Step 1 – Consultation
The first step of your implant treatment to replace a single missing tooth is an assessment with your dentist or surgeon.
This involved an intra-oral examination of your mouth to assess the remaining teeth and ensure they are healthy, if any tooth decay is found at this point or additional teeth need treatment to get them dentally fit, this additional treatment is noted to be carried out before the implant is placed. After the intra-oral examination is carried out a 3D scan is taken of the area to receive the implant also known as a CBCT scan, this allows the clinical to assess the site due to receive the implant in 3d and ensure there is enough bone in the area to receive the implant if there isn’t enough bone in the area an additional treatment is required called a bone graft which we will discuss later on in this book.
Pre-op CBCT Scan
Not only does the pre-op CBCT scan allow the dentist to ensure there is enough bone in the area, but it also ensures the procedure is performed in the safest clinical way possible by ensuring there are no nerves in close proximity to the implant site. By taking a 3D scan the dentist is also able to use planning software to virtually place the implant into the receiving site which helps in selecting the implant size so that all the necessary equipment is ready for the procedure.
Dental Implant Assessment
At the assessment, the dentist will also carry out a detailed medical history examination to identify any risk factors for the procedure such as any medication a patient may take that needs to be considered before the surgery. In many cases, implants are placed on the day of extracting a broken or failing tooth. An example of this would be if a tooth needs to be extracted due to it being cracked and the dentist is unable to save it. In order for the patient to not be left without a tooth on the day of the implant surgery the dentist may take a scan or impression of the teeth at the consultation and send these to the dental lab to make a temporary denture or bridge which is to be placed in the space of the gap once the failing tooth is removed on the day of the surgery. the idea is for the clinical to be as fully prepared and equipment as possible to ensure the smooth placement of the implant and the overall success of the treatment. At the end of the consultation the patient is provided with a treatment plan which includes the cost of the implant as well as any other treatment required before the implant treatment to ensure the patient’s mouth is dentally fit, the last thing a patient wants is for a dentist to place an implant next to a tooth that is decayed as this could be a factor that causes the failure of the implant which would result in the need for it to be removed. During the consultation the patient’s gums are also assessed and the health of the soft tissues are measured, in most cases, hygiene treatment is recommended before the implant is placed as the surgical site should be as clean as possible and the presence of plaque and calculus prevents this. Careful Planning is key and is imperative for the success of treatment.
Other additional treatments that can be discussed at the consultation are treatments that are required to aid the success of the implant placement. An example of this treatment is a bone graft or gum graft, the different types of grafts a patient may need will be explained later on in this book.
The consultation is concluded by the dentist putting together a treatment plan which outlines:
The necessary treatment (if any) required to ensure the mouth is dentally fit before the implant placement appointment. Any restorative treatment required e.g. a filling is usually carried out by a general dentist although in some cases can be carried out by the same dentist placing the implant
Details on additional treatment needed to aid the success of the implant such as a bone graft or a gum graft
Details on any temporary teeth included in the plan to replace the extracted missing tooth temporarily on the day of the surgery e.g. a single tooth denture
The number of implants included in the treatment plan – in the case of a single implant to replace one missing tooth it would be one
The consultation is also a time for the dentist to discuss the total cost for treatment, this should be a fixed fee and not left open-ended. Most clinics offer finance which can help spread the treatment cost out. It’s important the dentist is transparent with pricing and offer payment options that make the treatment manageable for the patient.
Step 2 – Implant Placement
It’s important to note that in the situation where a patient requires a type of graft before receiving an implant (e.g. bone or gum graft) as well as any treatment to make the mouth dentally fit such as a filling or hygiene treatment, this should be carried out in a separate appointment prior to the implant placement. So what does the dental implant placement appointment involve? First, the dentist will assess the previously taken 3D scan to prepare for the procedure and be guided on how to place the implant, the implant should ideally be placed in the middle of the gap which is the most favourable position for stability and healing. Once the dentist has checked the 3D and is mentally ready for the procedure a local anaesthesia injection is administered near the surgical site, much like what a patient would receive before a filling. After a few minutes once the area is numb a small amount of gum is gently peeled away from over the bone to expose it, called a surgical flap. This uncovering of the bone allows the surgeon to visibly see the bone that needs to be prepared to receive the implant. One the gum has been raised in the receptor site and the bone is exposed the dentist will use a series of surgical drills of differing sizes, these start from narrower drills and increase in size until the diameter of the implant is reached. For example, if a surgeon chooses an implant which is 4mm in diameter they may use two or three drills to prepare the area in the bone that will receive the implant, the last drill being 4mm so the implant slides into the bone and fits nicely. This is called osteotomy which is a fancy term for drilling a hole in the bone that is the same size as the implant which will follow.
Once the hole has been prepared in the bone by the dentist the implant is gently screwed into place until it locks into place. The next step after this depends on how sturdy and stable the implant is once placed into the bone, there are two scenarios that the dentist and patient may find themselves in:
In the first instance, the implant is really stable in the jaw and the dentist can be confident there will be little to no movement by the implant and as a result, it will heal well. In this scenario, the dentist may decide to place something called a healing abutment over the implant which allows the gum to form around the implant and reduces the overall procedure time by weeks as a step is eliminated from the treatment
In some cases the implant may not be stable enough to place a healing abutment over the tooth, this for example could be in the event of an immediate implant placement where an implant is placed immediately after a tooth is extracted. As the bone can be slightly broken down (understandably as a tooth has just been removed prior to placing the implant) the dentist may need to place the implant slightly deeper in the surgical area and so a cover screw is placed which essentially allows the gum to cover the implant. In this event, an additional appointment is needed to remove the cover screw and place a healing abutment, which allows the gum-shaping process to begin. This treatment route is slightly longer as there is a delay of 2-3 weeks between placing the cover screw over the implant and removing the cover screw to replace it with the healing abutment
Once the implant has been placed, the gum is replaced and sutured into place and the healing process begins. It takes around 8-10 weeks for the bone to heal around the implant and so this is the period of time between the implant placement appointment and the impression appointment.
Step 3 – Crown Impression
8-10 weeks later once the implant heals in the bone, it’s time for the dentist to take an impression for the lab technician to manufacture the crown. It’s worth noting in some cases there may be an additional short appointment between the surgery day and the impression appointment to remove the cover screw from the implant and place the healing abutment, if this appointment is needed, two weeks later it’s time for the impression to be taken.
At this appointment the dentist will remove the healing abutment from over the implant and in the event of a non-digital impression will place an impression coping over the implant which resembles a metal post. This metal post connects to the implant and is screwed into place over the implant for the sake of the impression. The dentist will then apply an impression material into an impression tray and apply it over the impression coping and wait for 4-5 mins with the impression tray in place. The coping is then loosened and the tray is removed which gives us an impression of the exact implant position.
Next, the dentist will take detailed images of the neighbouring tooth, this is especially important in the case of a dentist replacing a missing front tooth or another tooth that is extremely visible as if the colour communication to the lab technician is not detailed, the end result may be a tooth that is inaccurate in colour which will affect the overall aesthetic outcome of the implant crown.
Once the impression is complete, and images have been taken of the neighbouring teeth and patients’ smile, this information is sent to the dental lab that will be tasked with making the crown. In some cases impressions are taken digitally with a 3d scanner, this type of impression follows a similar process however the record is sent to the lab digitally via email rather than physically.
Step 4 – crown fit
A few weeks later once the implant crown is returned to the clinic by the lab the crown is placed over the implant and is tried in before being permanently screwed in. During the try-in, the dentist assess the fit, shape and colour of the crown as well as ensuring the crown fits into the patient’s bite without any issues. Once the dentist is happy the patient is provided with a mirror and is show the tried in tooth, should both the dentist and patient approve, the implant crown is screwed into place and the treatment process is complete. It’s normal for dentists to review the implant crown at a short appointment 2-3 weeks later to ensure the patient is happy and there are no issues with the implant or crown.