Dental implants, hailed decades ago as a cutting-edge technological breakthrough, are recognized today as the premier method for replacing missing teeth. Their use has become so routine that an estimated 2,000 are placed every weekday in the U.S. alone. Researchers have a good understanding of how the screw-shaped titanium implants become integrated with a person’s own bone cells, and dentists and patients alike appreciate the solid anchorage they provide for lifelike replacement teeth and bridges. Implants can also be used to hold dentures in place, and for some orthodontic treatments.
But the implant that makes the biggest difference in someone’s life may be the one that’s placed right up front. Replacing a missing or deteriorated tooth in the center of a smile can have a dramatic impact not only on a person’s appearance, but also on their self-esteem and overall quality of life.
A great deal of artistry goes into ensuring that a prosthetic tooth looks natural… and beautiful. Making sure replacement teeth are exactly the right size, shape and shade is very important. Yet, like a painting, the artistry isn’t shown at its best unless it is aesthetically framed — in this case, with healthy, pink gum tissue that covers the tooth’s roots and lines up evenly with the rest of your smile.
Achieving the perfect balance of long-lasting strength, attractive appearance, and gum tissue health is the challenge that implant dentists face regularly — and meeting that challenge takes a good deal of skill and planning. Here are some of the factors that your dental surgeon considers when placing a dental implant in a highly visible area.
Immediate or Delayed Implants
There are several stages in the implant process: exactly how many depends on the individual situation. First, if hopelessly decayed or damaged teeth are present in the mouth, they will need to be extracted (removed) before implants can be placed. Extraction, however, isn’t the forceful process you may imagine: In fact, it’s generally performed under local anesthesia, and is accomplished by gently manipulating the tooth until it becomes loose enough to remove.
When extraction is performed before implant placement, the goal is to remove the tooth with as little disturbance to the bony socket or surrounding gum tissue as possible. If done successfully, it is often possible for the implant itself — a small, threaded screw shaped post, the size of a tooth’s root — to be placed in the socket immediately after extraction. Immediate implant placement can be desirable for several reasons: It means less overall treatment time and it leads to a quicker result for the patient.
Immediate implant placement can be desirable for several reasons: It means less overall treatment time and it leads to a quicker result.
Traditionally, a newly placed implant is allowed to remain undisturbed for several weeks without any further treatment. The waiting period gives the process of osseointegration (“osseo” – bone; “integration” – fusion with) time to get started. However, in some cases it’s now possible to move right to the next stage: receiving a temporary crown (replacement tooth) the same day as extraction and implant placement.
Should You Consider Immediate Tooth Replacement?
The benefits of having an immediate single tooth replacement are clear: You won’t have to wear a removable prosthesis to hide the gap in your smile, and your treatment will require the least number of office visits. The temporary crown you initially get, however, won’t be permanent — it is made slightly less than full size, so it won’t come into contact with other teeth when you bite and risk disturbing the developing connection between implant and bone. You’ll still have to avoid chewing in the area, and you will need to have a permanent crown placed at a later date. Yet the temporary tooth will be hard to tell apart from your natural, healthy teeth.
However, there’s a potential downside to immediate tooth replacement: Placing too much stress on an implant that hasn’t yet completely fused with the underlying bone could cause the treatment to fail. The good news is that this happens rarely. In the right circumstances, research shows that the success rate of this procedure is very similar to that of delayed crown placement.
Which type of treatment is best for you? Your implant team (which often involves your dentist, the periodontist or oral surgeon and dental laboratory technician) will have specific recommendations based on your individual situation. In general, people who have thinner gum or bone tissue (whether due to genetic factors or resulting from a medical condition) may be better advised to consider a multi-step approach. The same is true for those who already have an asymmetric gingival (gum) display — that is, a gum line that appears uneven across the smile. It’s also recommended for anyone who would have trouble eating softer foods for a period of time, or complying with instructions for post-surgical care.
But when none of those things apply, immediate tooth replacement with long-term stability is a viable option — particularly when extraction is performed with minimal trauma; when diagnostic imagery shows that minimally invasive implant placement is possible; and when your implant specialist uses specific techniques to preserve healthy gum and bone tissue.
Regenerating Bone Tissue
While it may appear solid and unchanging, living bone tissue is constantly re-forming itself, with new cells replacing older cells. Whenever a tooth is lost, the surrounding bone begins to shrink. If left untreated, bone loss in the jaw will continue, and may lead to further oral problems — including gum recession, and eventually the loss of more teeth. Numerous studies have shown that dental implants can halt the progression of bone loss; that’s one reason why they are the preferred treatment for missing teeth.
Research has also shown that people who receive immediate implants with supplementary treatments to enhance tissue regeneration have significantly less gum recession than those who receive no extra treatments. Today, one of these treatments — bone grafting — is a routine part of many implant procedures. Grafting material placed in the tooth socket around the implant can reduce bone loss and aid the re-growth of natural bone. In the past, the patient’s own bone tissue was harvested for this use; today, it’s more common to use processed tissue from a human donor, or processed bone material from an animal that is sterile and safe for human use. Special barrier membranes made of natural or synthetic materials can also be placed in the area where bone growth is desired. These membranes are used in a technique called Guided Bone Regeneration (GBR).
Having sufficient good-quality bone tissue is important to ensure that implants are solidly anchored in the jaw. It’s also crucial for the long-term maintenance of healthy gum tissue. Research shows that a bone thickness of about 2.0 millimeters is needed to prevent gum recession around implants. When this amount of bone isn’t naturally present, it can be augmented via the techniques of bone grafting combined with GBR.
The Importance of Soft Tissue
In addition to bone, soft tissue (gum) health is also very important for successful implant therapy — especially in the visible areas of the mouth. Here, even minimal shrinkage of gum tissue will be highly noticeable. Gum tissue begins to attach to the implant as soon as it is placed, at the same time that osseointegration is occurring. Maintaining healthy soft and hard tissue can affect the success of the implant, both aesthetically and functionally.
Whether or not an immediate tooth replacement is chosen, gum tissues often require augmentation for the long-term preservation of their anatomy and healthy appearance. In places where gum tissue is naturally thin, having a soft tissue graft at the time of implant placement generally results in greater bone preservation. Research shows that the augmented sites maintained a comparable level of bone with sites that had naturally thicker tissues. Soft tissue grafts are especially valuable in preventing gum recession around implants in the front of the mouth.
There are several methods for obtaining and using soft tissue grafts. A thin layer of a person’s own gum tissue can be removed from another location in the mouth and surgically attached where it’s needed: This is called an autograft. Although highly successful, this procedure requires a second surgical site, which sometimes causes discomfort. It is especially suitable for people who have gum tissue that is naturally thin, and has been shown capable of preventing gum recession in the long term.
As is the case with bone tissue, it’s also possible to use processed material from a human donor instead of taking your own gum tissue, thus avoiding a second surgical site: This is called an allograft. The inert, processed grafting material does not contain cells and blood vessels, which means it is significantly slower to incorporate in its new location; however, it does eliminate the need for a second surgery.
Soft tissue grafts are especially valuable in preventing gum recession around implants in the front of the mouth.
A grafting procedure I have used successfully in immediate tooth replacements is called the “dermal apron” technique. Here, a composite mixture of sterile processed bone material is placed in the tooth socket at the same time the implant is being placed. Then the temporary crown is attached, and donated soft-tissue grafting material is adapted to augment the tissue around it. This technique can increase the thickness of the gum tissue and help preserve underlying bone, while reducing the need and discomfort of the second surgical site associated with autograft harvesting.
A Beautiful Result
Dental implants can be successfully used in many different situations. But when they are used to support replacement teeth in highly visible locations, both strength and aesthetics become paramount concerns. There are several steps in the implant procedure, which may include tooth extraction, implant placement, and attachment of temporary crowns. Depending on each person’s unique circumstances, these steps may be staged over months, or may be done at the same time. Your implant team will recommend a treatment plan based on your individual needs. But whether or not a replacement tooth is placed immediately, the long-term stability of the hard and soft tissues is critical to an implant’s success. Both types of tissues often require augmentation, to help them stay healthy and allow them to maintain an adequate size. Using proven techniques of tissue regeneration, implants can be placed with excellent results — even in the most aesthetically demanding areas.