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Putting A Tooth On A Dental Implant

Dr. Balaze, discussing dental implant treatment options with a dental hygienist and treatment coordinator.How Do We Put A Tooth On A Dental Implant


A Step-by-Step In The Mind Of Your Dentist

You’re missing a tooth.

Maybe you’ve been missing it since you were born. Maybe it’s a tooth that had a filling, then another cavity – which led to a crown and a failed root canal.

However we got here doesn’t matter much.

What DOES matter is that you had an implant placed and now you would like a tooth. I mean, you waited 3 months for the bone graft to heal and then another 3 months for the implant to “settle”, “integrate”, “heal”… It’s time. You’re ready.

Let’s take a moment to pause.

I’d like to explain something.

If you are a patient of our practice, you should know that I’ve been thinking about which of the following options is best for you. I’ve thought about it a lot. I’ve discussed it with the surgeon/periodontist that placed your implant. And I’ve discussed it with the laboratory that will make the final restoration.

If you are new to our practice, or are simply looking for a reliable source of information, let me explain how we decide where to put an implant.

Planning An Implant Surgery

There are three main areas that we consider when planning an implant surgery.

Surgical, Prosthetic, and Patient.

Let’s tackle each of these in order.

Surgical Planning

This area has everything to do with where the implant will be. Because of this it often gets the highest priority. This is unfortunate, because the best location surgically might be an awful location prosthetically, or equally awful for the patient.

The things we look at surgically include:

  • The quality of the bone.
  • The amount of the bone.
  • The amount and quality of your gum tissue
  • The location of and proximity to other important structures (sinus cavities, nerves, etc.)

Prosthetic Planning

This area is all about the shape and function of the future crown.

Things we consider prosthetically include:

  • The direction and amount of force that will be on the crown.
  • The contour of the future crown
  • Esthetics – color, translucency, luster, texture
  • Materials – titanium, anodized titanium, gold, zirconia, lithium disilicate

Patient Planning

This should be straightforward, but for most dental offices, it isn’t. This area is all about YOU, our patient.

  • Your smile
  • Your habits
  • Your expectations
  • Your hopes
  • Your fears
  • Your dreams
  • Also – things like your medical and dental history.

Once we have an idea about each of these three areas, we can plan.

Planning The Restoration of Your Dental Implant

Honestly, there are only a few choices when it comes to putting a crown on a dental implant.

  1. Cement Retained
  2. Screw Retained
  3. Screwmentable.

Saying that there are only a few options is deceiving though.

The process of figuring out which option to choose starts with the final angle of the implant.  Because, in order to attach anything to an implant, we need to utilize the internal threads of the implant body. This means… we need to put a screw in there! The location of this access channel will change with the angle of the implant.

Cement Retained Implant Crowns

If the angle of the implant is such that the access hole extends out the front of your tooth into your smile, well.. erm… we can’t very well put that hole in the crown, too.

In this case, we would use what is called a custom abutment.  First screw that into the implant and cement your crown onto the custom abutment.

We also use this technique in highly sensitive and esthetic/cosmetic treatment plans because we can control the color a little bit better. We do this in the design of the custom abutment. These pieces can be made out of titanium, ceramic, or a combination thereof. If we are using titanium, we can alter the color of the titanium using the science of anodization. Because most ceramic crowns have some translucency to them, the color of what’s underneath will show through.

Screw Retained Implant Crowns

Some research has suggested that when we cement a crown onto an implant abutment, there’s a chance that some residual cement makes its way into the gums. This will eventually cause inflammation and potential loss of bone around the implant. Maybe even the loss of the entire implant.

It is primarily because of these studies that we prefer to use the “screw-retained” technique. In this method, the crown is fused to the abutment in the dental lab. The whole thing is then screwed in together and the access hole is packed with a protecting barrier and covered/sealed with composite.

When I’m working with one of our local surgeons or periodontists, we work together closely and plan from the beginning which method would be best for the final restoration. Of course, we have the other method in our back pocket just in case.

Screwmentable Implant Crowns

The term, “screwmentable,” is a new one. You can imagine that it refers to a combination of the two methods mentioned above.

It takes the advantages of the cement retained implant crowns (color, esthetics) and combines them with the advantages of screw retained implant crowns (gum health, retrievability). When everything is planned well, and I have my choice of how we restore your tooth, this is usually my first choice.

The Procedure

After the implant has been determined to be stable, you will likely have a “healing abutment” placed. This is a covering that engages with the internal components of the implant and gives the restoring dentist easy access to the body of the implant.

On the day of your  appointment with the restoring dentist, they will remove the healing abutment and place a “impression coping”. This shouldn’t hurt at all, but may pinch the gums a little. After that is placed, we can take our impression of the implant. This impression can be any one of the following:

  • Closed tray analog
  • Open Tray Analog
  • Digital

Closed Tray Analog Implant Impression Technique

In this technique, the implant impression coping is designed to stay in the implant the entire time.

We place the impression coping, make an x-ray to confirm it’s in the right place, fill a tray with impression material, seat it in your mouth, let it set, remove the impression and the impression coping is still in your mouth.

We then remove the coping from your mouth, replace your healing abutment, attach a replica implant body to the impression coping and seat that back in the impression for the lab.

Open Tray Analog Implant Impression Technique

This is my favorite analog technique.

In this technique, the implant impression coping starts in your mouth, and is removed with the impression.

We place the impression coping, and fill a tray with impression material just like in the previous technique. The difference here is that the design of the coping. In the open tray technique, the impression coping has openings and fins for the impression material to lock in and around. The coping is taller as well. This is because we cut a hole in the impression tray for the impression coping to poke through. After the impression material is set, we first unscrew and disengage the impression coping. Then, when we remove the impression from your mouth, the implant impression coping comes with it.

This is my favorite technique because there is less chance for error in the relationship of the impression coping and the impression.

As soon as the impression material is removed, we then re-place your healing abutment.

Digital Implant Impression Technique

In this technique, we remove your healing abutment, place an impression coping designed for digital impressions, and then use a hand-held scanner to make a digital impression of your implant. Once that is complete, we remove the implant impression coping and re-place your healing abutment.

Other Important Information

  • Your
  • Your bite – It’s important for us to know how your teeth come together normally, so we will almost always record this with a special impression material or the digital scanner.
  • Your tooth color – We want to make sure that we capture the color of the teeth around the implant. Usually this means making a photo with a special tooth colored reference tab right next to, or in front of the implant.

Off To The Dental Lab

Once the impression of your dental implant is finished, we replace your healing cap and send you home while the crown and implant abutment are finished.

This process can take several weeks.

When the crown returns, it’s important to make sure that everything looks exactly as we ordered it. Everything is confirmed, from the final color to the design of the implant abutment.

Placing Your Final Implant Crown

On the day of your appointment, we will go through some of the same steps as we did during the impression.

Your healing cap is removed, and we will try in the implant abutment and/or crown. After confirming a complete seat with an x-ray, we ask for your final approval before we tighten the implant abutment retaining screw. For this process, we use a specialized torque wrench that allows us to precisely measure the amount of force on the screw. This is different for every manufacturer, and is measured in Ncm [Newton Centimeters].

If your crown is separate from the abutment, we first secure the abutment and then cement the crown using a soft cement. Why not use a hard cement? When a crown is being cemented on a dental implant, we really want it to be retrievable. Also, our ability to design the abutment with an ideal shape means that we don’t need to rely on the adhesive cements to hold onto it.

If your crown and abutment were fused together at the lab – either as a screw-retained or screw-mentable crown – then once we have tightened down the crown we will pack it with a teflon tape and seal the opening with composite.

After your bite is finalized and polished, we make a final x-ray with the crown in place.

From here on out, your responsibility is to take care of that implant crown the best way you can.  We will give you suggestions specific to you at this appointment. If you’re looking for additional ideas, or want to get a head start, you can check out this post about the best ways to continue to care for a dental implant!

Dental Implants In Orange County California

If you are local – meaning Laguna Niguel, Laguna Beach, Laguna Woods, Laguna Hills, Aliso Viejo, Mission Viejo, Dana Point, San Clemente, or San Juan Capistrano, (even Irvine!) – we are here to help. Please, don’t hesitate to reach out and ask any questions you may have. Of course, we’d be honored to see you as patients and help with your dental implant problems. Simply fill out the form below!

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