MK III Implant: When is the Best Time to Place the Final Abutment?

1. I think you cant get correct answer without examination, so only your periodontist knows what forces the graft can get without destruction 2. I don't think TiUnite is a gold standard 3. I won't like to have an implant with external connection in my mouth in aesthetic zone

You sure are a knowlegable patient. Hmmm.... There are many variables that can be factored into your question. As such, there is no single way to skin a cat. Your provider's current plan sounds acceptable. However, I would go with an internal connection implant. If your dentist converts your original tooth into an ovate pontic, you will get superior esthetic results. Ciao

The central incisor is now history. The extraction was a little complicated as the root had fractured into three parts - third part being a little stubborn (I think). No bone-grafting was necessary and a Nobel "cone-shaped" implant was placed instead of the originally planned Biocare MK-III TiUnite from Nobel. A gum graft was done as well. Question: What's the difference between the Biocare MK-III TiUnite implant and the cone-shaped one? Structural, esthetic, or both? P.S. The periodontist used nitrous-oxide. Initially I was reluctant (trying to save my remaining brain cells). But now recommend that ALL extractions/implants/grafts should be done with nitrous. The whole procedure was actually VERY pleasant.

Oh... I forgot. The temporary crown (which is actually the old laminent and some bonding material) is affixed to the two lateral teeth while the gum-graft heals and the implant osseo-integrates. The gum is still pretty dark up around the gengival line, as it was prior to extraction (due to endo treatment). Slowly it seems to be getting pinker, though (at least I hope so). Along with prosthodontic work, gum grafting seems to be the key to superior esthetic results. I've got more gum tissue where that came from and if it means more nitrous trips until we get it right, I'm good to go.

first of all...never read company literature...let me rephrase...Nobel reccommendations...they want more implants placed so they will say anything for that to happen...follow by the guidelines your DR treatment plans for...they usually know wha is best for you. Lastly, I hope the implant doesn't have future bone loss...Nobel gets a lot of bone loss arond their implants. Next time you look at your xray with your DR start to notice more and mor threads of the implant will show being out of the bone....if you see this then a bacterial response is happening which can be minimized but not stopped This is not the DR fault if this is all that he knows, however most DRs know there are other options than Nobel Good luck

Internal connection vs. external connection in the esthetic zone can be debated. In the hands of skilled technicians a beautiful outcome can be the result. Nobel customers have had incredible results with a Procera Esthetic Abutment placed at the time of implant placement. That doesn't mean that in every situation that immediate placement of an abutments is an appropriate protocol. How about determining if you have achieved 35ncm of torque in good bone quality before making that decision. As for bone loss, let's not pin bone loss on one implant company. Bone loss usually has more to do with compromised patient health and or anatomy and often times technician error.

Hello Tony, When you go on an open commentary site like this you will get a lot of dogma, bias and anecdotal information. So here is mine. I have long experience with using several different implant manufacturers and styles of implants. Nobel Biocare produces very good implants. The TiUnite surface is a good one. The conical shaped implant, probably a Nobel Replace, is a good choice for an immediate implant because it develops good primary stabilization. From your comments I think you have been attended to quite appropriately and the probability is that you will have a good result.

Tony, I agree with RTKR "You sure are a knowlegable patient. Hmmm…." and IN with their responses. GOOD LUCK

Funny how dentists are cynical about knowledgeable patients. Are dentists the only intelligent people in the population? Last I heard, there are 150,000 or so dentists in the US and most, if not all, of those dentists did not even go to medical school. So it's quite obvious that the patient population is much larger than the number of dentists, and as such patients as a whole, many of whom are doctors, lawyers, engineers etc. will be alot more intelligent than their dentists. I would think that instead of being cynical, dentists would do well to listen to their patients. With the advent of the Internet it's quite easy to do research on any medical topic and get some very good answers rather quickly. You don't need to go to medical school to find out about specific drugs, procedures etc. Dentistry is no different than any other field. The Internet will eliminate barriers of knowledge and level the playing field for all sorts of services, including dentistry.

I want to say "Thank you!" to Frank for the above post!!!!! I am the patient with multiple complications even tho in good health and have followed instructions completely. I bought a book (Contemporary Implant Dentistry by Misch) and learned for myself what options are out there for me to make my own "educated" decision. However, the restorative dentist has criticized my "knowledge" and my decision. I am referring to removable vs fixed prosthesis. Due to the problems associated with cleaning, I am deciding to have the removable but with the palate exposed. I have 8 maxillary implants, am 57 years (young) and have had an upper denture since age 12 due to abuse. The restorative dentist wants to decide what she thinks best for me. One example is as simple as tooth color. The dentist wanted me to have white teeth for the restoration and then veneers for the lowers to match. I do not want to grow old with WHITE teeth which would not look natural. Currently, I still have bone loss due to peri-implantitis and will accept the surgeon's opinion (who listens to me). I had lots of grafting and he has clearly explained my options which I then have researched through the internet. Thank you to all the comments from all the doctors on this site! I will keep reading until the time when I can have my finish! I'm nearing 2 years into this and the internet has proved 100% useful!

Update: The gum-graft is getting pinker (i.e. healthier) with each passing day. (I'm starting to think that once the implant sets, the gum-graft is the key to superior esthetic results. Is this the case?) Anyway... I had my one-week follow-up appointment yesterday with the periodontist/implantologist. He removed the stitches from the site where the gum tissue was taken and seemed extremely pleased with the shape and color the gum graft up front was taking. He also informed me that normal protocol is for a healing abutment to be placed AT THE SAME TIME as the implant, but at the time of implant placement, he felt that this would interfere with the natural healing of the gum graft, so he opted not to do it and to bond the previous crown/laminent to the lateral teeth instead (thus leaving abutment-placement to the future). That being so, the plan is to open up the gum tissue in a month and place a titanium healing abutment. Immediately following the placement of the healing abutment, it's off to the prosthodontist to make an impression and place another temporary crown. Two or three weeks after that, a CUSTOM-MADE zirconia abutment and the crown will arrive from the ceramicist who supposedly specializes in such work. (Question: Is it normal to have zirconia abutments custom-made???) I've gotta say... the state of implantology is moving beyond anything I (a lay-person and mildly informed patient) could've imagined. When this tooth abruptly broke off at the gum line (probably due to accessing it more than 30 times for repeated hydro-calcium treatments over the past 10 years), I was really worried that an implant would look lousy. Fortunately, all the internet information (message boards, photos, videos, etc.) calmed those fears and now that I'm going through the process of actually placing the implant, I'm increasingly confident it will come out structually sound and esthetically pleasing. The idea that it might come out strong and natural-looking, has me in a state of near-rapture. So... now it's just a matter of letting the titanium and bone do their sweet tango before we say our final goodbye to the Dr. Periodontist and hello to Dr. Prosthodontist and move into the esthetic phase of the process. Thanks for all of your insights and opinions, thus far. Any others???

To: Tony in Brazil You are very lucky; and your message gave me hope. I am also a dental implant patient, (implant in the esthetic zone), which according to my OS in the US I have a functional dental implant (maxillary central incisor) but with aesthetic failure. I don't agree with the "functional", because I need to be able to smile and since the dental implant I am hiding my smile. It has affected my personal and professional life. I am searching for an OS in Brazil, so I would like to know if you could provide me with the name and telephone number of your Oral Surgeon. Thanks!

I have also just had a dental implant as I had broken my central insicior below the gum line. My prosthodontist recommended an implant rather than to try and save the tooth. I have got a denture in the meantime to cover the gap, but still sound like elmer fudd! Why is it that I was not offered a temporary crown?

I was looking to expand my practice. I noticed a dentist in Redlands running an informercial about Dental Implants. Does anyone know who could make an informercial like program for me? Thanks- Jack Stone, D.D.S.

To Tony in Brazil. Hello from across the pacific! When I place implants without a healing abutment (that is, buried under the gum with a cover screw), they are left there for 5 months. At which point, the implant is then surgically exposed, the cover screw removed and replaced with a healing abutment and then the soft tissue is allowed to heal for a month before commencement of the restorative phase. The reasons for delaying the exposure untill 4-5 months pass are as follows. After an implant is placed, the retentive forces on the implant actually reduce over the next 1-2 months as the very thin margin of bone in contact with the implant's thread undergoes remodelling due to cell death and micro vascular damage arising from both the drilling of the hole for the implant and actual placement of the implant. To some degree there is some balance for this unwanted event, as the new bone forming within the voids of the implant thread and directly on the implant surface begins to generate retentive force. Therefore, if you were to uncover the implant after only a month, take off the cover screw and then place the healing abutment (which is held in by a screw) you will be imposing twisting loads on the implant (by unscrewing and screwing screws) when the implant is at its weakest state as far as integration goes. If it was my implant I would be patient, let osseointegration take its time and expose the implant after at least 4 months time. Anyway, discuss this with your periodontist. He/she will probably be receptive to this info as I certainly was. Regards John from Australia

Tony You are clearly in very good hands with your implantologist there is no doubt that you will have an excellent result I doubt however that you are a lay person!? Its not that we as dentists/surgeons etc are so smart its just the flawless nature of your presentation is very impressive for a lay person (contrary to karens post you cannot learn implantology from the internet..or any other proffessional skill..it takes a little more that) aside this I am sure the whole point of this thread has still proven to be useful to some Thanks for your case presentation

I'm curious about the comment "contrary to karen's post" about doing research on the internet. I have been presented differing options of fixed vs fixed removable or however to describe that. SO I have scanned all over this website to see what others have said about the fixed prosthesis. For example, Scott who had the fixed and had problems cleaning which is a huge concern for me since I'm battling implantitis. I'm also clenching which I did not do before all this started but keep having problems needing the implant cap or whatever it is called tightened on both sides of my mouth. When I said "the dentist isn't listening to me" it's that I do not want the fixed because of all the problems I'm currently having (had first graft, sinus lift etc Oct. 06) and I want the removable. The surgeon thinks I may have speech problems with the fixed but the dentist said I shoud accept her "professional opinion" and not read what others are experiencing. However, she won't be paying for the repairs or corrections should more of my implants fail as another one is currently. I only said "thank you for the comment that dentists listen to the patients desires". Anyone have any help for periimplantitis???? When I finally get to have a prosthesis made I'll have a night guard but until then the clenching is a big problem that seems to be getting worse.

This is precisely my point you have in your last post embraced at least 3 specialities that you think you may have the answers to Advanced surgical procedures "Implant prothodontics Implant maintainance Clenching /occlusion Dental proffessionals can dedicate a career to one or 2 aspects of the above PHDs are written on any of these topics Please do not presume you understand these huge topics from searching blogs on the net Proffessionals of many clinical years hotly debate these issues constantly Maybe you do have a reasonable understanding for a lay person but I assure you.... you are scratching the surface Your oppinions can only be cursory and isolated at best . It cannnot be from your years of clinical experience or your clinical knowledge or expertise ....? Perhaps your Dr may not be the right person for you it takes a lot to be a good Dr as well as a good communicator and have patients second guessing your suggestions . At the same time you are smart and "on the ball" you need one or two more CLINICAL evaluations and subsequent oppinions to satisfy your desires You also will need a personality who can deal with you to provide a treatment to your satisfaction "Diagnosis on line" is probably the single most dangerous consequence particularly from blogs How can you possibly know the circumstances of what people have in their mouth ? PeriImplantitis is another case in point This has been studied for 40 years You will not get your answer on a blog

It's hard to get across any point via this site w/o being judged! I have never stated "I know it all" as you have stated. This site is for everyone, right? I have questions and this site has been immensly helpful. Scott himself stated his problems and I read with great interest! I have been diagnosed with periimplantitis so am not "guessing" but only asking if any other ideas are out there to stop it. And the clenching. I have only been asking questions with the hope that other patients like myself can tell me their experience w/o judgment. I have not, nor do I intend to, diagnose myself. That's why I'm paying THOUSANDS for this treatment. It's been a long, long, painful road. Thank you for you superior kindness. My surgeon has said he appreciates all the knowledge I've gained on my own as I do understand a lot w/o the need for him to explain EVERYTHING.

Tony a 48 year old patient asks: Treatment (refresher): Four weeks ago, I had a non-vital, maxillary central incisor extracted and an implant immediately placed with a gum graft. My previous crown was slightly reshaped and bonded to the two adjacent teeth. The healing abutment is scheduled to be loaded in a week or two and a temporary crown affixed while I wait for a custom abutment and the final porcelain crown to be made. Pathology/Symptoms: During the past couple of weeks (weeks 3 and 4 post-placement), I’ve had a couple days where a mild aching seems to come and go – starting the day without discomfort/pain and usually becoming more discomforting as the day progresses. This is not any kind of debilitating ache, mind you –just a general discomfort emanating from the implant site. There’s no swelling in the apical area and the gum is getting pinker with each passing day. When looking very closely (and with my old man Coke bottle reading glasses) I can see one of the sutures in the front and I can feel a couple of sutures with my tongue in the back of the crown (where there seems to be a slight sensitivity of the gums). I’ve read through many of the posts on this WONDERFUL site, and have cautiously diagnosed that one of the following is the name of my pain: a) peri-implantitis (which could be due to bacteria left over from the endodontic treatment, but would be unusual a mere 2-3 weeks post-surgery), b) an infection due to suture opening and/or leakage (which is difficult to determine given that clear line of vision of the suturing is covered by the temporary crown), c) bone expansion (no real problem as the aching will go away) or d) bone overheating (which is bad). Obviously, I’ll schedule an appointment with my periodontist ASAP, but until then I’ve taken to saline rinsing and dapping the implant site twice daily with a cotton swab soaked in Peri-Guard (we can buy it over-the-counter here). Any insights, anyone might have would be greatly appreciated to help ease my mildly aching implant site and troubled mind. Thanks.

To: Tony in Brazil You are very lucky; and your message gave me hope. I am also a dental implant patient, (implant in the esthetic zone), which according to my OS in the US I have a functional dental implant (maxillary central incisor) but with aesthetic failure. I don’t agree with the “functional”, because I need to be able to smile and since the dental implant I am hiding my smile. It has affected my personal and professional life. I am searching for an OS in Brazil, so I would like to know if you could provide me with the name and telephone number of your Oral Surgeon. Thanks!