘periphery’ of food store where the ‘real’ food is usually located. Almost anything in a box (fake food) is high in salt, sugar, preservatives (which harm your microbiome) and MSG (many of these chemicals will ‘halt’ bone healing).

B.THE DENTAL EXAM

1. The Comprehensive Exam-This is a look at the entire mouth picture:

The stress Levels (from the bite, clenching and TMJ) on the teeth (periodontal bone loss, gum recession, loose teeth, tooth wear and lesions) can affect implants and bone healing.

Tooth healing (decay, erosions and enamel healing)

Gum Healing (gum inflammation, bone loss and gum recession)

Bone Health – is the bone healthy enough to prevent bone loss after an extraction and form healthy live (vital) bone?

2. IMPLANT SITE

THE FUTURE CROWN

Is there enough room to place a crown? Will it be cosmetic, comfortable and will I be able to chew on it?

THE BONE (into which the implant will be placed)

Is there enough bone (height and width) for the implant?

If there is not enough bone, can we add bone (see Treatment Section on Bone Augmentation)

COMPLICATIONS:

Upper back teeth

Do I have large or low sinuses which need to be grafted in order for future implants to be placed.

Lower back teeth

What is the position of the (Inferior Alveolar) Nerve and will it affect whether or not I can get implants?

C. DENTAL X-RAYS AND CT SCANS

1.TRADITIONAL 2-D XRAYS INDICATIONS:

For many simple cases, regular X-rays are adequate, particularly if there is no bone loss, sinus or nerve complications.

2.3-D CT SCAN INDICATIONS:

These are necessary for bone loss cases, sinus cases and nerve proximity issues.

3. BONE ASSESSMENT AND IMPLANT PLACEMENT (RULE)

MORE BONE =wider, larger implants=less implants needed

LESS BONE =smaller, shorter implants=more implants

D. DIAGNOSIS OF THE IMPLANT CASE

1. TEETH CASE TYPE:

Most people prefer fixed or permanent (non-removable) teeth. If removable is the only option, it is usually because of extensive bone loss and the inability to place enough implants to support fixed teeth.

2.BONE DETERMINATION: The findings for your case will be one of the following:

  1. Adequate bone (no additional bone grafting is necessary)
  2. Inadequate bone, but can be corrected with Bone Augmentation (additional) Grafting (See Section VII: Bone Grafting’s)
  3. Inadequate Bone with inability to add bone.

3. SINUS DETERMINATION:

For upper posterior (back) teeth, is there enough bone for implants or is a sinus lift or sinus augmentation (bone grafting) procedure necessary (see VII: Bone Grafting)

4. NERVE DETERMINATION:

For the lower posterior (back) teeth, is there enough bone for an implant. Can bone grafting (augmentation) and /or computer -guided implant placement minimize nerve risk?

5. BITE DETERMINATION:

If the bite is a problem, long-term survival of the implant is at risk.

6. HYGIENE FACTORS:

-Is the patient’s dental hygiene adequate to ensure long-term implant survival (this is a bigger problem for Titanium / metal implants because less plaque grown on ceramic implants).

-Does the patient get regular cleanings which allow us to monitor implants and intervene before the implant is lost?

-Is the patient a smoker? This is the number one risk factor for implant failure.

7. SYSTEMIC FACTORS:

-Does the patient have any systemic factors such as immune system problems (mast cell activation, Auto immune, Immune suppression, chronic inflammation, chronic infections etc), detoxification problem (MTHFR and other problems) or medications which affect healing and bone metabolism.

-Are vitamin D levels in the normal range and does the patient supplement if necessary?

-Are there any systemic conditions such as diabetes and coagulation which affect placement and survival of the implants?

E. TREATMENT OPTIONS

1. Single Crown-Implant Case:

The ceramic implant is clearly the indicated choice. An exception may be a back tooth in a patient who is a sever grinder/clencher.

2. Multiple Crowns / Bridges

The ceramic implant is also the indicated choice except if there is a complex problem or severe dental stress (clenching)

3. Full Archer (Upper or Lower) and Full Mouth

-“All on 4” / 4 implants per bridge

An implant based full mouth bridge can perform better with less implants and in more complex cases. (Sinus problems/extensive bone loss).

-“All on 8” (6 or 8 ceramic implants per bridge)

Ceramic implants can also support a full mouth bridge but may require additional implants. Each case must be thoroughly diagnosed and treatment planned by a skilled doctor.

If a bite problem can affect implant long-term survival, can a mouth guard minimize implant loss risk? How is treatment affected if a patient will not or cannot use one?

VII: THE TREATMENT PROCESS:  STEP BY STEP FOR CERAMIC (ZIRCONIA / METAL -FREE) IMPLANTS OUTLINE

A.PRE-SURGICAL CONSIDERATIONS

1.Pre-Surgical Clearance: Am I a Surgical Candidate?

2.Anesthesia: Local or General?

3.Goals of Surgery:  Live Bone and Proper Implant Size

4.Day of Surgery: Do’s and Don’ts

B.THE TOOTH EXTRACTION PROCESS

1.Treatment Goals: Are we treating the tooth or the whole body (Systemic Dentistry)

2.Systemic-Dental Causal Pathway: Tooth to organ connection

3.Treatment Philosophy and Technology: How can I get the results I expect?

4.Tooth Extraction: Systemic-Dental Protocol: Steps 1-4

C.THE TREATMENT PLAN:  WHAT ARE MY OPTIONS

  1. Extraction and Same Day Grafting

2.Same Day (Immediate) Implant Placement

3.Same Day Teeth

D.BONE REGENERATION AND BONE GRAFTING:  ARE THESE SIMILAR RESULTS?

1.Definition and concepts: Bone Regenerations vs. Bone Replacement

2.Bone Grafting Procedures:

~Bone Preservation (Socket Graft)

~Bone Augmentations (Replacement)

~Sinus Grafting (Sinus lift and Augmentation)

3.Chart: Bone Grafting Procedures vs. Bone Graft Materials

E.BARRIER MEMBRANES (FOR BONE FORMATIONS): DOES ONE SIZE FIT ALL?

  1. The Concept of ‘Creating Bone’
  2. Barrier Membrane Procedures (to enhance grafting)

~Guided Tissue Regeneration

~Guided Bone Regeneration

3.Protein Rich Fibrin:  Can One Size Fit All?

4.Barrier Membrane vs Procedure (chart)

F.SURGICAL PLACEMENT OF THE IMPLANT

  1. Techniques for Implant Placement

~Standard Surgical Procedure

~Guided Implant Procedure

2.Protocol: Basic Surgical Steps

  1. Healing Phase and Healing Time
  1. TOOTH RESTORATION OF THE IMPLANTS
  2. The First Appointment

~Type of Abutments; Impressions

  1. The Second Appointment

~Crown Fitting and Cementation: Insertion

3.Stabilization: Long-term Implant Health

~Hygiene Maintenance

~Stress Reduction: Mouth Guard

~Home Care

~References

VII: THE TREATMENT PROCESS: STEP BY STEP FOR CERAMIC (ZIRCONIA/METAL-FREE) IMPLANTS

A.PRE-SURGICAL CONSIDERATIONS

1.PRE-SURGICAL CLEARANCE

  1. 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.
  2. 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?

  1. 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.
  2. 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

  1. 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.

  1. 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

  1. 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.
  2. 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

  1. 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.
  2. Pain killers and anti-biotics are available to patients if necessary.
  1. 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?

  1. 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

  1. 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

  1. 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.

  1. BONE REGENERATION AND BONE GRAFTING: ARE THESE SIMILAR RESULTS?

A.DEFINITION AND CONCEPTS:

“BONE REGENERATION”

  1. Refers to the creation of new vital (alive) bone without infection, inflammation or dead bone.
  2. Vital bone conducts the acupuncture meridian energy through it. As a result, the tooth site and all the organs on that meridian remain healthy.
  3. 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.

  1. BONE GRAFTING PROCEDURES
  2. 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.

  1. 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.

  1. 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.

  1. 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

  1. 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.

  1. 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:

  1. There are NO Stem Cells in PRF (Every patient inquiring on this procedure were told it contained their stem cells)
  2. PRF, as a barrier membrane, may be superior in enhancing soft tissue (gum and mucosa) healing.
  3. PRF, for bone grafting, at this time is inferior to traditional bone grafting:
  4. Socket Preservation (conservative sites): bone grafting is still indicated.
  5. Bone Augmentation (growing new bone) PRF is not indicated.
  6. Root Canal Extractions –PRF is contra-indicated; root canals are difficult extractions with extensive inflammation usually requiring bone removal therefore, routine grafting is indicated.
  1. 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

  1. 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

  1. TOOTH RESTORATION OF THE IMPLANTS
  2. 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).