Dental Implantant & Cosmetic Information
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.
The dental implants used 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. we do 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 we use 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.
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, your dentist would 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.
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. Your implantologist can discuss this individually with you.
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.
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.
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.
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.
Your implantologist would prefer 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.
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.
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 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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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. These procedures are always carried out 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.
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.
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).
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.
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.
We do 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.
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.
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.
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.
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.
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. We prefer 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.
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, your implantologist 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.
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.
Can the implants be placed at the same time as bone grafting/augmentation/sinus augmentation?
Whenever possible your implantologist 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.
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 we generally uses the two stage procedure to gain the greatest control over the finished appearance of the gum around the implant.
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.
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 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.
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%. 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 your implantologist 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.