With over 40 years of clinical development, dental implants have clearly been positioned as the treatment of choice today for the replacement of missing teeth. Successful results can be predictable with careful analysis of the anatomy of the region, and appropriate planning. New technology has made dental implant therapy safer and more predictable than ever before. The most dramatic example is the use of three-dimensional imaging in the planning of individual patient cases.

We have utilized computerized tomography (CT Scans) for our patients over the past 12 years. For the appropriate cases, we would have local hospitals and radiologists provide medical grade CT scans to help us in proper diagnosis of these cases. Radiation exposure, additional costs to the patient and the inconvenience of additional procedures made the use of CT scans limited to the most demanding cases. However, the development of in-office scanning technology, called Cone Beam Computerized Tomography (CBCT), has overcome these challenges, and has brought this wonderful technology to the convenience of our private practice environment. Our practice, Shoreline Periodontics, was only the second private office to receive approval from the State of Connecticut, for installation of this technology this past summer.

Historically, implant diagnosis was limited to a two dimensional x-ray and a clinical exam (Fig. 1). This information provided an “idea” of what the surgeon may encounter during the surgical placement of the implant. However, the true anatomy of the bone and how it might impact the surgical procedure was not known until the time of surgery. Many times, this resulted in additional procedures the patient was not aware of, or compromises with the ultimate outcome of the case. In addition, there are certainly risks of surgically entering the bone without knowing the exact location of all critical structures.

3-D CBCT imaging can provide important information regarding the width, shape, quality and volume of bone in cross-section (Fig.2). Once the scan is obtained, this information can be immediately reviewed with our patient to discuss the findings of the scan. The shape of the bone can be clearly seen and a discussion can be conducted of whether procedures such as bone grafting will be required. Other important anatomic landmarks can also be identified such as critical nerve structures, and bony undercuts that can not be seen with traditional x-rays (Fig. 3).

3-D imaging has quickly become the standard of practice in our office, as we have seen the benefits to the patient and the treatment team. Some technologies can dramatically impact the delivery of care, and this is especially true when it involves the improvement in diagnostic knowledge and therefore increases in patient safety. CBCT improves treatment outcomes and this equates to patient benefits all around.

This article first appeared in the 2010 November / December edition of the The New London Women’s Journal

Over the past year, I have shared through the Women’s Journal how dental implants and computers can restore the function and confidence of a patient with missing teeth.  As a periodontist and implant surgeon, I am fortunate to work with the top family and restorative dentists across Southeastern Connecticut and Rhode Island.  We consistently see how careful collaboration with the restorative doctor can produce optimal results and beautiful smiles.  When working in the anterior “esthetic zone”, the demands on the dental team rise dramatically.  With careful diagnosis, planning and teamwork, the implant surgeon and restorative doctor can work together to achieve beautiful results.

Our featured patient this month is Jessica, a 21 year-old young woman who had congenitally missing lateral incisors, which means that the permanent teeth had never formed.  Following orthodontic treatment, Jessica was left with empty spaces in the lateral incisor positions which were temporarily replaced by denture teeth held by a retainer.  Following a careful diagnostic work-up and careful communication with Jessica’s dentist (Dr. Debra Daren, East Lyme) a plan was developed to create a final result that would support optimal esthetics and harmony to Jessica’s smile.

We determined that the best approach would involve a minimally invasive single surgery approach.  The goals for surgery would be gum and bone recontouring to match the height and shape of adjacent teeth, placement of two dental implants, and immediate “temporary” restoration of the implants.   Dr. Daren attended the surgery at my office and immediately created temporary teeth following the surgical placement of the dental implants.

With this approach, Jessica was able to leave the office with her first set of new teeth on the same day.  She was instructed to avoid aggressive chewing with these teeth over the first 6 weeks while the implants were healing in the bone.  In addition, the advantage of the temporary restoration phase is that we can critically evaluate our progress during healing and make any modifications prior to the final restorations.

After approximately 4 months of healing, the implants formed a “union” with the surrounding bone.  This process is called osseo-integration, and allows the implant to absorb and withstand biting forces.  The gum tissues have also healed and matured around the temporary restorations.  Dr. Daren then began the final restoration phase.  Customized restorative materials were utilized with state-of-the-art tooth-colored supporting posts.  The final porcelain restorations were carefully designed and created to match the shape and color of the surrounding the teeth.

With the team approach, we were able to achieve successful functional and esthetic results by utilizing the most appropriate surgical and restorative methods.  Meticulous communication allowed us to capitalize upon the expertise of each doctors’ diagnostic and therapeutic skill sets.  We have found that patients are most pleased with the final results of dental implants when receiving care from a carefully coordinated team consisting of an implant surgeon and restorative doctor.

This article first appeared in the 2010 September / October edition of the The New London Women’s Journal

Before I had my surgery for my dental implants, I never would have imagined receiving so many compliments on my smile. But thanks to Dr. Toback and my dentist (Dr. Daren), the experience could not have gone any smoother. My new smile has given me all the confidence in the world. Jessica H.

In the last issue of the Women’s Journal, we shared how dental implants and computers can restore the function and confidence of a patient with missing teeth.  Our objective today is to demonstrate how dental implants can support beautiful teeth in the highly critical “esthetic zone.”  Nothing is more alarming to an individual than when they hear the news that they will lose a front tooth. We know that beautiful teeth and healthy gums capture and frame a warming smile. Our smile is the core of the visual first-impression. Fortunately, dental implants now provide hope and peace of mind to those faced with losing a front tooth. With careful diagnosis, planning and teamwork, the implant surgeon and restorative doctor can bring back architecture and harmony to a smile.

Our featured patient this month is a 38 year-old female who had congenitally missing lateral incisors.  This means that the permanent teeth had never formed and the primary teeth (“baby teeth”) were maintained by this young woman until the time of treatment.  The primary teeth had no root formation to provide support, and therefore the teeth became extremely mobile (loose) and were facing imminent loss.  After a detailed analysis, we determined that the removal of the baby teeth was necessary, and dental implants were the treatment of choice to create the necessary foundation for new incisors.

Whenever possible, utilizing minimally invasive approaches can help preserve normal gum architecture. Implant surgery without incision can be conducted in appropriate situations to avoid the disturbance of soft tissue contours. In addition, the use of immediate restorations can support the preservation of those tissues. This is a critical benefit to the patient seeking the most esthetic result.

Following removal of the primary incisors, the area is prepared for implant placement. Once the implants have been positioned, temporary posts and crowns are made chairside to be seated immediately. With this approach, the patient is able to leave the office with the first set of new teeth on the same day. The patient is instructed to avoid aggressive chewing with these teeth over the first 6 weeks while the implants are healing in the bone.

After approximately 4 months of healing, the implants have formed a “union” with the surrounding bone.  This process is called osseo-integration, and allows the implant to absorb and withstand biting forces.  The gum tissues have also healed and matured around the temporary restorations.  The patient’s restorative dentist then begins the final process of making the porcelain crowns.

Successful implant therapy results in restorations that blend with the surrounding teeth and gum tissue, and are in harmony with the individual’s facial and oral features.  Gum tissues that frame the restorations should mimic the scalloping shape and contours of gum tissue surrounding natural teeth.  Most importantly, when our patient smiles, the new implant teeth appear natural, appropriate and pleasing to the eyes.

In conclusion, careful analysis and management of the soft and hard tissues during implant treatment can lay the foundation for a successful result in the esthetic zone.  The restorative-surgical team approach can offer patients the most advanced implant options including minimally-invasive surgery and immediate restorations.  I would like to thank Dr. Debra Daren for her excellent restorative work, and for allowing me to share with our Women’s Journal readers.

This article first appeared in the 2009 November / December edition of the The New London Women’s Journal

Dental implants have clearly been positioned as the treatment of choice for the replacement of missing teeth. Successful results can be predictable with careful analysis of the anatomy of the region, and appropriate planning. Most patients prefer the team approach to implant rehabilitation; combining the expertise of a surgical specialist such as a periodontist, with the restorative skills of their general dentist. This “two doctor team” must communicate the desired goals of the patient and create a sophisticated plan that can be put into action. Computer guidance has been one of the single most important developments in implant surgery in the past twenty years. This technology now allows the implant team to digitally and virtually perform the implant surgery long before the patient is in the chair. A variety of treatment options could be explored and the potential complications can be identified. Ultimately, the best treatment plan can be selected and surgically executed with a precision never before possible.

The case reviewed here describes a 28 year-old male who had a developmental anomaly whereby his permanent teeth had never formed (fig. 1). With the exception of two back molars, this young man had only a primary dentition (“baby teeth”) to function with in the lower jaw. These teeth had cracked and become mobile. As an active individual, the patient desired to have implant treatment that would not require the use of removable dentures at any time during treatment. He desired a plan that was efficient with his time, and would allow him to enjoy chewing function, esthetics and ultimately, social freedom throughout treatment.

The first step to computer guidance is to obtain a detailed x-ray called a CT scan. CT scans (computed tomography) provide very precise images of the bone and can allow the visualization of the jaw bone in three-dimension (fig. 2). The image can be digitally manipulated to see the area of interest from many different perspectives. Once the case has been thoroughly diagnosed, implants can be virtually positioned in the desired locations. For the first time, the restorative doctor can be directly involved in the decision-making of the exact location for implant placement. The surgeon and the general dentist can interact in a meaningful way that results in the selection of the optimal positions for the implants to achieve the desired goals of the case.

Once the implant positions were finalized for this case, a template was made called a surgi-guide, that was utilized during the implant placement procedure (fig. 3). In addition, this template allowed the restorative doctor to make the temporary bridge for the patient prior to the removal of the baby teeth. The immediate restoration of the implants upon the day of placement has been termed “teeth in a day” (fig. 4). Following 4 months of healing, the final restoration was completed (figs. 5,6).

The great benefits of computer guided surgery include accurate diagnosis of the case, precision planning of implant placement, enhanced communication of the implant team and outstanding results. In addition, some of the greatest patient benefits of computer guidance is that surgery can be conducted in a minimally invasive fashion. Guided surgeries require fewer incisions and can be completed in a fraction of the time of traditional implant surgery. That translates to less post-operative swelling and discomfort and speedier recovery times. I would like to thank Dr. Dennis Sindel for his fine restorative work with this case, and allowing me to share with our readers.

This article first appeared in the 2009 September / October edition of the The New London Women’s Journal