Dental Implants 101

Dental Implants 101

As adults, we lose teeth for many reasons.  75% of adult tooth loss is due to periodontal disease.  However, we may also lose teeth into adulthood due to traumatic injury.  After tooth loss, it’s important to replace with an artificial root and crown.

We tend to think of our bone as a very static system.  In fact, our skeleton is very dynamic, constantly undergoing breakdown balanced with rebuilding.  One of the major stimuli for bone rebuilding are external forces.  Just as weight-bearing exercise is important to keep our large bones strong, chewing applies forces to our jaw bone that keeps them strong!

When we lose a tooth, the bone that once supported that tooth no longer experiences the forces applied when we chew our food and the bone begins to resorb (i.e., deteriorate).

If left for long enough periods of time, this bone loss can eventually alter the integrity of your facial structure, changing your appearance.  It can also compromise the function and security of the adjacent and opposing teeth (without a tooth to chew against, the opposing tooth will also suddenly lose the chewing forces it was once used to).  Ultimately, this may even change your ability to maintain a healthy diet and proper digestion.

In some cases, bone has deteriorated so drastically that Dr. Fritz or Dr. Schuldt may need to use additional bone material during the implant placement procedure to stabilize the implant.  Or, your periodontist may even need to perform a preliminary procedure to add bone, allow time for it to calcify and harden, before inserting the dental implant.

The only way to know if you are a good candidate for a dental implant and if you may require additional bone to support an implant is to visit your periodontist for a comprehensive examination.  A CBCT, 3D X-ray, is also essential in the planning stages of your dental implant to allow your periodontist to visualize in 3-dimensions your exact anatomy and the quality and quantity of your bone into which the dental implant will be placed.

Dental Implants 101

How does a dental implant integrate?

A dental implant is an artificial root that is used to replace a natural tooth root that has been lost.  Dental implants are made of titanium.  Titanium is a natural element with non-reactive properties.  That is, it causes very little, if any immune response in the body. 

Titanium does have a unique property, it attracts bone cells.  When a titanium dental implant is inserted, it undergoes a process known as osseointegration.  In this process, bone cells fuse to the implant and secure it firmly in the jaw bone.

This process of osseointegration takes several weeks.  Therefore, it is important to allow the body this time to create a strong anchor on the implant before loading it with an artificial dental crown.  Just like glue needs time to set, if a crown is placed on an implant to early, it can lose its grip and fall out.

To test the strength of the integration of the implant into the bone, an Implant Stability Quotient (ISQ) value can be calculated by your periodontist.  If your ISQ value falls within a specific range, it is safe to proceed with the final stage of your implant process, fabrication of an artificial dental crown.

Post-Operative Instructions – Care after a Dental Implant

Post-Operative Instructions – Care after a Dental Implant

After your dental implant surgery, there are some steps to follow for quick and smooth recovery.  Healing after a dental implant can be broken into periods.

In the first 24 hours:

  • Only after freezing has completely warn off, you can apply ice to the area as needed in 10 min ON/10 min OFF for 3 cycles.
  • Do not apply heat to the area as this can stimulate blood flow and increase bleeding in the area
  • Do not brush or floss the area
  • Rest with your head elevated to avoid blood pooling to the area, discomfort, and swelling
  • Do not do any activity that raises your heart rate
  • When sleeping, use an old pillow case in case your bleed through the night

After 24 hours:

  • Do not apply ice
  • Brush the area and neighbouring teeth very gently with the post-surgical toothbrush that was given (this toothbrush is even softer than a ‘soft’ toothbrush and is made specifically for surgical sites)
  • When using the post-surgical toothbrush, avoid the sutures and the gum line at the surgical site
  • Pool Peridex rinse at the surgical site twice per day (morning and night) for two weeks.  Peridex mouthrinse works like a “toothbrush in a bottle” and works to keep the surgical site clean without the manual disruption by a toothbrush at the sensitive site.
  • Do not spit, gargle or swallow Peridex.  Simply let it fall from your mouth.
  • Do not eat or drink for 2 hours post-Peridex rinse.
  • Do not floss the area
  • Brush and floss all other areas of the mouth with your regular electric toothbrush

After 48 hours until your 2 week post-operative appointment:

  • Apply a warm compress to cheeks as needed
  • You may begin to exercise at 50% intensity being careful to monitor for any bleeding at the surgical site
  • Eat only soft foods on the opposite side of the mouth.  A general rule of thumb is to eat foods that require 3 chews or less.
  • Do not eat extreme temperature foods as this can damage the tissues and can increase blood flow in the area – eat room temperature foods only
  • Avoid alcohol, tobacco and cannabis during the healing phase (2 weeks)
  • Do not pull at the lip to see the healing area.  This may loosen the stitches and can disrupt the healing tissues.
  • Do not use straws, whistles, wind instruments as the force applied may damage the delicate healing tissues
  • Avoid wearing a denture or flipper as much as possible as this may rub against the healing tissues

It is important to take all medications as prescribed, especially an antibiotic.

To manage pain, Ibuprofen can be taken by the clock, as necessary.  Any antibiotics prescribed are essential to take until completion.  Use the Peridex mouthrinse twice daily for 2 weeks.

Patients report experiencing their peak discomfort immediately following surgery and experience a steady decline in discomfort through to Day 5.  However, patients report the greatest level so swelling, which can sometimes be accompanied by bruising, 3 to 5 days following surgery.

Should you experience any bleeding, swelling, bruising, or discomfort that is out of greater concern, it is important that you contact your periodontist.

How do I care for my implant?

How do I care for my implant?

Just like natural teeth, dental implants require care and attention to remain healthy and viable.  Although the implant is artificial, the gum and bone tissues that anchor and support it are living and susceptible to infection and deterioration.

When the tissues around an implant become infected with bacteria, they can become red, inflammed, sore, and can bleed.  The tissues can even have a thick, yellow, pus-like substance come from the gums when the infection has worsened.

Together, these symptoms cause peri-implantitis.  Similar to what happens around natural teeth in periodontal disease, in cases of peri-implantitis, bacteria infiltrate the spaces around the implant and cause infection, inflammation, and deterioration of the supporting bone tissues.

Any deviation from health at the implant site is a cause for concern and requires immediate assessment by your periodontist.

The best strategy to keep your implants healthy and sturdy for years and years is proper home care and regular visits with your dentists and periodontist.

If you have a removable crown or denture, it is important to remove it daily and to thoroughly clean the locators.

If you have a fixed crown, it is important to clean around it using the cross-over floss technique.

The Fonthill Implant Care Protocol

The Fonthill Implant Care Protocol

This article is focused on the best evidence to prevent peri-implant mucositis and peri-implantitis using a systematic approach which is personalized for the patient. This critical update has eliminated several steps from our former algorithm and replaced them with innovative approaches generated from new concepts of peri-implant health.

The Fonthill Implant Care Protocol adapts the “recall hour” into six stages outlined in Figure 1. The six stages of Implant Care are to assess, disclose, motivate and empower, instrument, check and document, and recall. These six stages are adapted from the Guided Biofilm Therapy protocol for dental biofilm management as proposed by EMS (Nyon, Switzerland). Our evolving supportive implant maintenance protocol continues to successfully maintain more than 8000 implants in a private specialty practice (Fonthill, ON, Canada). The protocol is useful for all implant designs and for implants not having had previous implant care. This protocol allows the early identification of peri-implant mucositis and peri-implantitis and has recently been tailored to reflect the disruptions in biofilm management strategies.

Written by: Peter C. Fritz; Donna M. Lavoie; Roxanne More; Linda M. Dakin; Angie Nahli; Amanda B. Longo

 

Peri-Implant Diseases And Conditions

Peri-Implant Diseases And Conditions

In 2017, the world of periodontology was redefined with significant updates to the classification system for periodontal and peri-implant disease. The work of more than 170 leading clinicians, scientists, and educators from around the globe culminated in the publication of 17 articles and four consensus statements summarizing a contemporary, evidence-based and clinically relevant system. This system is modelled after others used in medicine and stratifies the severity, rate of progression, and the extent of periodontal disease and helps to clarify clinical approaches for treatment. Since its unveiling in 2017, this comprehensive classification system has become the new standard of clinical practice around the world. It encourages clinicians to view the patient through a systemic lens, connecting and reinforcing the link between oral health and overall health. An executive summary of the updates to the new global classification system for periodontal disease have been shared in an earlier version of this publication.

The previous periodontal classification system was published in 1999, at a time when dental implants had only been in North America for approximately 20 years. Since then, dental implants have become an increasingly popular treatment option for the replacement of missing teeth. It soon became apparent that much like natural teeth, the supporting structures of dental implants can experience disease and therefore require specialized considerations for diagnosis of a healthy versus diseased state. It is obvious today that there can be no implantology without periodontology and the periodontal classification system from 1999 did not capture this relationship. The new system elegantly defines peri-implant diseases and conditions in great detail. The aim of this executive summary is to highlight the principal concepts and key updates in regard to peri-implant health and disease culminating from the 2017 World Workshop on the Classification of Periodontal and Peri-Implant Diseases and Conditions.

Written by: Amanda B. Longo, BSc, MSc, PhD; Peter C. Fritz, BSc, DDS, FRCD(C), PhD (Perio), MBA

Base Camp 9 – Implant Dentistry in 2020

Base Camp 9 – Implant Dentistry in 2020

Presented by: Dr. Peter C. Fritz, B.Sc., D.D.S., F.R.C.D.(C)., Ph.D. (Perio), M.B.A.

Implant dentistry has evolved dramatically in the past years.  In this lecture, learn of the advancements in implant dentistry from past to present.  Discover the role that virtual treatment planning, experience, and long-term maintenance play in the success of a dental implant.

LEARNING OBJECTIVES:

  • Understand the current protocols for implant surgery along with their timelines
  • Identify the metrics for success and success rates of practitioners

Base Camp 9 – Implant Dentistry in 2020

Base Camp 6 – Implant Maintenance and Peri-Implant Pathology

Presented by: Dr. Peter C. Fritz, B.Sc., D.D.S., F.R.C.D.(C)., Ph.D. (Perio), M.B.A.

It has been eight years since we published our Supportive Periodontal Implant Maintenance Protocol, which has been shared and implemented in dental practices and hygiene colleges across the globe. With the exciting new periodontal and peri-implant classifications published simultaneously by the American Academy of Periodontology and European Federation of Periodontology, we felt it was necessary to revisit our implant maintenance protocol to better reflect the new information and technologies available today. This lecture is focused on the best evidence to prevent peri-implant mucositis and peri-implantitis using a systematic approach which is personalized for the patient. This critical update has eliminated several steps from our former algorithm and replaced them with innovative approaches generated from new concepts of peri-implant health.

 

LEARNING OBJECTIVES:

  • Define and identify peri-implant health, peri-implant mucositis, and peri-implantitis based on the new periodontal and peri-implant classification system (2018)
  • Learn the Fonthill Implant Care Protocol algorithm to support implant reconstructions
  • Identify peri-implant pathology
  • Identify treatment of peri-implant disease
  • Understand the co-dependent relationship between implantology and periodontology

Intra/Extra-oral Examination

Intra/Extra-oral Examination

The intra-oral and extra-oral soft tissue examination is an essential part of all dental exams.  This examination is performed in a thorough and systematic nature to ensure that no parts of the head and neck region are missed or overlooked.

This examination can be broken down into sequential steps to review all tissues and to determine if they are within normal limits (WNL) or if there is an abnormality noted.

If an abnormality is noted in an intra/extra-oral examination, further detailed notes about the abnormality such as size, colour, location, surface texture, and consistency are made.  Information about the onset, location, duration, characteristics, aggravating and alleviating factors, related symptoms, and treatment are all considered by your dental hygienist and periodontist.

As part of a full intra/extra-oral examination for abnormalities in our oral pathology, a detailed medical history, family history, drug/medication history, and social history are taken.

As a patient, we can prepare for our intra/extra-oral examination by being aware of any abnormal colouration, bumps, textures, or sensations in our head and neck region. 

A full video of what to expect during a full intra/extra-oral examination by your dental hygienist or periodontist can be viewed below.

3D Dental X-rays

3D Dental X-rays

Cone beam computed tomography (CBCT) is a recent advancement in dental imaging and provides a 3D image of the tooth and jaw with high spatial resolution and diagnostic ability.

The dental CBCT does not replace conventional 2D x-rays, but is an additional tool that your dentist or periodontist uses to gain more information, to avoid exploratory surgery, and to perform a ‘virtual surgery’.

A CBCT works by three basic steps: Acquisition, Reconstruction, and Analysis

1. Acquisition
CBCT technology uses the same basic technology of conventional 2D x-rays.  That is an x-ray source sends a beam of x-rays through the object of interest and an x-ray detector collects them on the other side.

As the x-ray beam travels through the object of interest (i.e., our teeth), some x-rays pass through the less dense material and others are absorbed by the dense tissue.

For example; If your tooth has a crack in it, the x-ray beam will be absorbed by the tooth, but will pass right through the empty space of the crack and hit the detector.  This paints a picture on the detector of a solid tooth with an empty space through it.  Voila! Your dentist or periodontist can now confirm a crack in 3D, something they would have missed with the low resolution of a 2D x-ray.

The major difference in the acquisition stage between a 2D and 3D image is the sheer number of ‘pictures’ taken.  With 2D technology, only one photo is captured at a single angle.  With 3D technology, many many photos are captured as the x-ray source and detector move around the patients head.

2. Reconstruction
After all of the individual images are acquired, sophisticated software reconstruct the images to re-create the 3D volume.

Like a Rubik’s cube, the individual images are stacked on top of one another in the sequence they were taken in to build a 3D cube.

3. Analysis and Interpretation
The final stage involves the analysis and interpretation of the images captured.  A great benefit to CBCT technology is the ability to manipulate, maneuver and rotate the 3D volume to scroll through the “stack” of images created.

This drastically improves the ability of your dentist or periodontist to diagnose and plan treatment accordingly.

A question that we are asked all the time is “How much radiation is this going to expose me to?”

This is a highly complex question, with so many factors influencing the answer for each individual patient.  The simple answer is, not more than three dental film x-rays but the information we receive from a single CBCT is exponentially more!

There are many factors and settings in the acquisition stage of the CBCT scan that can be manipulated by the dentist or periodontist to limit the radiation exposure to the patient.  To stay informed, always ask your prescribing dentist or periodontist how they plan to limit you to the lowest possible radiation exposure.