All these measures prolong the treatment phase considerably compared with previous modality of work. Additionally the cost of the treatment is affected. We hope that you will understand all these procedures for the prevention of public health and you will justify time lengthening of your treatment.
The implant corresponds to the tooth’s root. It has the shape of a screw and it is placed in the jaw’s bone. What shows in the mouth (the «tooth») is a porcelain crown which is supported by the implant.
An implant can be used when one, more than one or all the teeth are missing.
A. One tooth missing
An implant replaces one tooth, usaually a front and rarely a posterior, in order the adjacent unimpaired teeth won’t be harmed.
B. More teeth missing
It is indicated in cases that posterior or front teeth are missing and the placement of a removable partial denture is not desirable. Placement of implants helps construct of a fixed bridge. Futhermore, implants are used in cases where the gap between teeth is extended making the construction of a bridge difficult or even impossible.
C. All the teeth are missing
Implants offer two options:
No. Implants are manufactured by pure titanium, a material compatible with the human organism. Besides, titanium is being used for many years in orthopeadics without causing any problems.
Yes, in very few cases. The reasons are technical. Still, even in this case it can be replaced without a problem. The failure percentage depends on the doctor’s experience. In sepcialized and well-experienced dentists this percentage is less than 1%.
With proper care implants can last a lifetime. At first glance implants are far more expensive than a conventional bridge or a denture. In the long run one must have in mind that a bridge or a denture must be remanufacrured 2-3 times and then realizes that the overall cost of implants is much lower.
Our office has chosen to work with one system of implants the last 20 years. This is the Swiss Straummann and the reasons for this choice are the following:
No. The only exception are children. In that case, growth must be completed before the implant placement (after the age of 16-18).
Usually is less painful than a tooth extraction. In the case that many implants are being placed in the same operation, mild pain and swelling can be observed, but nothing that cannot be settled by a simple painkiller. In most cases the patient can return on his/her job immediately after the operation. When many implants are placed the intercession of a weekend allows the patient to return to his/her job without any annoyance.
After the first visit usually it takes 6-12 weeks for the therapy to be completed. As long as therapy lasts provisional restorations are made in order to achieve satisfactory mastication and esthetics.
As in many other cases, smoking can cause various problems.
So, decreasing or even quitting smoking is recommended at least the first week after the operation because smoking affects the process of healing.
No. As natural teeth, daily brushing is sufficient as well as frequent visits to the dentist.
First, there are very few manufacturers among hundreds that produce primary applied research trying to explore the properties and behavior of their implant.
Second, the serious manufacturers provide insurance policies for their implant. They are replacing any implant lost for biological or mechanical reasons.
Thirdly, if we know the identity of the implant any other dentist can find spare parts replacing and repairing possible problems.
Finally, serious manufacturers maintain spare parts and replacement parts for damaged implants. Otherwise, with no possibility of repair the restoration is useless.
These are inflammatory diseases that develop around the implant. They may affect only the soft tissue around the implant but they can also invade deeper structures of the implant support. This means bone destruction and denudation of implants from their support.These diseases are considered similar to periodontal ones but there is a distinct difference; Inflammation is evolving and spreading more rapidly causing extensive and more important destruction.
The symptoms are: swelling of the mucosa, intensive bleeding, abscess and pain. Dental literature indicates a mean 10% of frequency in all implants, but unfortunately this percentage can affect only some individuals and thus many implants at the same time. This means that for these individuals implant loss will be a total loss!!!!
There are three main reasons. The first reason is the level of everyday oral health. This can be also related to the quality of prosthesis. How accessible is to good cleaning. The second reason is the existence of active periodontal disease in the adjacent teeth or even more in the previous dentition (even if the individual had lost all his teeth because of periodontal disease).Your doctor should treat your periodontal condition BEFORE placing the implant Otherwise bacteria from adjacent teeth can colonize implant surfaces and that is the beginning!! Third causative factor is the quality of your implant restoration. This comprises a lot of factors of the surgical procedure (how neat and precise), the type of implant, their position in the arch, the accessibility to oral health measures. Final causative factor is smoking. More than 10 cigarettes is considered a heavy smoker!!
Let’s see some examples of periimplant diseases that were referred to our office for treatment.
It is obvious even for an amateur when he sees the x-rays to understand several problems of these cases:
These are infectious diseases which means adherence and concentration of bacteria around the neck of the implant that produce inflammatory reactions that are followed by tissue destruction. These bacteria originate from adjacent structures or from other parts of the oral cavity (tongue, cheeks, throat).
Yes there is!
It demands a holistic approach again which comprise.
Evaluating the risk factors for every case!! It is advisable 2-3 times a year to provide a “thorough” cleaning of teeth and prosthetic superstructure.
This lady presented to our office with a lot of pain and swelling in the upper jaw. She had placed implants five years ago and she had already lost one implant in the lower jaw two years ago. Her x-rays demonstrated huge bone destruction around the implants,arrows 1 2 3 photo 1. With the removal of her bridge photo 2 one implant was explanted automatically No3. In the 3rd photo we can see the swelling and the granulomatous hyperplastic tissue. The implants are mobile which means they have lost their osseointegration. One tooth which was maintained, had an extensive carious lesion and should now be removed. Thus after the removal of the 3 implants and the carious tooth, the only possible prosthetic solution is a full upper denture.
What was the cause of this case?
Conclusion: The success of an implant supported prosthesis is a very delicate procedure demanding careful treatment attention to all biologic and biomechanical parameters. It is more than pity to sacrifice all that time, pain and money due to an insufficient medical work!!
The perfect disaster!
This lady six years ago had an implant operation. Her doctor placed 14 (!!) implants for upper and lower jaw rehabilitation (please multiply the number of implants with the dentist’s fee per implant and you will find the sum of money that she paid). She came to our office complaining of multiple episodes of swelling pain antibiotics over and over again in the last years.
In the x-ray that she brought it is marked with a white line photo where the bone level should have been and with red line where is situated now. A marked difference all over!
Many of the implants should be removed. What happened??
Conclusion: It is sad to observe cases like this without surgical and prosthetic plan. It is obvious that this case presents matters of medical ethics, but also misjudgment of this individual in choosing the proper doctor.
Two cases executed with the same mistaken concept: multiple implant placement in sites where one implant was sufficient. It is for this reason that bone loss around the implants is more advanced (red arrow) compared to that of the adjacent teeth!
Final conclusion: Doctor’s ignorance or profit expectations have detrimental effect on your implant work. It should be made clear that peri-implant destruction could be faster compared to the periodontal bone destruction around the teeth of the same patient. Thus, placement of implants could produce more problems than solving ones in case that proper planning is inadequate!!!
Internal (osteotome creastal) approach
External (lateral window) approach
It is a surgical procedure that is used in the upper posterior jaw in cases of terminal bone reduction and pneumatization of the sinus cavity. Then by using a small portion of the sinus cavity, which is filled with graft material new bone is regenerated and implants can be placed in a later time.
Unfortunately yes! It takes 4-6 months waiting time. In addition has a higher cost because of the second surgical procedure plus a considerable quantity of graft material needed to fill in the space.
Statistics for implant success in these procedures are very high and equivalent to normal implant placement. However it should be noted that duration for the final restoration is longer, cost is a lot higher and side effects could be more prominent.
Every surgical approach should be planned and executed through accurate diagnosis and proper treatment plan. There are 5-10% of side effects reported in the literature. For this reason, before the decision for such an operation, a search for other conservative approaches is advised. The alternative solutions are:
a. Very short implant (>6mm). In this case for biomechanical reasons an increased number of implants is recommended.
b. Placement of tilted implants that can bypass the sinus cavity
c. Closed sinus lift procedure which can increase the height of remaining bone through a more conservative approach.
This is an organized agglomerate of bacteria originating from the microbial flora of the mouth attached mainly on the surface of the teeth. The maturation of the plaque increases its infectious potential and so becomes aggressive to the tooth itself and the tissues around the teeth. In the mouth microbial plaque can be recognized as an off-white colored agglomerating where the tooth meets the gums. The only way to remove the plaque and thus to protect tooth and gums, is by the mechanical action of the tooth brush.
This is the calcified hard structure initially found in areas where the saliva exits from the salivary glands (for example inferior surfaces of lower front teeth). Absolute prerequisite to have calculus is the presence of dental plaque. Then mineral ions infiltrate the organic matrix of plaque and form crystals and thus starts the mineralization process. Calculus is harmful because its surface is porous and microbial plaque can “hide” and mature inside protected cavities. So its presence is more harmful. At this time removal of calculus can be accomplished only by the specialized dentist.
This is an infection of soft tissues around teeth that produce bleeding and local swelling. These symptoms ( blood on the pillow is frequent) can appear to recede and then again “flare up”. So it can be of a cyclic nature. However these main symptoms can be aggravated due to hormonal disturbances ( puberty- pregnancy- menopause etc) and to systemic diseases ( diabetes). Treatment of this infection can totally reverse disease to health.
Removal of microbial plaque and calculus, education in effective daily tooth brushing and removal of local factors that increase plaque accumulation ( bad fillings etc) are the main elements of treatment. This treatment can be accomplished under anesthesia in two or three visits in the office.
When the infection from the soft tissues (gingivitis) propagate to the underneath supporting bone. This process produces destruction of bone and decreases tooth support. There is gum recession and finally this can result in tooth loss depending to different factors but mainly to the rapidity of this bone loss. This condition can be diagnosed as early, medium, advanced and aggressive. Treatment cannot reverse destroyed tissues but can succeed in arresting the disease and in some specific cases localized regeneration can be accomplished.
Periodontitis does not produce pain as in the case of caries in the tooth. In early stages symptoms (swelling- bleeding- pain) come and go (cyclic nature). It is only in late stages that tooth mobility appears and teeth move in other positions. Abscesses can occur, taste is bad and oral breath is annoying.
These are infections associated with very virulent and aggressive bacteria that usually develop in anaerobic conditions. There is also a predisposing family factor (genetics) and most of the times reduced interest in daily oral health.
Since we have an infection, treatment should be antimicrobial. This does not mean antibiotic therapy. Treatment should aim to “clean” thoroughly teeth underneath the gums. This is performed under local anesthesia in quadrants. Access to tooth cleaning can be done surgically ( open flaps) or conservatively (closed curettage) depending on the severity of the disease. Daily oral health should be thorough and applied intensively in order to preserve results of treatment.
Very seldom so, this can only happen in acute stages of the disease. Abscess formation with pus exudation can provoke pain. Usually there is a feeling of “etching” on gums. You want to “frot” the gums in order to remove this symptom.
Periodontal diseases are infections of inflammatory nature. This means that there is an ongoing process of tissue destruction. Bi-products of this destruction are sulfur chemical unions that produce bad smell and cannot be hidden with mouthwashes.
In advanced periodontitis pocket formation occurs. Because of bone destruction and when the gums are not receding there is a gap between the margin of the gingiva and the level of the supporting bone. In other words there is a crypt underneath the gums that bacteria can agglomerate and be “protected” from the action of the toothbrush. When a critical volume of bacteria is reached then a ”burst” occurs- like a microabscess- producing a localized destruction. The bone, recedes and a new equilibrium is established until the next “burst”. Thus pocket formation is potentially very dangerous in tooth prognosis. One aspect of periodontal treatment is to eliminate pocket formation.
When the depth of the pockets extends beyond 5mm measured from the margin of the gum then this pocket is a potential aggravating factor of the disease. It is estimated that the extent of the pocket surface in the case of periodontal disease equals the surface of the palm of the hand. The bacterial population of this area is enormous. Three objectives of the periodontal surgery are 1. elimination of pockets, 2. access to the hidden areas of the tooth in order to clean then from bacterial plaque and calculus, 3. establishment of a tissue contour that enables better oral health of the patient.
Laser is a high energy beam. Despite the fact that every laser instrument could be different, there is no scientific evidence that lasers are more effective in periodontal treatment. On the contrary there is evidence that some of them “burn” the tissues producing extensive esthetic damages.
It depends on the surgeon! How aggressive is the technique and whether is needed to approach surgically the area, when there is a possibility of a conservative approach.
Of course! The case of surgical approach should be targeting only in areas that need such intervention. After conservative treatment this approach could be very localized where is truly needed. Sometimes periodontists overtreat patients!
In some cases due to anatomic reasons (very thin gingiva) bone resorption is followed by tissue recession. This is more frequent in front teeth. So we can say that there are two cases of equal periodontal destruction. One can appear with recession and no pockets while the other with pockets and no recession.
Most of the times the answer is no. Sometimes localized recession defects can be treated by plastic surgery. It is important however to understand that even in these cases there is no proper regeneration of the lost tissues but rather an esthetic approach of “covering” this recession.
Unfortunately no! Spaces have been formed because the edema and inflammation have been gone. The gum in a physiologic manner seek to take its place near the underlying supporting bone. Gingiva now appear pink, firm and healthy. Spaces can be closed only by restoratives means (see bonding).
There is scientific evidence that supports a relationship between cardiovascular disease and periodontal disease. Periodontopathic microbes can induce formation of atherosis in the vessels. There is also general agreement that the same periodontopathic bacteria of the mouth can enter circulation and affect remote organs.
The fist step is periodontal treatment. Reduction of inflammation will reduce tooth mobility. Empirically if tooth mobility does not affect our masticatory function means no intervention. If on the contrary we estimate that this is the case we can proceed in tooth splinting. Teeth are ”bonded” together to withstand better masticatory function. Additionally occlusal adjustment can be done to equilibrate masticatory contacts in all teeth. These are not invasive, reversible methods with a high success rate.
This is the main issue. Every individual is educated in oral health witch comprises effective tooth brushing with use of interdental brushes. Interdental cleaning is an absolute mean of oral health because tooth brush cannot have access in spaces between teeth. We try continuously to modify and educate our patients in daily propper oral health. Every patient then, depending on its effort will participate in a prevention programme every 3 to 6 months.
Unfortunately no. Treatment will arrest the progress of the disease. However every individual will have to understand the primordial importance of oral health ( brushing- interdental cleaning), to understand that smoking aggravates the disease and integrate in his life regular visits 2-3 times a year for professional cleaning.
No, these infections are not transmitted. However it is not pleasant to live with a person that has a bad breath and sure enough this is not a good example for the children. Oral health is an important part of our body health.
In every office there is different approach in dental treatment. According to our principles esthetic dentistry cannot be performed without treatment of periodontal disease or caries removal.
The second philosophical approach is minimal intervention. Teeth that are prepared (cut) cannot be restored in their previous situation. It is a non reversible approach. It should be known that prepared teeth can develop sensitivity, pain, and this can lead to root canal treatment.
Therefore our approach to dental esthetics is a minimal intervention.
What are the procedures? A. Minor tooth movement, this is a targeted and of short duration orthodontic movement,
and B. Bold adhesive techniques.
That is bonding of teeth with tooth-like materials that absolutely match the color of the tooth. The procedure is like modeling the tooth in the desired shape and color with material behaving like tooth. This minimal approach cannot create Hollywood- type smiles. If this is the desire of the individual then more invasive techniques are needed.
This is an orthodontic technique based on the prevision of the final result we expect using CAD-CAM technology.
This procedure enables the prefabrication of a series of splints that can move teeth in the desired position. Every splint moves the teeth for some millimeters and then after 2-3 weeks another one continues the movement. This treatment can last 6- 12 months depending on the aim of the study. We use this method for small movement in adult patients to accommodate their esthetic needs. The advantage of the method is that do not have to wear wires or brackets. The splints are transparent and cannot be distinguished in the mouth. They have to be worn as long as possible except eating time.
The MC is a crown placed on a tooth with a metal frame covered with porcelain. An AC is a crown fabricated totally with porcelain. The esthetic outcome of both is excellent. The disadvantage of MC could be that sometimes due to gum recession the appearance of the metal frame on the edge of the crown is unaesthetic, thus there is an esthetic advantage of AC.
Unfortunately MCs present fewer strength problems. AC crowns develop more often fractures thus they are not recommended to cover teeth with extended restorations or when these teeth bear excursive occlusal forces.
An AC demands complete grinding of tooth whereas a laminate demands minimal grinding of the facial aspect of the tooth.
Bonding is a procedure that tooth-like substance is attached to the tooth modeling its appearance. The laminate needs very careful grinding of the facial aspect of tooth, impression, fabrication of the new facial structure of tooth. So the main differences are reversibility of tooth (no tooth grinding, possibility to reverse in previous situation), time (fewer visits), cost (no laboratory involvement), so lower cost for the patient.
Bonding can be detached very easily without intervening the integrity of tooth. Laminate should be detached and replaced by a new one following all the procedure again (impression- fabrication- placement).
This is a procedure that aims to whiten the tooth. It is a chemical reaction that reduces or eliminates deep color staining of the tooth. The dentist can give information on the potential whitening (how many shades will drop), on the hazards and on time and effort needed.
This can be done by the following methods.
It can produce tooth sensitivity, which is reversible following directions. It does not harm teeth but it should proceed slowly, having patience
This can last from 1 to 5 years depending on the nutrition habits and the coloration of food. Also it depends on smoking, frequency of coffee and wine drinking. Repetition of the procedure can be done in cases of relapse.
Basically yes. It is not indicated for persons that have extensive caries, recession of gums and extensive denudation of teeth, pregnant women, different oral pathological conditions, children and people with allergies to whitening solutions.
Definitely no! This solution can act only on the enamel surface. In the end of the procedure it is also imperative to change all fillings (at least in the front teeth) since their color will not match the whitening result of the teeth. This should be considered when cost analysis is discussed.
Dr. George Makris is a periodontist graduated from the postgraduate programme of Periodontology at the University of Pennsylvania, probably one of the most prestigious postgraduate programmes in USA. Moreover he is graduate of the postgraduate programme of Periodontology of Paris University in France with two certificates in Oral Biology and Periodontology, His PhD degree was awarded from the University of Paris (with honors). Since 1992 he is As. Professor in the Department of Periodontology and Implant Biology of the University of Thessaloniki. He is author of a textbook “Biology of Dental Implants” which is part of the curiculum in the dental school of Thessaloniki.
He is a member of:
specialized in Esthetic Dentistry
specialized in Prosthodontics
specialized in Prosthodontics
intern in Oral Surgery
Specialized in Periodontology
specialized in Stomatology
Postgraduate Diploma in implant dentistry European association of osseointegration
field of interest Pediatric Dentistry
field of interest Endodontology
His team comprises dentists with postgraduate studies in Oral Rehabilitation, Implantology, Esthetic Dentistry, Oral Pathology and Oral Surgery. Moreover the team is working together for more than ten years. This has resulted in the development of a common philosophy in treating the most complex cases of mouth rehabilitation. The team has a continuous participation in postgraduate seminars and scientific meetings all over the world.