What is a Dental Implant?

Dental implants are made from pure titanium, which is a metal that has been shown to be well tolerated by bone. Bone grows onto the titanium implant surface, and effectively fuses with it, providing a stable fixing, which can be used to support dental restorations. They are essentially a substitute for a natural root and commonly they are screw or cylinder shaped. You can think of them a bit like a Rawl plug in a wall. They provide a strong fixing off which you can support a single tooth or many teeth.  In order to connect the replacement teeth to the implant, they 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 many teeth can be supported by implants?

All the common forms of tooth replacement such as crowns, bridges and dentures, can be retained by dental implants. If you are missing just one natural tooth, then one implant is normally sufficient to provide a replacement. Larger spaces created by two, three or more missing teeth do not necessarily need one implant per tooth – the number required will depend upon the quality and volume of bone available at each potential implant site.  In the upper jaw, bone density is generally poorer than in the lower. If you have no teeth at all, we would normally need 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 are needed. 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 6.

What else can be done with dental implants?

Denture mobility can be hugely improved. Many patients have had problems with mobile lower dentures. Food can get stuck under them, and they can move around a lot when talking. A lower denture can be stabilised by placing two implants placed towards the front of the mouth, and placing retentive mechanisms onto the denture base, which clip onto the implants. This is called an ‘overdenture’.  The same overdenture concept, when used to treat the upper jaw, would require more implants, as the bone is generally softer. Implant supported overdentures are still removed for daily cleaning. Once back in the mouth the implants virtually eliminate movement, making the denture much more stable, secure and comfortable.

Who is suitable for dental implants?

If you have good general health then dental implants will almost certainly work for you. However, habits such as heavy drinking or 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. Smoking in particular carries an increased risk of implant failure.

Do you need to have a healthy mouth?

When you first enquire about dental implants it is often in response to an ongoing dental problem or the recent loss of teeth. Each of these problems will need to be diagnosed and treated first before any implants are placed, to ensure they have the best chance of success. 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 implant.

What else causes bone loss?

Normal Remodelling – Whenever a tooth is lost or extracted a considerable amount of bone that once surrounded the root 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. Sometimes, the simplest measure to minimise bone loss after an extraction is to place the implant immediately or within a few weeks.  

Periodontal Disease – Gum disease is a major cause of bone loss and patients who suffer from this condition can have a significant reduction in the amount of bone available. This can make dental implant treatment more complicated, as there is less bone available.  

Dentures – Many patients report that after a while their dentures get loose and do not fit as well as they once did. Initially the increased rate of bone loss following extractions is responsible for the worsening fit. Over the long-term it is the direct effect of chewing forces that causes slow resorption of the supporting bone. Most people who have had dentures for many years will have needed to have them relined to compensate for this bone loss. The longer dentures are worn, the more the amount of bone available for dental implants may have been reduced.

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 increasing in density. Like all things there are limits to how much work an implant can do. We will be able to discuss this in more detail, if it relates to your case.

What can you do if an implant does not work?

If an implant does not achieve or cannot maintain a rigid fixation with the surrounding bone it will eventually become loose and no longer be able to support replacement teeth. Commonly the failing implant causes no discomfort and can easily be removed. If there are enough implants remaining it may not be necessary to replace it at all. Failures may not always be so easy to deal with and if you embark upon this type of treatment you have to be prepared to deal with this possibility. If an implant fails, it may be possible to allow it to heal and simply place another.

How long does treatment take?

For routine cases, treatment times can vary from a day to six months. The availability of better quality bone can be used to decrease treatment time, whilst more time and care must be taken with poorer quality bone, which can therefore extend treatment times beyond six months.

How do I look after 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 work around natural teeth and tooth supported bridges. In some areas inter-dental toothbrushes and other cleaning aids may be needed to maintain good oral hygiene. For the first few months the implants are in function we may ask that you are seen more frequently, however once we are satisfied that your treatment if performing as planned, ongoing care will be similar to any patient with natural teeth.

How long will the implants last?

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 the most influence on how long they will last. If 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. 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 from conventional crowns, bridges and fillings your implant-supported teeth may also have similar maintenance requirements.

How do I know if I am suitable for implants?

First of all, it will be necessary to take a detailed medical history and there will be a complete examination of your mouth and remaining teeth to discover if there are any other dental problems. We would need to take x-rays of your remaining teeth. Plaster models and photos will also be needed so that these can be examined after your visit, and a list of treatment options compiled. You may find that you have a surprising number of options open to you, all of which need to be carefully explained. Good basic dental health is a key stage in any treatment plan. At this first appointment we will make you aware of any problems that are urgent, and what treatment is required to stabilise any gum or tooth related problems. At the same time we will be able to offer you a verbal outline of how your particular implant treatment might be approached.

What should I know before treatment?

Before any treatment is started, we will give you 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 overview 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 would be dealt with here accordingly.

Do I have enough bone for dental implants?

Routine dental x –rays show large amounts of detail, but only in two dimensions. From these views it is generally possible to judge the height of bone available for implant placement however more advanced imaging techniques are sometimes needed to determine the equally important bone width, which can otherwise only be estimated from clinical examination. There are now a number of advanced x-ray techniques which allow our jaw bone to be looked at in all three dimensions. The most accurate and widely available is a CT scan (like a CAT scan in hospital). Images obtained by CT scanning will normally be able to show all of the information required about your bone, including quantity and quality, but most importantly the presence of anatomical structures that must be avoided.  CT scans are not required for every implant case, and will only be recommended if the additional information they provide is thought to be necessary to help us to achieve a successful clinical outcome.

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 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 the premolar teeth are or used to be. This is why a normal dental anaesthetic produces a numb lip even if the injection is given right at the back of the mouth. If the nerve is disturbed or damaged during the placement of dental implants it can lead to temporary or even permanent numbness of the lip on the affected side. This is a rare but important complication, and obviously something we plan to avoid. CT scans are generally the best means for identifying the location of this nerve and allow implants to be placed with considerable confidence.  Whilst CT scans are more expensive than routine dental x-rays, the information they provide is often invaluable for complex treatment planning and knowing where important anatomical structures are located.

Can you wear teeth during the course of implant treatment?

If the teeth 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 bridges. If replacement teeth are used during treatment stages it is important that they do not apply uncontrolled pressure to the underlying implants, as this can interfere with their integration.

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 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 have for a headache would normally be all that is needed for a few days. If you were to experience more discomfort than this we would obviously provide stronger medication for you. Healing is generally uneventful. Any stitches are normally removed a week or so later. You may also be asked to take a course of antibiotics, some anti-inflammatory painkillers and to follow some simple procedures such as rinsing with salty water. It is important that you carry out these instructions, as they help to promote uneventful and easy healing.

If I do not have enough bone what can be done?

For some people, bone loss after the removal or loss of teeth leaves them with inadequate bone to allow an implant to be placed conventionally.  For these individuals, it may be necessary to increase the bone height and volume, which would involve an additional procedure.

Sinus Augmentation – In the upper jaw above the back teeth, it is possible to increase the height of the bone available by creating new bone in the sinus.  This procedure is called ‘sinus augmentation’. It is a very predictable method by which new bone can be formed and allow implants to be placed. Without the general success of this technique, many patients would be unable to have implants in a part of the mouth where teeth are so commonly missing.

Onlay Grafting – 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 and secure it as an ‘onlay’ graft to a deficient area. It then heals in a similar way to how a fracture would heal. The new piece of bone will slowly join to the underlying region and mature. The implant(s) can then be placed in the ideal position to allow for a better aesthetic outcome.

Where can you get extra bone from?

Bone can be harvested from a number of sources such as the hip, chin and posterior regions of the lower jaw.  When you use your own bone to create new bone in another area of the mouth you will have to contend with the discomfort created by the donor site as well as the surgical site.  Many people feel this is well worth any additional discomfort as your own bone is normally considered the ‘gold standard’.

Alternatives to your own bone for grafting
For those who would prefer an easier, but slightly slower solution, there are other sources of bone-like materials available. All of these materials including your own bone, simply provide a scaffold into which new bone can grow and mature ready to receive dental implants a few months later. New bone can take anything from 3 to 12 months before it is ready to receive dental implants. If you need a large volume of bone it will take longer to mature than a smaller amount.  
 
Guided Tissue Regeneration – Using this technique, slow moving bone cells are given time to fill a space by placing a barrier material between them and the fast moving cells of the soft tissues lining the mouth. The material forms a resorbable barrier that will disappear naturally a few months after it has done its work.  
 
Same day implants – This technique is most often used to treat the lower jaw and requires considerable planning before the actual day of the surgery. Several implants are installed and a few hours later a complete arch of temporary or permanent teeth can be fixed in place. If temporary teeth are used these would normally be replaced with a permanent bridge after a suitable healing interval.  Not all patients are suitable for this style of treatment.  
 
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.  
 
Immediate Implant & Early Loading – This is distinctly different from an immediate implant placement. It is effectively a one-stage procedure where the implant is placed into a new healing or healed extraction site and is fitted with a new tooth at the same appointment. This first tooth will normally be kept out of direct contact with opposing teeth for a healing period of more than 3 months, after which it is finally restored. This technique tends to be more common in regions of the mouth where optimum aesthetics are important. Again, not all patients are suitable for this approach.

Summary of Stages for Routine Dental Implants

  • Diagnosis and treatment planning after which it may be necessary to carry out repairs or treatment to any remaining teeth.
  • Implant placement is usually followed by a period of healing lasting from 6 weeks to 6 months.  Often the implants are completely hidden beneath the gum, however one-stage procedures where the implant is visible from the time of placement are also commonplace.  Stitches are normally removed/dissolve in  7-10 days after implant placement.
  • Several visits may be needed over the next few weeks to adjust temporary teeth or dentures and to monitor healing.
  • Once the implants have healed for the required time, they are uncovered if necessary and made ready to connect the teeth.  Sometimes the time allowed for implants to integrate may be increased or decreased to suit the local bone conditions and the overall quality of healing.
  • In some cases the first teeth fitted to your implants are not the final ones, but replicas of the intended design.  This stage can be used to assess the implants, control early loading and in areas where aesthetics are more critical, also gives the gums time to mature around each implant before final teeth are fitted.
  • Final teeth are commonly fitted between 3 and 9 months after the implants were first placed.  The way that the teeth fit together is carefully adjusted to ensure that they do not interfere with each other.
Regular examination and hygiene appointments are then all that is required to maintain the health of the mouth, teeth and implants.

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