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What is the implant procedure like?

Implants is a  relatively long, intensive procedure. Cannot be done in 1 visit-  even immediate implants cannot be done in one visit. Because it is multi stage process, and also have to go for regular reviews.

Assuming a relatively simple two stage procedure without complications. If requires bone graft, will take longer and more visits.

First visit: treatment planning, Xrays, consultation, impression taking, whether LA or GA

Second visit:
First, your dentist will give you an injection to numb the area. The implant surgery itself should not hurt at all. However, some people make the assumption that they will not feel anything at all during the process - this is wrong - you will feel pressure and a ‘drilling and vibrating’ sensation during the procedure. The anesthetic only removes the sensation of pain and not all sensation.

Another more radical option is to do the surgery under general anesthesia, in which you will be put to sleep with no awareness and sensation of the surgery. Of course, GA is exponentially more expensive as it has to be done in a hospital in the presence of a trained anesthetist, and you will also have to be warded. It has also considerably more risks and adverse effects compared to LA.

In most cases, surgery can be done under LA. While it is far from the more pleasant thing you have ever done, the majority of patient find the procedure tolerable.

The implant procedure can be viewed as 2 major stages: the surgery stage, and the prosthodontic phase.

The surgery stage is the where bone is removed to make space for the implants, and is the staged most patients are concerned about in terms of discomfort and pain.

The prosthodontic phase is when the crown is fabricated, and is usually a painless stage.

Incision to expose bone

After LA is administered, your dentist will check if the area where the implant is to be placed is totally numb. A sharp instrument is usually used to check for anesthesia. You should not feel anything sharp or painful. What you should feel is some pressure. Sound off to your dentist if you feel pain. More anesthetic will be given and that should do the trick. Once we have ensure that the area is fully numb, we will start the procedure.

First, an incision is made in your gums. The gum is then retracted to expose the underlying bone. We call this ‘flap raising’.

Once the bone is exposed, the drilling will start. During this stage, you will feel the vibration of the drill as well as some considerable pressure. Drilling noises will also be expected. This is perhaps the most unpleasant part of implant surgery. The trick is to be calm and to relax. Being tense only heightens your anxiety. Your dentist will usually talk to you to update you as the procedure is being carried out.

A small drill is first used. After bone is drilled to ____mm, the dentist will check if the orientation of the drilling is correct. Changes are usually made at this stage if the orientation is incorrect. Once we have determined the correct orientation, the small drill is used again to drill to the depth of the implant proper.

What we have now is a hole which corresponds to the length of the implant. However, as a small drill was used, the hole is usually small and does not correspond to the correct width of the implant.

The reaming stage

This is the stage where we gradually expand the hole to fit the width of the implant. As mentioned earlier, we have already reached the correct depth at this stage. The depth of the hole will no longer be increased.

We increase the width of the space by using gradually bigger drills. Drilling bone is a very delicate procedure. Bone is a living structure. Hence, we cannot use excessive force and pressure to increase the width of the implant space. If we do that, we will injure and kill the bone tissue, causing some nasty side implications.

By gradually using bigger drills and using a very slow speed, we drill away bone without injuring it. This reaming stage usually hence takes the longest time.

Once we have achieved the correct width of the implant space, the implant is now placed into the hole. There are many different brands of implants in the market, and they can differ in shape and size.

Hence, some implants will have to be ‘screwed’ into the implant space, whereas some implants can just be placed into the hole with a firm tap. (click here to learn more about the different brands of implants in Singapore)

After the implant is placed in, X-rays may be taken.

The implant has a space within in called the implant well. The implant well eventually allows the crown to be placed in at the final stage. The implant well is covered up now with a cap. The gums are then stitched up. You will be sent home and told to rest for the day. We will usually cover you with an MC for a couple of days so that the wound heals.

Post-operative pain is normal. Just like extracting your tooth or having wisdom tooth surgery, it is common to feel discomfort and pain for a few days as the gums are healing. You will be given painkillers and may be prescribed with a dose of antibiotics. Remember to avoid strenuous activities for a few days. Avoid chewing or eating at the area.

The implant is left buried underneath the gums for a period of 4-6 months. Implants have classically been done this way because studies have shown that it requires time for the bone around the implant to heal and to form a strong union with the implant (known as osseointegration).

Recently, however, dentists have been trying to shorten this waiting time. Many feel that it is not necessary to wait for such a long time for osseointegration, and that implants can be completed in a shorter period of time. Many clinics have even gone so far as to offer ‘immediate implants’, whereby the crown is issued on the same day of the surgery. (Thinking about getting implants immediately? Click here for my comprehensive article on immediate implants)

The prosthodontic phase

After waiting for a few months, we are now ready to move on to the second stage. An incision will be made at the implant site to uncover the implant. Again, local anesthetic will be used and you should not feel any pain.

The implant well is uncovered. In its place, a temporary, healing abutment is placed. This is a structure that is placed into the implant well and projects out of the gums.

The healing abutment allows the gums and soft tissue to grow around it to establish a healthy and natural looking soft tissue contour. This is an important stage so that the final crown will look natural once it is placed in.

At the next visit, the healing abutment is removed and the area is cleansed thoroughly. The final abutment is placed. What is an abutment? Think of it as the part which attaches the crown to the implant screw.

At the same visit, a mould will be taken of the abutment (known as an impression). The mould is then sent to the dental laboratory to fabricate your final crown.

The crown arrives at your final visit, designed to be fitted onto the abutment. The crown may either be screwed or cemented onto the abutment.

What you have described is a ‘two stage implant surgery’. My dentist mentioned that I can get a ‘one stage implant’. What’s that?

Two stage implants are the traditional method of doing implants as it has the longest track record and also has had the most studies done. The first stage refers to the sinking of the implant into the bone. The second stage refers to uncovering the gums and placing in the healing abutment.

‘One stage implants’ means that at the visit when the implant screw is sunk into bone, the healing abutment is also placed in at the same visit. Hence, we can avoid having to do a second surgery to expose the bone to place in healing abutment.

Theoretically, choosing this will save you time as well as avoid a second surgery to expose the implant.

However, there are a few prerequisites that have to be met before selecting single stage:

- Sufficient stability of implant. If the implant is not fully stable at the time of its placement into bone, it is better to cover the wound and give it time to heal before doing the second surgery at a later stage

- You did not have to do bone grafting

- The implant is not placed in the aesthetic zone

- No healing issues like being a smoker

- No occlusion issues: not a grinder or a bruxer

- Certain brands and types of implants are better suited for 2 stage (short implants like bicon)

All these factors place the stability of the implant at risk.

What do I do while I wait for the implant to osseointegrate? Can I get a temporary tooth?

If you decide to stick to the normal protocol of waiting 4-6 months for the implant to osseointegrate, you will be thinking of temporary options to fill in the missing space in the interim.

There are usually 2 main solutions:
- Temporary denture
- Temporary tooth bonded to adjacent teeth

A temporary denture is usually recommended as it is the simplest and it allows the implant site to heal. The denture is a piece of removable plastic that can be inserted and taken out. It takes some time getting used to and may not be the most comfortable.

Some clinics are offering ‘temporary implants’ so I don’t have to wear a denture. What’s that?

Temporary implants refers to a temporary crown that is attached to the implant after the surgery stage

This is tricky because we are now wading into the territory of ‘immediate implants’

Temporary implants operate on the concept of immediate implants

The implant screw is not given time to osseointegrate and there is no waiting time before placing a crown in. Check out my definitive article to immediate implants here.

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