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What
is a dental implant?
During
the last forty years the use of dental implants has changed dentistry beyond
recognition. Implants are no longer considered experimental but are now used
routinely the World over to replace a missing tooth or teeth. In fact, in the
United Kingdom we have been slow to use these newer treatments and trail behind
most of Europe in their use. They are, of course widely used in the USA.
In many
situations dental implants are the first choice for treatment as they offer the
best answer when all the advantages and disadvantages of different treatments
options are considered. It is rare to come across situations where they cannot
be used at all. John Grummitt has been placing dental implants since 1991 at
Compton Acres Dental Practice, West Bridgford, Nottingham.
The
dental implants John uses today are made from titanium, a material that has been
shown for over forty years to be well tolerated by bone. “Osseointegrated”
implants are dental implants that have “joined up” with bone in order to support
replacement teeth. John does not recommend other types of implants as they do
not have the same predictable and proven success rate over such a long period of
time.
A
dental implant is essentially a substitute for a natural root. The implants
John uses are a cylinder shape with a screw thread. Each implant is placed into
a socket carefully drilled at the precise location of the intended tooth. The
main aim during installation of any implant is to achieve immediate close
contact with the surrounding bone. This creates an initial stability, which over
time is steadily enhanced by further growth of bone onto the microscopic
roughness on the implant surface, when it fuses with the implant surface –
‘Osseointegration’.
In
order to support replacement teeth, the dental implants we use have an internal
screw thread that allows a variety of components to be fitted. Once fitted,
these components provide the foundation for long-term support of crowns, bridges
or dentures.
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How are
implants used?
Implants
are used to replace missing teeth. All the common forms of tooth replacement,
such as bridges or dentures can be replaced by dental implants.
If you are
missing just one natural tooth, then one implant is normally all that will be
needed to provide a replacement. Larger spaces created by two, three or more
missing teeth do not necessarily need one implant per tooth; however the exact
number of implants will depend upon the quality and volume of bone at each
potential implant site.
It is also
often possible to join natural teeth to implants with a conventional bridge.
In the
upper jaw, bone density is generally poorer than in the lower and if you have no
teeth at all, John will want to place a minimum of 5 - 6 implants to support a
complete arch of 10 or more replacement teeth.
In the
lower jaw, the bone towards the front of the mouth is often very strong and as a
direct result, fewer implants may be needed than are required to treat a whole
upper jaw. A simple treatment plan to provide 10 or more teeth in the lower jaw
might be possible with as few as 4 implants, although it is still more common to
use 5 or 6.
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What
else can be done with dental implants?
If you
have no teeth in the lower jaw, a conventional lower denture can be considerably
improved with two implants placed beneath the front section - this is called
an ‘overdenture’. The same overdenture concept when used to treat the upper jaw
will usually require more implants as the bone is generally softer.
Implant-supported overdentures, just like conventional dentures are still
removed for daily cleaning, however, once back in the mouth, the implants make
them much more stable as they “lock” into place.
Dental
implants have to obey simple engineering principles, in that they must be placed
in strong foundations with enough of them to prevent overloading. In addition
each implant must be accessible for daily cleaning so that the biology of the
mouth can be used to maintain healthy surrounding bone and gum.
In certain specific
situations it is sometimes possible to use
‘same day’ implants
but these can only be used in a limited number of situations. John can
discuss this individually with you.
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I have
teeth missing, am I suitable for dental implants?
Whatever
your age, if you have good general health, then dental implants will almost
certainly work for you. However, habits such as smoking can increase the number
of problems associated with initial healing and thereafter may negatively
influence the long-term health of gum and bone surrounding each implant.
Uncontrolled diabetes can also reduce implant success rate.
John
Grummitt has successfully placed implants in patients in their eighties, in
smokers and well controlled diabetics.
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Do I
need to have a healthy mouth?
When you
first enquire about dental implants it is often in response to an awareness of
ongoing dental problems or the recent loss of teeth. Each of these problems will
need to be diagnosed and treated in a logical manner, often prior to placing the
dental implants.
Although
it is tempting to focus on the more glamorous aspects of teeth supported by
implants, basic dental health, which includes the treatment of gum disease,
repair of decay and the elimination of abscesses will be just as important for
the long-term success of your treatment.
If you are
aware of bad breath, loose teeth, or have noticed excessive bleeding,
particularly when your teeth are cleaned professionally, you may have gum
problems. Periodontal (gum) disease is a major cause of bone loss and with
reduced bone; dental implant treatment can be more complicated. John Grummitt
has considerable experience in treating gum disease, having a Masters degree in
periodontology and restorative dentistry.
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I lost
my teeth many years ago, can I still have implants?
Whenever a
tooth is lost or extracted a considerable amount of the bone that once
surrounded the remaining root portion may disappear. This loss can be
particularly rapid during the first few months and is described as ‘bone
resorption’. Although the rate and amount of bone resorption is highly variable
between individuals, it will always occur to some extent.
Many
patients who have had dentures for years will report that after a while their
dentures become progressively looser and do not fit as well as they once did.
Initially the increased rate of bone loss following extractions is responsible
for the observed deterioration of denture fit. Over the long-term it is the
direct effect of chewing forces that causes slow resorption of supporting bone.
Most people who have had dentures for many years will have needed a reline
procedure to compensate for this bone loss. Therefore the longer dentures are
worn, the more the amount of bone available for dental implants may be reduced.
Fortunately, if there is currently insufficient bone for an implant or implants
to be placed there are many techniques to generate new bone or augment the
existing bone so that implants can still be placed. These can be discussed in
detail with you at your consultation and initial assessment stage of your
treatment.
John
Grummitt has helped many patients who have been missing teeth for many years by
providing them with implants. In some cases they have lost their teeth over
twenty years before but still been able to have implant based treatments to
restore their teeth.
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Can
dental implants preserve bone?
This is
one of the most important features of dental implants. Once in place and
supporting teeth, everyday functional forces stimulate the surrounding bone
which responds by becoming stronger and denser and helps maintain the bone.
Sometimes, the simplest measure to minimise bone loss after an extraction is to
place the implant immediately or within the first few weeks.
John
Grummitt therefore likes to place implants at the same time as the teeth are
extracted or in some situations (for example when there is an infection present)
a few weeks later. This helps preserve the bone and produces the best ends
result.
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I
grind/clench my teeth is that a problem?
Bruxism
- Patients who have a habit of clenching or grinding (bruxing) their teeth may
be at risk of overloading their implants. For most people bruxism occurs during
sleep, which is why they are generally not aware of it. Heavily worn or
flattened teeth, chipped enamel edges and/or regularly breaking pieces of
heavily filled teeth are the most common clinical signs of bruxism. The effects
of bruxism need to be considered during treatment planning and can be
compensated for by placing additional implants, selecting appropriate
restorative materials and providing a night time bite guard to protect the new
teeth.
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What
can you do if an implant does not work?
If an
implant does not achieve or cannot maintain ‘Osseointegration’ with the
surrounding bone it will eventually become loose and no longer be able to
support replacement teeth and may have to be removed.
The 3i
Osseotite implant currently used by John Grummitt is one of the most successful
and widely used implants in use in the World today. Their published success
rates are 97.2% at five years from placement of the implant and 99.4% success at
five years from when the implants are brought into function in normal bone
quality. However implants can fail to osseointegrate or be lost in the future.
If you
embark upon this type of treatment you have to be prepared to deal with the
possibility of failure of an implant. A failure rate of less than 3% is to be
expected, and it should not be forgotten that this means that 1 in 30 of the
implants placed might not survive in long-term function. It is important to
discuss how your treatment plan might be affected by the loss of an implant.
Commonly
the failing implant can be removed and if there are enough remaining, it may not
be necessary to replace it at all. Often another implant can be placed and this
one will be successful. Occasionally alternative treatments may need to be
considered.
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How
long does treatment take?
For
routine cases, from the time of implant placement to the time of placing the
first teeth, treatment times can vary between 6 weeks and 6 months. The
availability of better bone can be used to decrease treatment time, whilst more
time and care must be taken with poorer bone, which can therefore extend
treatment times beyond six months.
If there
is no reason to shorten the duration of your treatment then be prepared to wait
- nobody loses an implant from being patient and allowing nature to take its
course. The highest success rates with implants are achieved by taking time over
the entire procedure.
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Are the
new teeth joined together?
When
multiple implants are placed, they are routinely joined together in the same way
that a bridge supported by natural teeth would be designed.
This
ensures that they are mechanically stronger than the individual parts and can
better resist the forces of normal function which will try and undo the screw
components, posts and/or cements that secure the underlying structure to each of
the implants.
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How do
I look after the implants?
For most
implant-supported teeth you will be able to clean around each supporting implant
by brushing and flossing in just the same way that you would around natural
teeth and tooth-supported bridges. In some areas special floss, interdental
toothbrushes and other cleaning aids may be needed to maintain good oral
hygiene. Cleaning is not at all difficult, provided that you do not have
impaired use of your hands.
It is
reasonable to expect some of the daily hygiene procedures to be a little more
complex than around your original teeth - equally expect to spend more time than
you may have done in the past to maintain optimum implant health.
For the
first few months the implants are in function we may ask that you are seen more
frequently, however once we are satisfied your treatment is performing as
planned, ongoing care will be similar to any patient with natural teeth.
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How
long will the implants last?
During the
period after the new teeth are fitted, the success of each treatment stage will
be the main factor determining how the implants are performing. Once the
implants and surrounding soft tissues are seen to be healthy and the new teeth
comfortable and correctly adjusted, it is the quality of your home care and
willingness to present for regular maintenance reviews that will have most
influence on how long they will last.
When
poorly cared for, implants will develop a covering of hard and soft deposits
(calculus and plaque) which is very similar to that found on neglected natural
teeth. Untreated, these deposits can lead to gum infection, bleeding, soreness
and general discomfort, just as can occur around natural teeth. It could
probably be said that implants much like teeth will last for as long as you can
keep them clean.
Well
maintained implants placed into adequate bone can be expected to last for many
years and probably for your lifetime. However, just as you would expect
conventional crowns, bridges and fillings to need occasional repairs or
replacements during their lifetime, your implant-supported teeth may also have
similar maintenance requirements over theirs.
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What
should I know before I start treatment?
After your
assessment and discussion you will be given a written summary of your treatment
planning discussion(s), highlighting your current dental situation and any
alternatives there are to dental implants. This summary will also include an
over-view of the anticipated treatment stages and give you some idea of how long
treatment is likely to take, how many implants are required and what the fees
are expected to be. There may well be other issues specific to your case and
these will be dealt with accordingly in the treatment plan letter you receive.
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Do I
have enough bone for dental implants?
Routine
dental x-rays are usually sufficient to assess this. From these views it is
generally possible to judge the height of bone available for implant placement,
however, more advanced imaging techniques, such as CT scans, are very
occasionally needed to determine the equally important bone width, which can
otherwise only be estimated from clinical examination.
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What
anatomical structures must be avoided during the placement of dental implants?
Upper jaw
- In the upper jaw, provided the implants stay within the bone that once
supported your own teeth there are really no important risk areas. If you have
missing upper back teeth then the shape and location of the maxillary sinus (the
region above the roots) can be shown to you. The maxillary sinuses can be seen
on most x-rays and are therefore readily avoided.
Lower jaw
- In the lower jaw the most important anatomical structure to be avoided is the
‘inferior dental nerve’. This nerve runs from the area behind the wisdom teeth,
passes under the molars and emerges onto the skin of the face in the region
where your premolar teeth are or used to be. This is why a normal dental
anaesthetic produces a numb lip even when the needle was placed right at the
back of the mouth.
If this
nerve is disturbed or damaged during the placement of dental implants it can
lead to temporary or even permanent numbness or parasthesia (strange sensations)
of the lip on the affected side. This is a rare but important complication.
Radiographs and occasionally CT scans identify the location of this nerve and
allow implants to be placed with confidence.
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Can
dental implants be placed next to natural teeth?
Dental
implants are routinely placed beside natural teeth and this is generally very
safe to do. The only exception to this would be if the natural root was very
curved or tilted unfavourably in the proposed path of the implant. This could
cause the root to be damaged by the implant; however this can usually be avoided
by careful pre-operative planning.
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Will I
have the appearance of teeth during the course of implant treatment?
If the teeth
being replaced by dental implants are in a clearly visible part of your mouth it
is most likely that you will want to have some teeth present whilst the
treatment is underway.
There are
a number of ways that this can be done, ranging from simple plastic dentures to
removable temporary bridges. If replacement teeth are used during treatment
stages it is important that they do not apply uncontrolled pressure to the
underlying implants. You should expect to make a number of visits after the
implants are placed and before they are brought into function, for small
adjustments to any temporary teeth.
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Is it
uncomfortable when the implants are placed?
Most
patients will be very familiar with the dental anaesthetics used for routine
dentistry and will know how effective they are. Implants are placed using the
same anaesthesia. Depending upon the complexity of your case, the operation
might take anything from 30 minutes for a single implant, to several hours for
complex bone grafting and multiple implant placements.
Since the
surgery normally involves exposing the bone in the area where the implant and/or
bone graft is to be placed you can expect some minor swelling and occasionally
bruising afterwards.
For most
patients, any of the simple painkillers you might take for a headache will be
all that is needed for a few days. If you experience more discomfort than this a
stronger medication can be provided.
Healing is
generally uneventful and any stitches are removed a week to ten days later.
During the first few days you should report any unexpected levels of pain or
swelling so that it can be assessed. If in doubt, you should always ask for
advice, as early detection of a problem will often lead to a simpler solution.
As with any
operation there is also a potential risk of infection of the surgical site.
John Grummitt always carries out these procedures in aseptic conditions (room
specially prepared, gowns etc.) to reduce this risk as much as possible. You
will also be offered a pre treatment antibiotic taken at the time of the
procedure. You may also be asked to take a course of antibiotics
and to follow some simple procedures such as rinsing with salt water or an
antiseptic mouth rinse. It is important that you carry out these instructions.
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Is it
uncomfortable when the implants are uncovered?
This is
also a minor surgical procedure carried out under local anaesthesia, and again
there is a very slight risk of swelling, bruising or infection but is normally
this is a much simpler and quicker procedure than when the implants are placed
and the risk of these problems is even less. Only the top of the implant is
uncovered allowing a small screw in the top of the implant to be removed and a
taller one put in its place. This will just come through the gum, bringing your
implant(s) into the mouth. A few sutures are again placed. Any denture or
temporary bridge will be adjusted to fit over this taller screw and hide it from
view.
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Is it
uncomfortable when the implants are restored?
This
procedure is usually completely painless and no anaesthesia is usually necessary
(although you can, of course, have one if you wish). It usually involves
removing the tall screw in the implants(s) screwing a slightly different one
into place and taking an impression over the implants. This “transfer impression
screw” is removed with the impression and the original tall screw put back into
place. Your temporary denture or bridge is then put back into place so that you
will appear to continue to have the appearance of teeth throughout the
procedure. Your definitive restorative work will normally be fitted two to
three weeks later (although this may take more visits or a longer period of time
if the restoration is particularly complex).
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Can I
have treatment under sedation?
Although
it is quite straightforward to provide good pain control during surgery, most
people will be quite anxious for all but the most simple of implant cases. There
is no need to suffer in silence as there are several very effective means by
which you can achieve a relaxed state.
Relative analgesia
– We can offer ‘relative analgesia’ where you inhale a mixture of nitrous oxide
(laughing gas) and oxygen through a small mask placed over your nose. This gas
mixture is breathed for the duration of the treatment stage.
Oral sedation
- Another simple way to aid relaxation is to be given a dose of a short-acting
medication such as Temezapam (normally used to help with sleep difficulties).
This will reduce anxiety for most patients and provides a very good effect for
uncomplicated surgical stages taking less than an hour. You will not be able to
drive or operate machinery for 24 hours afterwards.
Intravenous
sedation - This involves an injection in your arm or back of your hand. It
is a very effective sedation with an amnesic effect. You will not be able
to drive or operate machinery for 24 hours afterwards.
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If I do
not have enough bone what can be done?
So far we
have covered the building blocks that are part of routine implant placement.
This has included the initial examination and diagnosis, special tests, and what
to expect after the implants have been placed. However, for some people, bone
loss after the removal or loss of teeth leaves them without enough bone to
secure an implant. There are many techniques to generate new bone sufficient
for implants to be placed, where before it was not possible. These include
particulate bone graft (autograft), onlay grafting,
augmentation (allograft), use of membranes, and osteogenesis distraction. Often
these techniques can be combined with implant placement to reduce the number of
minor surgical procedures carried out, but sometimes the severity of bone loss
will determine that they have to be carried out as separate procedures.
If carried
out as separate procedures, new bone can take anything from 3 to 12 months
before it is ready to receive dental implants. Do not be in a hurry to move to
the next stage. If you need a large volume of bone it will take longer to mature
than a small amount. Any of the above techniques can be combined.
John
Grummitt does not generally recommend Xenografts which are grafts using
materials obtained from other animals (such as pigs and cows) or autografts
using material derived from human cadavers. Although these materials are widely
used and work well, because of the risk of CJD (Mad Cow disease) HIV (AIDS), prion or other
infection these materials can never be considered totally risk free.
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What is
sinus augmentation?
In the
upper jaw above the back teeth, it is possible to increase the height of bone
available by creating new bone in the sinus. This procedure is called a ‘sinus
augmentation’ and is combined with a particulate bone graft and/or augmentation
with allograft. John Grummitt can carry out this procedure if necessary.
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What is onlay
grafting (autograft)?
There are many ways in which bone can be added to, however one simple concept is
to take a piece of bone from somewhere else, such as the chin, and secure it as
an ‘onlay graft’ to a deficient area. The new piece of bone will slowly join to
the underlying region and when healed and mature, an implant can be placed in a
more favourable position. John Grummit can carry out this procedure if
necessary.
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What is particulate bone graft (autograft)?
For small
defects bone can often be obtained locally to the implant or from other areas in
the mouth and used to fill small defects where bone is missing.
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What is augmentation (allograft)?
For those
who would prefer an easier, but slightly slower solution, there are other
materials, mainly synthetic, specially prepared to make them safe for use in
humans. All of these materials, including your own bone simply provide a
scaffold into which new bone will grow and consolidate ready to receive dental
implants a few months later. These materials will be replaced with your own
bone.
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What
are barrier membranes?
There are
several types of barrier membranes made of different materials including Goretex,
collagen, titanium, and synthetic materials. Some are resorbable (disappear
after a period of time) some are non resorbable and require a second surgical
procedure to be removed. Some are derived from animal sources. John Grummitt
prefers to use resorbable synthetic membranes as there is no need for a second
surgical procedure and no risk of worrying about their source in the future.
All membranes work by trying to keep out gum tissues encouraging new bone to
grow from underneath them.
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What is osteogenesis distraction?
This is a
fairly new and complex technique for growing new bone. Using similar techniques
to surgeons who lengthen leg or arm bones, John Grummitt can encourage new bone
to grow very rapidly by fitting this “bone stretching” device, which with the
daily turn of a screw can in a matter of weeks rapidly increase your bone
height. It cannot be combined with implant placement at the same time but
implants can be placed a few months later.
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Does
bone grafting/augmentation affect the length of treatment?
If you
need bone grafting and or augmentation, it will almost invariably increase the
length of time your treatment will take, however when successfully applied it
will greatly improve the outcome of the implant(s) placed. When used in the
front of the mouth it can also allow for creation of very much better
aesthetics.
Bone
grafting is often more complex to perform than the placement of the implant
itself.
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Can the
implants be placed at the same time as bone grafting/augmentation/sinus
augmentation?
Whenever
possible John Grummitt will combine the implant placement with bone grafting
and/or the placement of a barrier membrane or synthetic material and place all
the materials at the same time. This considerably reduces treatment time and can
produce results that are difficult to achieve any other way. However, sometimes
it is necessary to carry out bone grafting/augmentation/sinus
augmentation as a distinct stage, so that the implants are only placed
when the procedure(s) has been successful.
Whatever
method is chosen to improve the bone quantity the time, effort and expense is
generally well worthwhile. However the amount and quality of the bone generated
will to some extent depend on your bodies response to these treatments and each
case will therefore be dependant on your body successfully generating new bone
in the treated area.
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One
stage or two stage implants?
One-stage implant
- The implant is placed into the jaw bone and is visible above the gum
immediately after placement. The advantage of this method is that a second
surgical stage is not necessary to expose the implant. The implant will not
normally be ready to support a tooth for several weeks or months.
Two-stage implant
- The implant is placed into the jaw bone and then covered by a layer of gum so
that it cannot be seen - this is the first stage. At the second stage some weeks
or months later, the implant is uncovered and components added bringing it above
the gum ready to begin placing a new tooth.
Both
methods work equally well but John Grummitt generally uses the two stage
procedure to gain the greatest control over the finished appearance of the gum
around the implant.
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What is
an immediate implant?
For this
technique a tooth is removed and an implant placed immediately into the
extraction site. Depending upon the local bone and soft tissue conditions, the
implant surgery may be a one- or two-stage procedure. Not all patients are
suitable for this approach. Provided there is no infection present on the tooth
to be extracted this procedure can produce the best result as the gum shape and
the bone can be preserved as well as possible.
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What
are mini implants?
Mini
implants are small, narrow implants that were for many years suggested for
temporary use only. They were used to hold temporary bridges and dentures in
place whilst conventional implants became osseointegrated. Although not widely
used they worked well for this procedure as they did not osseointegrate
predictably and were removed a few months after their placement when the
conventional implants were restored. However, recently these implants have been
suggested as giving a stand alone answer. They can often be placed with a
minimal amount of surgery and are a considerably cheaper answer.
Conventional root form osseointegrated implants (as used by John Grummitt) have
over forty years of supporting literature in refereed dental journals (this
means that experts in the field believe that these articles appearing in these
journals are as correct and proven as it is possible to be at the time of their
publication). There is very little published literature on these “mini
implants” used as a stand alone answer or their long term success rate. What literature there is, only goes
back a few years for this use, and very little has appeared in the top journals
about these implants. Generally at this moment in time they should be
considered temporary and experimental.
Their life expectancy should be considered unpredictable and possibly short
lived.
However, they can be very
useful in certain situations, for example where the bone is very narrow, cost is
a factor, or a patients health is so poor that conventional implants could not
be placed. John Grummitt is able to offer this new treatment choice.
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What
are same day implants?
The
field of implantology is an exciting one and dynamic one to be working in. The
boundaries are always trying to be pushed back to make the whole process quicker
and simpler. In certain very specific situations some implantologists are
placing implants and restoring them into function on the same day. Although
this is what patients and implantologists would like to be able to do,
unfortunately success rates drop considerably when this approach is taken.
The refereed dental literature would suggest that the success rate drops from
over 95% to below 90%. John Grummitt believes this success rate is unacceptable and
at the moment would not recommend this technique. However there is no doubt
with new knowledge, techniques and implant surfaces, in many case implants can
be placed on ever decreasing time scale with the highest success rates.
Occasionally John will be able to place and restore an implant in a six week
time scale. Most implant situations will, however require a at least a three to
six month time scale to obtain the most predictable outcome.
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