Institute for Periodontics and Implant Dentistry
Dentistry is all about precision. The field of dentistry is one that is based in fractions of a millimeter. For me, a surgical result can be successful or fail if I am 1/10th of a millimeter in the wrong direction. The ultimate success or failure of a dental restoration can be held to that standard or even smaller. One excellent example of this is in the area of implant restorations. Over the years, there have been many changes in dental implants and especially the restoration of dental implants.
A dental implant is simply an anchor that is placed in the bone that binds to the bone through a process called osseointegration. The implant has a transitional intermediary piece called a healing abutment which allows the gum tissue to grow around it in a shape that mimics the way gum resides around natural teeth. Once the gum tissue heals around this healing abutment, it can be removed and replaced. Gum tissue will form a bond to this metal. Every time it is removed, this bond has to reform. Later, the healing abutment is replaced by the final abutment. This piece is the connecting piece from the body of the dental implant to the restoration that will be placed in your mouth. Lastly, a crown or bridge is attached to the final abutment.
When I began private practice over 22 years ago, typically, as the surgeon, I would place the dental implant and the healing abutment. After the gum tissue healed, I would replace the healing abutment with a stock final abutment. A stock abutment is one produced to hit the majority of the shapes and sizes that will accommodate typical restorations. It is not custom made for your site, but one would be selected that would most closely replicate your natural tooth. A temporary cover would be place on this final abutment. Then your general dentist would make a standard impression of what I had placed using the same things he would for a regular tooth. Often, retraction cord would be packed in the gum space surrounding the abutment and a polyvinyl impression would be made using dental impression trays and the gooey colored impression materials that take 5-10 minutes to harden in your mouth. It would then be tugged off your teeth giving the restorative doctor and his laboratory a replica of what was in your mouth. This was then sent to the lab where it would be poured and made into a stone model that replicated your mouth. The technician would then try to find the margin of your implant abutment and carve the stone away from the model to gain access to this margin. He would then take instruments with hot melted wax and build a crown out of this wax. The wax would then be cast into metal and porcelain would be placed to cover the metal and make a structure that replicated your natural tooth as closely as possible. This is called “analog dentistry.” As you can tell, there were many places here where error could occur. The doctor could miss the margin of your implant in the impression. The impression could distort. The model could shrink or expand when converted to stone. The lab tech could misinterpret where the margin is. They could do a poor job on the waxing, casting or stacking of porcelain.
This method was improved on by the implant companies when they started realizing some of the shortcomings. The next improvement came with stock impression copings. Here, I would place the dental implant and the healing abutment. After the gum tissue healed, I would replace the healing abutment with a stock final abutment. A stock abutment is one produced to hit the majority of the shapes and sizes that will accommodate typical restorations. It is not custom made for your site, but one would be selected that would most closely replicate your natural tooth. A temporary cover would be place on this final abutment. The difference was, a piece was now made that I would send to your dentist. Instead of packing cord and trying to get the exact contours of the implant abutment in an impression, this impression coping would be snapped onto the abutment. It would then be impressed with polyvinyl impression which would be made using dental impression trays and the gooey colored impression materials that take 5-10 minutes to harden in your mouth. It would then be tugged off your teeth giving the restorative doctor and his laboratory a replica of what was in your mouth. An accompanying piece would be sent to the lab which was an aluminum replica of the exact shape and size of your abutment. This replica would be snapped into your impression at the lab and poured up in stone. This was a big improvement because it removed some of the spots in the process where human error could occur. It gave an exact replica to the lab so a much better fitting crown could be made. There were still areas where error could occur. One other huge limiting factor was the fact that if the stock abutment needing any altering, in any way, this completely removed the ability to do this and it would revert back to the original way. In 22 years in private practice, I have seen very few times where I would say a stock abutment wasn’t a little too short, too tall, too angled, not angled enough, to narrow or too fat. Every tooth and every person are so greatly different, it is most often adequate at best but rarely ideal.
The third change that came with dental implants to try to improve on this process was what is called “fixture level impressions.” In this method, I would place a healing abutment and send a fixture level impression kit to your restorative doctor. They would unscrew the healing abutment, screw an impression coping to your implant, make the gooey impression and then remove it from your mouth after it hardened. They would then replace your healing abutment. This would be sent to the lab where a replica of the implant body would be screwed to the impression coping. This coping would be placed back into your impression and turned into a stone model. Now the lab would have a replica of your mouth with the exact position and orientation of your implant. The lab tech would then either select a stock abutment and refine it to fit your space or would design and fabricate a custom abutment to the exact contours of your mouth. They would then go through the process of waxing and casting a crown. This would all be sent back to your dentist who would remove your healing abutment again and then screw in your final abutment and cement your crown. This method was by far the best and gave the most customized result possible. There were still areas where issues could occur with the analog impression taking and stone models. But with standardized techniques and quality control, this can be a very accurate method with beautiful, customized results. The one thing that can’t be avoided is the placement and removal of the healing abutment multiple times which can cause the gum tissue to not rebind to the metal surface as well every time it is removed.
Now, some implant companies are changing the game again. The company I use is Zimmer Biomet. They are world leaders in medical and dental prosthetics and in the field of bone growth and bone grafting. Zimmer completely revolutionized the restorative end of dental implants with the introduction of the BellaTek Encode® Impression System. In this system, I place a specialized healing abutment onto your dental implant called a BellaTek Encode Abutment®. The BellaTek Encode® Impression System aims to provide optimized solutions to clinicians by eliminating the need for implant level impressions, which streamlines the treatment process for the surgeon, restorative clinician and laboratory. In addition, patients have a better experience and a beautiful aesthetic outcome as compared to traditional procedures with an impression coping.
A BellTek Encode® abutment has several advantages. The greatest advantage is the elimination of removing and replacing the healing abutment multiple times for impressions, try-ins and final placement of the definitive restorations which can damage the soft tissue barrier associated with the dental implant. An appreciation of the protective effect of the soft tissue barrier is important for providing optimal aesthetic outcomes. Recent studies show that multiple abutment removals (disconnections/ reconnections) are associated with increased crestal bone loss. These findings suggest using the fewest number of abutment removals to achieve better aesthetic and functional results.1,2 Ultimately, the goal is to use “one abutment, one time” and the BellaTek Encode Impression System provides an important step for achieving this objective.
BellaTek Encode® benefits to the patient and restoring doctor include:
- There is no need to use impression copings, resulting in a less invasive impression procedure for more patient comfort.
- The intraoral scan can be taken by the specialist at the surgical release visit, eliminating a restorative appointment and resulting in less visits to the dentist’s office compared to traditional procedures.
- Abutments designed specifically for the patient for better aesthetic outcomes compared to traditional non-digital procedures.
BellaTek Encode® abutments work by having a unique coding system built into the structure of the abutment itself. When recorded by an intraoral scan with a 3D scanning CAD CAM or through standard impression techniques (which are digitally converted by a lab), this information is exported to a specialized computer program that interprets the recordings made of the BellaTek Encode® abutment surface. This information gives the information of the implant size, implant style, implant angle, implant depth and the exact rotation of the implant. A computer interprets all this data and prints a 3D model that is an exact replica of what is in your mouth. The lab technician designs a custom abutment within an Encode design program as well as the crown that will be in your mouth. Both are milled to the exact specifications and sent to the restorative doctor ready to be placed in your mouth. So much human and material errors are eliminated with this method. Time is saved for the patient by potentially eliminating the impression appointment. Time and discomfort are saved for the patient by eliminating an extra visit at the restorative doctor’s office and not having to endure the gooey impressions needed for analog dental impressions. This also eliminates the need to remove the healing abutment multiple times. Once it is placed, it is only removed when the final restoration is being placed. Below shows the workflow of a BellaTek Encode® case borrowed from Zimmer Biomet literature. To see the workflow click this link.
Out of all the advances I’ve seen in implant dentistry, this is by far one of the best and for so many reasons. It saves the patient and restorative doctor time and discomfort. It saves me as the surgeon in follow-up issues like soft tissue attachment loss or bone loss and from issues like the healing abutment falling off or not being replace properly requiring additional procedures. This jump into digital dentistry is the wave of the future. Within the next 10 years, I think almost the entire dental field will move more and more to digital dentistry because the results and accuracy are unmatched. To summarize the advantages:
-Fewer visits to the dentist’s office. Intraoral scanning at our final appointment can be done eliminating the dental impressions.
-Increased patient satisfaction with a quicker process and more comfort
-Better functional outcomes with a customized abutment and no abutment swapping.
Restoring Clinician Benefits:
-Simplified process, single appointment and no more impressions, parts and pieces.
-Increased patient satisfaction with a quicker process and more patient comfort. Both will increase practice growth through better patient care.
-No need to prepare teeth and less chairtime.
-No need to create working models. No special articulator needed and no need to mail anything to the Zimmer Biomet Milling Center.
-Quicker turnaround time for cases.
-Less technician time on models and waiting times.
Please tell your dentist that you would prefer to use BellaTek Encode® technology to get the most advanced restorations possible. We will give you the best and easiest experience possible for a beautiful tooth replacement to help you smile and function perfectly. Call our office today to schedule a free implant consultation and see how we can help you smile.
What is the difference in an Implant and a Mini-Implant?
The first modern, root form implant was developed by a Swiss orthopedic surgeon in the 1960’s. The mini-implant was developed in the late 1970’s but not put into use until the 1990’s.
The original intended use of mini-implants was for temporary use to help hold temporary teeth while more stable, conventional implants healed. That is part of how mini-implants received FDA approval.
Mini-implants received long term approval through a loophole that many medical devices use to get on the market for patient use. The regulatory review process known as 510(k) for a section of the FDA law covering medical devices. Manufacturers typically show their product has “substantial equivalence” to a “predicate device” that has already been legally marketed. A claim of substantial equivalence does not mean the device(s) must be identical. Substantial equivalence is established with respect to: intended use, design, energy used or delivered, materials, performance, safety, effectiveness, labeling, biocompatibility, standards, and other applicable characteristics.
That standard can perpetuate problems. Your device is similar but only in theory. It can fall within certain narrow standards to get approval and then be used in off-label means once it is on the market.
A conventional implant is considered to have an overall diameter of 3.0mm or greater and a mini-implant is one with a diameter less than 3.0mm. A regular implant is typically two pieces: the part that goes into the bone that replicates the missing tooth root and a piece that ties to it called the abutment. This connection is vital for several reasons. First, teeth and bone are rarely in a straight line. In the front of your mouth, teeth have more of a shovel shape with a bend as they leave the bone and emerge through the gum tissue. Second, the shapes of teeth are much wider than the diameter of a mini-implant (less than 3mm). This abutment allows the doctor to replicate the shape a natural tooth has as it emerges through your gums into the oral cavity. This is much better cosmetically because the gum tissues contour to the abutment giving you the most realistic and esthetic profiles possible that most replicate what you naturally had. It also gives contours as nature intended allowing for normal homecare and maintenance making cleaning identical to natural teeth. The abutment connection also allows the doctor the ability to correct for angles that your body dictate to get your bite (occlusion) correct for less stresses and more longevity.
The mini-implant procedure was originally intended for medically compromised patients, patients with extreme bone loss that cannot be rebuilt and financially compromised patients. That use has been expanded, inappropriately, to all patients and all applications.
False Claims about Mini-implants:
They hurt less than conventional implants…in both mini and conventional implants, the bone and gums are numbed, a small opening is made for the drill and then a small hole or osteotomy site is drilled to the diameter of the implant being placed. You would be hard pressed to tell if a 2.2mm osteotomy site or a 3.3mm or 4.7mm osteotomy site was prepared. I have patients who have conventional implants placed tell me almost daily that they took nothing more than ibuprofen and had no pain. I think the amount of pain has more to do with the surgeon’s ability and the patient’s pain tolereance.
No need for complex flap surgery…that sounds like a great selling point. The reason they market that way is the though that these “mini” implants are so small that there is no need to see the underlying bone or anatomic structures. Only with in-depth surgical imaging like a computer aided tomograph (dental CAT scan), use of computer software to pre-plan a virtual surgery and the fabrication and use of a surgical guide that is custom 3-D printed from the scan and surgical plan can this be accomplished SAFELY and EFFECTIVELY with almost 100% assurance of the implants position. That is not done in these cases. A hole is drilled to the placer’s ability and experience and the mini-implant is placed “in the dark.”
Shorter Healing Time…bone and gum heal at the same rate, regardless of the type of injury. There is no magic elixir that makes bone integrate to a mini-implant faster than a conventional implant.
No need for bone grafts…typically, this is a guess, because a flap is rarely, if ever performed, to assess the actual bone for these cases. It is highly likely that parts, or most of the implant aren’t completely in bone when they are placed, but this is never confirmed.
Mini-implant look and feel just like regular teeth…The only time this is true is in people with extremely small, narrow teeth such as the front lower four incisor teeth and the maxillary lateral incisor (next to the front two center teeth). In people with extremely limited space with minimal bite forces, mini-implants are often a good choice in those limited areas. Otherwise, in teeth with a normal diameter, the tooth becomes the equivalent of a bowling ball sitting on top of a pencil. This causes unnatural emergence profiles (how the tooth appears to come up and out of the gum tissue), and causes oral hygiene difficulty. This difficulty in adequate cleaning causes more problems such as trapped odor, gingivitis, and ultimately leads to bone loss. Conventional implants are made to mimic the diameter of the natural tooth they are replacing with home care usually being no different than it would be for the tooth it is replacing.
Mini-implants are significantly cheaper than conventional implants…Although prices vary, mini-implants are not significantly cheaper than conventional implants, and in some cases, can be more expensive. For example, to replace a molar tooth, it takes only one conventional dental implant which Blue Cross Blue Shield values at $1500. To replace the same molar with mini-implants, it requires two implants splinted together under one crown to try to approximate the force a conventional implant can absorb. Blue Cross Blue Shield values one mini-implant at $1300. So a conventional implant molar replacement would be $1500 and a mini-implant molar replacement would be $2600. Uninformed buyers don’t know this.
The negatives with mini-implants
Mini-implant do not emerge like conventional implants making esthetics difficult.Hygiene is difficult with mini-implants.
A doctor can take a single day course and legally begin placing them into patients the following day with no further training.
Limited angle correction.
Much higher chance of fracture in normal function.
Many doctors that place them, place significantly more than needed expecting one or more to fail. That’s not what should be an expected outcome.
The positives with mini-implants
Are excellent for temporary anchorage or as additional anchorage in a denture case.
Are good for extremely atrophic ridge patients (small/minimal bone) who can’t have their bone rebuilt.
Are good for someone looking for a slightly less expensive option.
Are good for patients with limited space in mandibular incisor areas or maxillary lateral incisors.
Are excellent to obtain temporary anchorage in patients undergoing orthodontics that don’t want to wear headgear.
Don’t let the hype and marketing fool you when considering mini-implants. Also, go to an implant surgeon like a periodontist or oral maxillofacial surgeon who has been trained for years in the field of dental implants, bone and surgery, or minimally, a general dentist who has completed a multi-week course in dental implants. Let an experienced and qualified surgeon help educate you so you can make an educated and informed decision about dental implants and what type is best suited for your specific situation.
Just remember, when something sounds too good to be true, it usually is.
Platelet-Rich Plasma (PRP)
Most everyone has heard about Vampire Facials. For people on the hunt for a unique and effective facial treatment, many people have found the tremendous benefits of “Vampire Facials.” Technically referred to as a platelet-rich plasms (PRP) facial, this type of treatment got its name based on the blood-based procedure used. In recent years, doctors have learned that the body has properties in it that greatly promote self-healing. Platelet-rich plasma therapy is a form of regenerative medicine that can harness those abilities and amplify the natural growth factors your body uses to heal tissue.
What is plasma and what are platelets?
Plasma is the liquid portion of whole blood. It is composed largely of water and proteins, and it provides a substrate for red blood cells, white blood cells and platelets to circulate through the body. Platelets, also called thrombocytes, are blood cells that primarily cause blood clots, but they also contain many other necessary growth healing functions. Platelets play a KEY role in the body’s natural healing process.
What is platelet-rich plasma (PRP) and what are PRP injections?
In medicine, especially regenerative medicine, platelet-rich plasma therapy uses injections of a concentration of a patient’s own platelets to accelerate the healing of injured tendons, ligaments, muscles and joints. These techniques use each individual patient’s own healing system to improve musculoskeletal problems.
PRP is harvested by taking from one to a few tubes of your own blood and running it through a centrifuge in a special process to concentrate the platelets. In medicine, PRP has been found to significantly enhance the healing process and shown to improve function and reduce pain.
Advantages of PRP
Some of the key advantages of PRP are that they can reduce the need for anti-inflammatories or stronger medications like opioids. In addition, the side effects of PRP are almost non-existent because, since the injections are created from your own blood, your body will not reject or react negatively to them. Also, the concentration of advanced healing and growth factors, increase your own body’s healing potential exponentially.
Gum recession occurs when gum tissue wears away, exposing areas of the tooth root that should be covered by gums and bone. This recession may lead to increased sensitivity, especially when eating or drinking hot or cold foods. It also exposes areas of the tooth that don’t have a protective coating which makes the tooth more susceptible to decay and other issues. Because gum recession tends to happen slowly with rarely any pain or discomfort, many people do not realize it is happening to them. If left untreated, gum recession will eventually lead to tooth loss with progression.
Gum grafting is a type of dental surgery performed to correct the effects of gum recession. It is a surgery, where traditionally, a periodontist removes healthy gum tissue from the roof of the mouth and uses it to build the gum back up where it has receded. It has been a proven technique that has been performed successfully for well over 50 years.
Types of grafts
Traditionally, there are a variety of gum grafts available , and the type of surgery depends on the extent and severity of damage, the condition of the remaining soft tissue, and a person’s individual needs.
- Connective tissue grafts: In this procedure the periodontist removes tissue from the roof of the mouth by making a flap and taking tissue from underneath the top layer, stitches the tissue onto the existing gum tissue to cover the exposed tooth root, and then stitches the flap on the roof of the mouth where they took the tissue.
- Free gingival grafts: This is the preferred method for people with thin gums who require extra tissue to enlarge the gums. The periodontist grafts tissue directly from the top layer of tissue on the roof of the mouth and stitches the tissue to the existing gum area.
- Pedicle grafts: This is the preferred method for people who have abundant gum tissue growing near the exposed tooth. In this procedure, the periodontist grafts tissue from the gum around or near the tooth needing treatment. The tissue is only sectioned leaving one edge intact. This tissue is then repositioned covering the exposed tooth root and held in place with stitches.
Variations on traditional grafts
Because the types of grafts mentioned above do come with some risks and involve multiple surgical sites, other methods that modify their technique have been developed. One modification of connective tissue grafts and free gingival grafts is done using AlloDerm. AlloDerm is a donor tissue that comes from human donor tissue, thus eliminating the need to remove tissue from the roof of your own mouth. The donated tissue is minimally processed leaving a dermal matrix that provides a guide for your body to use expanding on the available gingival tissue using its own regeneration process. Donors are screened for contagious diseases, and a review of medical records and social history are also performed before the tissue is considered for processing. The downfall to this type of graft is that there are no cells that promote healing or growth. The tissue is foreign, so sometimes there can be an inflammatory response or delayed healing.
Another very popular variation is the Pinhole technique. In this technique, a less aggressive manipulation of the gum tissue is performed through a tiny “pinhole” puncture. The gum is freed up and elevated to cover the root of the tooth. Tiny strips of collagen are packed under the gum tissue to support it in place and act as a matrix to allow new tissue to repopulate the area. The advantages are that no tissue is removed from the roof of the mouth so there is no additional surgery site, and with the pinhole technique, multiple areas can be addressed simultaneously. The negatives are that patient compliance is a MUST. The healing period is 6-8 weeks before a patient can function on the area or begin normal oral hygiene. Another negative is that there are no cells present that promote healing or growth.
Vampire Gum Rejuvenation(tm)
In a quest to improve on the mousetrap, Dr. Lance Culley thought there had to be a way to provide the benefits of less invasive surgery but have the benefit of a quick healing with cells present that could promote growth. The opportunity arose where a patient, for religious reasons, could have no materials used in the surgery other than tissue harvested from themselves. This patient had other health issues that made it very risky to harvest palatal tissue. After discussions with the patient of possibilities, risks and outcomes, Dr. Culley decided to attempt to use PRP harvested from the patient as the graft. The outcomes were amazing. At the 2 week follow-up, there was 100% root coverage in a severe defect that would have been difficult to correct using any existing techniques. The area was healed beyond what would normally be expected using tissue from the roof of the mouth. Dr. Culley used this technique in several other patients with equal success. At that time, he decided to Trademark the technique as Vampire Gum Rejuvenation(tm). The benefits of the technique are: multiple areas of the mouth can be treated at the same time; there is no second surgical site; there is no chance of disease transmission because only the patient’s own blood is used; there is no chance of rejection; there are cells that promote healing, reduce swelling, and reduce post-op pain; more severe defects can be repaired; and patients can resume normal activities sooner than with other techniques.
Am I a candidate?
Almost everyone is a candidate. The following conditions would negate you as a candidate for PRP and for the Vampire Gum Rejuvenation ™ technique.
- Critical thrombocytopenia (low platelet count)
- Hypofibrinogenemia (deficient fibrin in the blood)
- Haemodynamic instability (collapse)
- Sepsis (infection)
- Acute and chronic infections
- Chronic liver disease
- Anti-coagulation therapy that cannot be discontinued (warfarin, coumadin etc)
- Metastatic diseases
- Certain bleeding disorders
CALL US TODAY TO SCHEDULE YOUR FREE CONSULTATION TO SEE IF YOU ARE A CANDIDATE FOR THE VAMPIRE GUM REJUVENATION(TM) TECHNIQUE. WE LOOK FORWARD TO HELPING YOU. (731)660-6244
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