Last week one of our young female patients came to see us. She was in a lot of pain and complained of a broken tooth. It’s not uncommon for patients to tell me they hate the dentist, or that they have anxiety, but this patient was absolutely terrified of us. Unfortunately, her tooth had to be pulled, and she knew it. Bedside manner and patience are key when working with patients who have high anxiety.
Once a tooth is removed, we always want to have a plan for replacing it. We talked about placing a dental implant or a bridge. After we discussed both options, she chose the implant.
Something I haven’t really discussed on this site yet is the difference between a one-stage and a two-stage implant. In our patient’s case, she is young, and we were removing a tooth that appears in her smile. So, it was important to her that we replace the missing tooth as soon as possible. Because of this, we decided to place a one-stage implant, otherwise known as an immediate implant. Before we dive any further into this case, let’s take a moment to cover some implant basics.
Dental Implant Basics
What we refer to as dental implants usually have three separate parts. First is the implant itself, which is placed directly into the bone. Second is the crown which will replace the missing tooth or teeth. Finally, there is the abutment that joins the crown, bridge, or overdenture to the implant.
The dental implant must be placed into bone surgically. Then, after a period of time, we can place a crown on top of the implant to look like a natural tooth. Whether we place an abutment the same day as the implant placement, or later, determines whether this will be a one-stage or a two-stage procedure.
For more information about dental implants, please see my other article here.
Two-Stage Implants
Dental implants are typically placed months after the tooth has been extracted and the bone has healed. In cases where there is no immediate need to replace the tooth, or in cases where we need a better margin of safety, we will extract the tooth, place a bone graft, and then wait for the bone to heal. After 3-6 months, we will assess the area and see if it is ready to hold a dental implant.
The next step in the process is the placement of the dental implant into bone. After successful placement of the implant, we hide the implant underneath the gum. We then wait a few weeks and give the gum time to heal over the top of the implant. You most likely won’t be able to tell that there is an implant there after the gum heals.
After the implant has healed into the bone, we will open up the gum and expose the implant. This second step is why this procedure is referred to as a two-stage implant procedure. Once we open the gum and find the implant, we place what is called a healing abutment on top of the implant. The gum will then heal around the healing abutment to simulate a tooth emerging from the gum. After a few weeks, we take impressions for the crown, bridge, or overdenture that will eventually sit on top of the implant.
One-Stage Implants
In the case of a one-stage implant, we place the implant, and then we put a healing abutment on immediately instead of burying the implant under the gum. Remember that in the two-stage procedure, we placed the implant and then covered it with the gum. Several months later we have to uncover the implant and place a healing abutment. Note that one-stage implants are sometimes called immediate implants or single-stage implants.
With a one-stage implant, we skip straight to the healing abutment. By skipping the uncovery process and placing the implant immediately, we can shave off between three to six months from the process.
One-stage implants may not be possible in cases where infection has destroyed a lot of surrounding bone. Likewise, if bone is damaged or destroyed during the tooth extraction process, then it may not be possible to place a one-stage implant. Finally, the bone quality may simply not be sufficient for a one-stage implant, particularly in certain areas of the mouth or in patients with certain health conditions.
Below is a table showing the differences between one-stage and two-stage implants.
| Two-Stage Procedure | Duration | One-Stage Procedure | Duration |
|---|---|---|---|
| Extraction and bone graft | 3-6 months | Extraction, implant placement, bone graft, and healing abutment | 3-6 months |
| Implant placement | 3-6 months | Impressions for final restoration | 1-2 weeks |
| Uncovery | 2-4 weeks | Final restoration delivery | 20 minutes |
| Impressions for final restoration | 1-2 weeks | – | – |
| Final restoration delivery | 20 minutes | – | – |
| Total Duration | 7-12 months | Total Duration | 3-6 months |
Back to our Patient
Now you have some background information, let’s get back to our patient. As you may recall, she had high anxiety in the dental chair. She is also on the autism spectrum. When I am working with patients who have special needs, I am always mindful to try to mirror them. My patient was quiet, and had lots of questions. I’m naturally a big, loud guy, so I had to tone it down and match her energy.
Throughout the procedure, I told her what I was doing. I explained that placing an implant is a lot like hanging a picture on the wall, first we drill a small hole, then we make it bigger for the screw. Some patients don’t want to know anything, others want to know everything. This patient definitely fit into the latter category. For some patients, including her, hearing me talk them through the procedure calms their nerves.
Preparation
Before we start drilling holes in bone, we need a plan. In order to see where the bone is, and how to orient the implant, we need to take a special x-ray called a Cone Beam CT Scan, or CBCT for short. Using special software, I can digitally plan my implant placement before ever touching a surgical instrument. By the time I numb the patient, I already have an idea of what implant size I am going to use, and where I am going to place it.
Extraction
There is no way to sugar-coat a tooth extraction. For patients with high dental anxiety, few things are worse than a dental extraction. It is imperative that the anesthesia is complete and effective. I always check my anesthesia to be sure it worked before commencing with the procedure.
We managed to numb our patient completely, and she felt relaxed and calm. Many patients judge the competence of their dentist based on their shots. Because of this, I take my time giving slow and comfortable injections. Once a patient loses confidence in you, it’s difficult, if not impossible, to win back their trust. So, we want to make sure we have the confidence of the patient from the first shot. You literally only have one shot; you can’t blow it.
I got to work as soon as the anesthesia had set in. The extraction went well, we were able to preserve all of the bone around the tooth. Sometimes when pulling teeth, the surrounding bone is damaged or destroyed. In those cases, it may not be possible to place a one-stage implant. Luckily for our patient, we managed to keep the bone completely intact.
Implant Placement
As I said before, placing an implant is a lot like hanging a picture on the wall. The actual process isn’t all that complicated, though it can be difficult to get all of the angles right.
We start with a pilot drill to be sure that we are lining things up properly. Because of the way teeth are positioned in the mouth, it may sometimes look like you are going straight, but really you are about to drill into the adjacent tooth. Even though I’ve placed many implants, I still take care to check myself throughout the process by taking x-rays.
After we determined that our drill was placed well, we get to work widening the hole. After a series of drills to make the hole wider, we can finally place the implant. We screw the dental implant in using a torque wrench and measure the total torque used to screw in the implant. If we feel good about the torque measurement, we can go ahead and place the healing abutment.
It is important that we again get an x-ray showing where our implant ended up. The implant should ideally sit between the neighboring teeth. Also, any critical structures should be avoided. In this area of the mouth we have to be aware of neighboring teeth and the maxillary sinus.
Grafting and Closing
Because our implant is smaller than the tooth it replaced, there was some space around it from where the tooth had been pulled. In this particular case, we ended up placing a bone graft between the implant and the walls of the extraction socket.
Once the graft had been placed, we placed two stitches to close up the gum around the healing abutment. As you can see from the photo below, the gums closed up nicely around the healing abutment. The white lifesaver you see is the healing abutment, it connects to the implant under the gum. Around the healing abutment you can see some of the bone graft granules.
If you are a keen observer, you may notice the brown spot on the tooth at the bottom of the image above. That spot is actually a large cavity, and we have plans for that tooth. Our patients anxiety has been a barrier to receiving routine dental care, and she has not .
What Are Surgical Guides?
Surgical guides allow the dental professional placing the implant to precisely drill and place implants. There are many types of surgical guide, with varying degrees of precision and methods of attachment. Some implantologists use surgical guides for every implant, others never use them at all.
I use surgical guides on occasion, though not for the case discussed in this article. Surgical guides can be useful, particularly when the dentist who restores the implant isn’t the same dentist who placed it. Another good use for surgical guides is when the placement of the implant has to be exact. For example, implants we use on implant-supported overdentures need to be as close to parallel as possible, this is difficult to achieve without a guide.
Surgical guides typically incur an additional fee to the patient. Also, most dentists are not equipped to fabricate surgical guides immediately. So, in our patient’s case, I would have had to take an impression and send that to a lab to fabricate the guide. One or two weeks later we could have accomplished what we managed to do for her the same day she came in. Given that the patient was in pain, waiting for a guide really wasn’t an option.
Final Thoughts
Although the implant placement went according to plan, there are still reasons our implant could fail. The fact that our patient is autistic, coupled with her dental anxiety, and the overall condition of her teeth, are all factors that could lead to the failure of the implant.
Our patient is young, and her appearance matters to her. We have done everything we can to provide her with a great looking crown, but the rest is up to her. One of the most difficult aspects of dentistry is the fact that I can only control what happens in my office. The vast majority of the time, I have no control over how my patients treat the work I do, and consequently I can’t guarantee a good outcome for everyone.
Luckily, the success rates for implants is very high. As a general rule, our implant has better than a 95% chance of lasting ten years. If you figure a person eats roughly three meals per day, 365 days per year, then that is over 1,000 total meals per year. Over ten years, she should reasonably expect to eat over 10,000 meals with the implant. In many case, when properly cared for, implants can last much longer than that.