An implant is a screw. The tooth comes afterwards.
I do not place implants. I design and build what is fixed on top of them, and their position is decided starting from the final tooth rather than the other way round.
A gap that can no longer be filled with a tooth of your own
An implant solves a missing root. Everything else, meaning the shape you can see, the way it emerges from the gum, how it meets its neighbours and how it can be cleaned, is the prosthetic part, and that is where I work.
The correct order runs backwards from how it sounds. The missing tooth is drawn first, in the position it has to reach, and only then is it decided where the screw goes so that it can carry that particular tooth. An implant placed without a prosthetic plan often lands somewhere the bone was comfortable but from which no normally shaped tooth can emerge.
The surgery is done by a colleague I work with, following the plan and, where it is warranted, a guide made from it. I send the intended position rather than just the patient, because a millimetre and a half sideways translates into a crown leaving the gum at an angle.
What I watch after integration is the emergence profile, the route between the screw and the visible margin. It is built gradually, with a temporary that shapes the gum over a few weeks so the tissue settles into its final form on its own. This is what keeps the finished work from looking like a tooth that appeared abruptly out of flat gum.
Between the surgical and the prosthetic stage there is a healing interval I do not shorten. Bone keeps its own calendar.
Three hands, one plan
- 01
Prosthetic planning
Scanning, three-dimensional imaging, the final tooth positioned digitally. This is where we establish whether there is enough space, whether extra bone or gum is needed, and whether an implant really is the right answer for your situation.
- 02
Surgical stage
Done by the surgeon, to the plan. I stay in the conversation throughout, because decisions taken during the procedure change what I can build above. Healing follows, during which you wear a temporary solution.
- 03
Shaping the gum
Once integrated, I fit a temporary that gently pushes the tissue into the shape we want. It is adjusted a few times. This stage decides whether the final work will look like it grows out of the gum or sits on top of it.
- 04
The definitive work
The shape achieved on the temporary is copied exactly and sent to the laboratory. I favour solutions that can be unscrewed, because something that can be taken apart can also be repaired years later without destroying what sits underneath.
The whole arch is the hard case, not the easy one
When almost every tooth on an arch is gone, you do not place one implant per missing tooth. A fixed piece of work rests on four to six implants, the back ones tilted so they catch the bone that is still there. The four-implant version is called All-on-4.
I learned the prosthetic side of the technique in Prof. Paulo Malo's team, where All-on-4 was formulated.
With a single tooth I have something to match against: the one next to it. On a whole arch there is no neighbour left. The length of the teeth, the line that shows when you laugh, how much support your lip gets, where the work ends and your own gum begins, all of it is decided from nothing. And what is decided badly here shows in the first second and cannot be adjusted once it is screwed down.
The division of work is the one described above: my surgical colleague places the implants to the plan, I design and build the arch that is screwed on top of them. What differs from a single tooth is that here the plan also decides how much bone is removed during surgery, because that line is what decides whether the edge of the work shows.
Where the implants are stable enough, a fixed provisional goes in the same day or within the next few days. Where they are not, we wait. I do not promise that day in advance: it is decided during surgery, with the bone in view, not in the consultation.
The provisional is not a way of filling the time, it is the instrument the definitive arch is designed on. It is where the height gets tested, and the way you bite, and how it looks when you speak, and how easily it cleans. Whatever comes out right is copied, after the months of healing.
This arch includes artificial gum. Where both bone and gum were lost, the pink part replaces what is missing, which is why the teeth can be a normal length instead of looking stretched. It is fair to know from the start that these are not your own teeth put back one by one, it is an arch. And it is cleaned underneath, with interdental brushes and a water flosser, not by ordinary brushing. That part is not optional: it is how implants are lost years after they were placed, however well the work was made.
Things I rarely hear said at the start of the conversation
It does not create bone. Where bone is insufficient it gets added through a separate procedure, with its own healing and with a result that is checked before anything moves on. An implant placed in insufficient bone does not become stable because we would like it to.
It does not feel like your own tooth. Around a natural root there is a ligament with receptors that tell you how hard you are biting. An implant has none of that. People adapt quickly, but in the first weeks they often tell me they bite differently, and they are right.
It is not maintenance-free. Tissue around an implant inflames more easily than tissue around a tooth and defends itself less well. Without interdental cleaning and without regular review, the risk of losing it rises. That is not a cautious formula, it is the main reason implants are lost years after being placed.
It is not a better option than your own tooth. If a tooth can be saved with a reasonable outcome, we save it. Removing a treatable tooth because something simpler to plan could go in its place is a bad deal for you.
And it does not sit well with smoking. That is not a moral judgement and not a condition I impose on you. It is information that changes the risk, and you would rather hear it before deciding than after.
The questions that come up almost every time, in this order
Does it hurt?
The procedure is done under anaesthetic and does not hurt while it happens. Afterwards there are a few days of soreness and swelling, manageable with the medication recommended to you. The prosthetic part, which is my part, is painless.
How long will I be without a tooth?
In the visible zone, not at all. A temporary solution is worn throughout healing. Further back it is sometimes possible to wait without one, but that remains your choice.
How long will it last?
I do not give figures and I do not guarantee durations. What affects longevity is hygiene, control of chewing forces, smoking, and keeping to reviews. The first three are yours to control, and the last one we book together.
Will people notice it is an implant?
It depends on your gum and on how much bone was there when it was placed. In the front I will tell you realistically, beforehand, how close to symmetry we can get and where a difference might show. I would rather you knew at the start than compared at the end.
Why do you not do the surgery yourself?
Because the part I am good at is the prosthetic one, and results improve when everyone does what they do often. The surgeon knows the plan before starting, so this is a division of work rather than a handover of a patient.