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get prepared with CBCT
Patients make better decisions when they receive good information. Thedental community has an obligation to deliver good dental implant information
.
Copyright 2008/2009 by Murry Shohat. All Rights Reserved
Shredded nerves?Numb lip?Constant pain?Perforated sinus?
Not if you...
Dental Implants
2
Once again,
science and technology tothe rescue! Standard dental implants arenow the preferred way to replace missingand damaged teeth, regain lost chewingfunction and rebuild confidence after along period without teeth. For front teeth,implants offer an even more cosmeticallyattractive smile than veneers, in what den-tists call the
esthetic zone
. For these rea-sons, implants have rapidly become amainstream but expensive treatment. Isyour dentist properly trained to offer them?Fig. 1 is a representation of a tapered tita-nium implant, magnified. Standard im-plants measure 4 - 6mm wide by 5 - 15mmlong (6.35mm = ¼"; a U.S. dime is1.35mm thick). It's not unusual for patientsto receive several. Under proper condi-tions, fully edentulous patients (no teeth) can receive amouthful of these long lasting cylindrical tooth root replace-ments. Candidates include patients who are missing one or several teeth or wear partial or full dentures or bridges.These patients want a much more stable chewing solution.For others, an implant is sometimes useful to immediatelyreplace a tooth that has to be pulled. In some cases, animplant is an alternative treatment for a root canal.Although
mini dental implants
are similar, they are
not
of-ten used to replace whole teeth and are therefore
not
thesubject of this article. Mini dental implants are very narrow – 2mm or smaller. A growing debate characterizes dentalopinions on the use of mini implants as temporary or per-manent solutions for tooth replacement and denture sup-port. The most experienced implantologists use them inlimited situations, observing warnings like this one:
http://dental-implants.com/cms/frequently_asked_questions/faqs.
Based on tooth root-shaped titanium cylinders that are ma-chined with screw threads as shown in the photos on thispage, standard implants are surgically placed in jawbone,below the gum after careful drilling and preparation. Thetitanium implant is literally screwed into the prepared hole(the
osteotomy
), where it bonds with jawbone over severalmonths. The bonding is a unique property of titanium.Bonded or
osseointegrated
implants then receive a metalabutment or anchor post, permanently inserted in the top. Itextends through and above the gum. The abutment either receives a temporary or permanent ceramic crown or firmlyconnects to a denture (the process is called
restoration
).Restored implants often function better than healthy teeth(they don't get cavities). With excellent patient care, prop-erly restored implants can last decades.The illustration below conceptualizes a restored single im-plant. The gap below its tip illustrates required proceduraldrilling depth of theosteotomy. Theimplant must becarefully torquedinto the osteotomyto establish idealconditions for os-seointegration.The gap ultimatelyfills in with newbone growth.Implants are nowbeing placed byoral surgeons, pe-riodontists (gumspecialists), prost-hodontists(denture special-ists) and regular restorative / cos-metic dentists.Even endodontists(root canalspecialists)recommend an implant instead of a root canal in certaincases.Because a single implant can cost upwards of $3,000 to$5,000 including restoration with a custom ceramic crown,the dental profession loves the cash flow. Worldwide, den-tists are rushing to offer implants. However, it's your mouthand money. Careful advance preparation protects your dental and financial interests. Each case benefits from pa-tient education (the mission of this article
).
The knowledgeenables you to ask good questions and to take advantageof widely available precision technology, which includes
Fig. 1
Fig. 2: Implant supported crown
Dental Implants
Get prepared with CBCT
Excellent results from increasingly popular but expensive dental implant surgery can be as-sured. Technology that your dentist should be telling you about will preclude nerve injuries, per-manent numbness, involuntary drooling, perforated sinuses, incorrect tooth angles and broken jawbones. Here’s why and how to protect yourself.
By Murry Shohat
Download the article to activate the links
Be sure to read the revised version of this articleand its companion directory:
http://knol.google.com/k/murry-shohat/
3
three-dimensional or 3D cone beam X-rays for comprehen-sive diagnosis and safety and precision computer-manufactured surgical guides that assure proper drilling. A3D digital X-ray is the dental equivalent of a CT scan(dentists call it
CBCT
). It fully reveals your jawbone struc-ture and can guide the actual surgery with precision far su-perior to 2D dental office X-rays.Many patients should not proceed without the benefits of 3D because it prevents mistakes like drilling at wrong an-gles or into dental nerves or other vital structures of the jawbone. Given eachimplant's cost, an-other $300 - $500 for a CBCT is a moder-ately priced insur-ance policy. And thecost is dropping ascompanies like PreX-ion, Planmeca andothers convince den-tal practices to add3D scanners.
Initial Prepara-tion
For most cases, firstand second opinionstop the list of thingsto do before surgery.When your dentistrecommends im-plants (or you ask for them), you'll want afull discussion and asecond opinion.Seek full disclosure fromtwo restorative/cosmeticdentists even before you speak with an implantologist. Thebalance of this article will help you organize questions.Begin by understanding the role of the dentist or oral sur-geon who surgically installs the implants. If your dentistalso plans to do the surgery, you'll want an opinion from aclinician who does not place implants. Oral surgeons andother implantologists — even cosmetic dentists — whomake a living from implant surgery are biased. Seek anopinion from a dentist who does not rely on implants as away to send kids to college or buy a yacht or vineyard.The most effective way to assure excellent dental opinionsis a CBCT, which has quickly become the standard of carefor many implant cases. This type of X-ray has been of-fered for years by specialized clinics located in urban areasand at schools of dentistry. As you'll learn, CBCT is worthevery penny.Some forward-looking dentists and implantologists are in-stalling CBCT units in their offices. These clinicians knowthat 3D is becoming the standard of care. Be suspicious if adentist claims this isn't true (any dental malpractice attor-ney will affirm). Brand names to look for include PlanmecaProMax, PreXion, Accu-i-Tomo, NewTom 3G, i-Cat andseveral others.Unless your case is simple, a CBCT is the most importantthing you'll need. It enables clinicians to see inside your jawbone with an accuracy as small as 0.07mm (less thanthe width of an average human hair), and to avoid the prob-lem shown at left. This illustration portrays three implants,two of which have been drilled and placed into the nervecanal inside the
mandible
(lower jaw). This nerve serveseach tooth and "enervates" the lip and chin through abranch called the
mental nerve
. Our ability to sensetouch, heat, cold andpain is this nerve'sfunction. A patient'scomplaint (after sur-gical anesthesiawears off) might be
"my (right or left side)lip and chin are pain-fully numb, and I can't stop drooling because I can't feel it to control it."
Figure 3B provides aclose up of the for-ward implant strikingthe mental nerve.The drills used toprepare the osteot-omy would shred or cut the nerve first,and the patient, evenunder deep sedation,might moan or cry out. Ex-treme pain for days, weeks or months may follow. Numb-ness may be irreparablypermanent.As you prepare for im-plants, you’ll also need anappreciation for the sur-geries in the treatmentplan. Some implant casesrequire advance bonegraft surgery (with amplehealing time before im-plants can be placed). If you're replacing an oldimplant, additional healingtime is needed to allow jawbone to
remodel
(jawbone regrows under the right conditions). It'snot unusual for implant prep, sur-geries and restoration to span more than a year. A fullmouth can take longer.Prudent implantologists facing a complex case will refer thepatient for a CBCT as the leading diagnostic, planning and
Figure 3A: Two of three implants impinge nerveFig. 3B
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