The long and winding implant road?

Often treatment planning for replacing a missing tooth is easy. An examination shows sufficient space for an implant and replacement implant crown. Usually my surgeon has my patient take a cbct scan. This is a 3 dimensional xray that shows the bone where the implant should be ideally placed. If there is sufficient bone he will be able to place an implant. Sometimes the scan shows insufficient bone there is not enough bone present for placement of an implant, my surgeon may recommend bone grafting as an option. After a period of three or 4 months afterward he will usually place the implant.

Sometimes, especially for maxillary posterior teeth, it can be more complicated to place an implant because the maxillary sinus can be in the way. Sometimes this neccesitates the placement of a short implant, sometimes a sinus lift is needed. A sinus lift involves the surgical elevation of the floor of the sinus and addition of bone grafting material in order to develop the implant site and make room for a long enough implant to help facilitate implant placement.

the blacker area posterior to the implant restoration shows a
 maxillary sinus that must be "lifted" if an implant is to be placed there.

Implant replacement of maxillary anterior teeth can be especially challenging since these teeth are in the esthetic zone and a smiling patient will often feature the implant replacements and the gingiva around it After an anterior extraction, usually a mm or two of bone resorbs and this can result in an implant tooth that is longer than the adjacent natural teeth and can be unaesthetic especially if the when a patient has a high smile line and shows the anterior gingiva. In that case ,when treatment planning an maxillary implant , the position of the gums after implant placement must be considered and sufficient gums are needed to fabricate an esthetic implant restoration. Often bone grafting and even connective tissue grafting must be performed in order to develop natural looking gums to surround  the  implant restoration. These additions can keep the alveolar ridge ( the area of the jaw housing teeth) plumper and at the proper height necessary for esthetic anterior implants.

Usually my surgeon and I are pretty good at anticipating problems and together we have successfully restored a good number of implant that he has placed in the maxillary anterior region. Thankfully we have a high percentage of happily restored implant patients.

Even so, sometimes in the process of restoring a missing anterior tooth we can encounter a speed bump or two. About five years ago a new patient showed up, who had a missing maxillary incisor. When examining him , I observed a tiny screw that was protruding labially from his gums in the spot where he was missing the lateral incisor. He explained that he had bone grafting an NYU College of Dentistry in order to build up his edentulous site but he hadn't had them remove the screw that was used to hold the grafting material in place. I tried to unscrew it with a tiny screw driver but it seemed firmly in place and I asked him to return to NYU to have it removed.

edentulous site too narrow for implant

Also I showed the site to my surgeon and he commented that the space was too narrow to place even a narrow 3 mm diameter implant and he suggested I use Invisalign to widen the space slightly. My patient was agreeable and we decided to start his Invisalign treatment once he had the tiny screw was removed.

My patient got busy and there was a lag in time before he had the screw removed.  Planning his Invisalign took additional time since I used a service that helps dentists treatment plan some of their more "complicated" cases. My Invisalign expert corresponded via emails with me for two months or more. Each time I made the changes in the Invisalign Clincheck he suggested, he reviewed my the new Clincheck and sugeested some additional tweaks. After 3 or 4 Clinchecks , my patient and I approved a Clincheck ( a computer animation that displays the programmed Invisalign tooth movements).  At at the end of his Invisalign it was anticipated that he would have 6 mm of space in order to place a small implant in the #10 site.

Invisalign treatment took amore than  a year to complete and involved a several refinements. When we were completed I took a periapical x-ray of the #10 implant site and I was pleased that our root movement had bodily torqued the adjacent roots so that it seemed that implant placement would work out well. (Sometimes after orthodontics involving these adjacent teeth their
roots are "tipped towards each other and there can still be a space problem for an implant placement.)

After orthodontics assisted enlargement of edentulous site

My surgeon ordered a cbct of the implant site to check the bucco-lingual width of the bone and he called me up and explained that even though we had enough mesio- distal width, there wasn't enough bucco lingual width for even a small 3.0 implant.  I explained that  after all this time we had to figure out something to do! My surgeon didn't feel the conventual bone grafting with particulate bone would be likely to work, but  instead gave me the name of an oral surgeon that performed " block grafts" who might be able to help my patient. A block graft involves taking a piece of bone from the patient or a cadaver and tacking this small block over the implant site. It usually has particulate bone grafting material around it.

Most of the periodontists I know aren't comfortable with this procedure, but the Oral Surgeon we used was extremely skilled  at this procedure and he said he would try to accomplish a block graft at the site. That was more than a year ago and just last week my patient came in for a cleaning  and low and behold an x-ray of the site showed a small 3.0 implant placed in the site.  I called the surgeon up and he explained although it had been tricky had been able to graft the site and place the implant and soon he would be able to uncover the implant so that I could restore the tooth.

It has take far longer than I assumed and fortunately for me, my patient has been good natured and remained cooperative through out the process! We both look forward to the last leg of this journey and hope that there will be no more curves in the road so that we will be able to successfully complete our implant journey in 2018!



from Ask Dr. Spindel - http://lspindelnycdds.blogspot.com/2018/11/the-long-and-winding-implant-road.html - http://lspindelnycdds.blogspot.com/