Fractured root - my patient has a
fractured root what should I do?
Infection is the main complication of leaving a fractured
root in situ. The most common fracture is the buccal wall
of a post crowned upper anterior tooth. Infection in these
cases can seriously compromise the implant therapy due to
the loss of the buccal plate of bone.
Loss of this bone can compromise implant placement and increasing
the likelihood of a bone graft being required. Loss of buccal
bone can also complicate and reduce the predictability of
the final cosmetic outcome of the restoration.
The management of a non-infected fracture is urgent referral
within 2 days.
The management of an infected fracture is extraction with
the use of a periotome or antibiotics with same day or next
referral depending upon the dentists experience with implant
extractions.
Advanced periodontal disease
– can my patient have implants?
It is a misconception that patients who are susceptible
to periodontal disease are equally susceptible to bone loss
around implants. They are two different pathological processes.
There is some evidence however those bacteria from uncontrolled
periodontal disease can lead to infections around implants.
I would therefore carry out treatment where the patient has
a history of controlled periodontal disease.
I would not recommend implants are placed into a mouth where
there is uncontrolled periodontal disease for the following
reasons.
- Implant placement should be considered as part of a whole
mouth treatment programme. It is only following the elimination
of periodontal disease that it is possible to assess the
long-term prognosis of each tooth which may in turn change
the position and number of implants placed.
- Sepsis is not conducive to controlled surgery. In my
opinion surgery should not be carried out in the presence
of infection unless it is for purposes of drainage or debridement.
- The final cosmetic result will be compromised by a non-healthy
mucosa making the prosthetic construction more difficult
and less accurate.
Smoking – my patient
smokes 10-15 cigarettes a day can they have implants?
It is now generally considered that smoking is not a contraindication
for implant provision. Studies show with the osseotite surface
the integration will be reduced by 0.5-2%. Should a patient
wish to eliminate this risk they should consider stopping
two months prior to implant placement and two months after
placement. The one area where smoking has a more marked effect
is cases where a bone graft is required. There is a higher
risk of wound dehiscence and non-integration of the graft.
My policy is not to carry out onlay bone grafts or sinus lifts
in smokers.
One other consideration of smoking is that smoking will mask
the effect of periodontal disease leaving the clinician with
the impression that the health of the mucosa and supporting
structures are in a higher level of health. Thereby clouding
the diagnosis and treatment planning stage.
Is age a restriction to implant
care?
In my opinion a patient is never too old to benefit
from implant care as long as their general health is high
enough to undergo the procedures involved in implant dentistry.
A patient can however be too young. I would not recommend
that a female patient undergo implant care before the age
of 18 and a male 20. This is because if an implant is placed
before growth is complete there is a possibility that the
jaw will continue to grow leaving the implant in a non-ideal
position.
What medical conditions exclude
patients from implant care within our clinic?
- Chemotherapy within the past 6 months
- Radiotherapy to the oralfacial area – Hospital referral
required
- Alcoholism
- Mental illness - uncontrolled
- Serious illness within the past 3 months
- General health of a level where minor surgery is not conducive
to the patient’s well being.
- Uncontrolled diabetes
- Steroid therapy - Heavy doses
- Smoking - Onlay and Sinus lift grafts only
What medical conditions may
exclude patients from implant care within our clinic?
Assessment will be required by another health professional
following consultations
- Bleeding disorders
- Warfarin therapy
- Transplant therapy
- Bone disorders including severe osteoporosis
- Steroid therapy - moderate dose
What are the normal stages
involved in having an implant?
There are a number of stages involved in implant dentistry.
Stage 1 - diagnosis, treatment plans and consent
During the first stage of care a full diagnosis is made and
a provisional treatment plan formulated. The patient is then
informed of their suitability for implant therapy, alternative
treatment options and advantages and possible complications
of each option. In my opinion only at this stage is it possible
for a patient to consent to implant treatment. Implant therapy
is an elective procedure and should be patient driven.
Stage 2 - stabilisation of disease
During stage 2 the affected tooth or teeth is removed
and an appropriate provisional denture or bridge is placed.
It is at this stage when other general dental health requirements
if required are also stabilised.
Stage 3 - Planning and implant placement
The implant is placed into the jaw using a minor surgical
technique. This is normally carried out under sedation using
Midazolam. It is usually administered by a second practitioner
and has the advantage of making the procedure as comfortable
as possible leaving the patient with few recollections of
the treatment. Some patients occasionally prefer not to have
sedation however in my experience especially with multiple
implant placement sedation is preferable.
Stage 4 - Abutment connection
This procedure is a limited surgical procedure to locate
the top of the implant and allow connection of the abutment
to the implant. The abutment is the second implant section,
which attaches to the implant top with a screw and holds the
implant crown or bridge. This stage is carried out 4-6 months
after implant placement. It is at this stage when the implants
integration is confirmed.
Stage 5 - Provisional crown and bridge construction
Following confirmation of the success of the implants
integration the provisional or temporary crown and bridge
can be constructed. This stage is carried out 2-6 weeks after
stage 4. I prefer to use a provisional stage to help control
the aesthetics and soft tissues
Stage 6 - Final construction
The final crown or bridge is made. This stage is carried
out after 4-12 weeks following the provisional stage.
Stage 7- Maintenance
This stage involves clinical monitoring and patient home care
advice to ensure that the implants are maintained to a high
standard.
Can patients have immediate
implants?
There are two distinct concepts when considering
this question:
- Immediate placement
The tooth is removed and the implant immediately placed.
- Immediate restoration
The implant is placed and the tooth is restored at the
same time to a provisional stage.
It is possible to have a tooth extracted and an implant immediately
placed and restored. This option has a number of advantages
for the patient including speed of treatment and avoiding
the need for temporary dentures or bridges. The major disadvantage
especially with single teeth is the reduced success rate and
difficulty in controlling the gum level.
I rarely carry out immediate placement and restoration of
single teeth for the above reasons and prefer to use a delayed
approach, which provides me with greater success and control
of the final cosmetics.
I do however carry out immediate placement where it is clinically
indicated leaving the restorative phase for the normal time.
The exception to the rule is where patients have or are about
to loose all their lower teeth. Research shows that this is
of benefit for the patient and the integration compared to
a delayed approach.
This is possible due to the ability to link the lower implants
together and the limited visibility of the necks of the lower
teeth.
The options available to each patient will be discussed at
the time of their initial consultation.
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