So you want to have an implant..?

1. What is a dental implant?

Dental implant is a treatment option for replacing missing teeth. A dental implant is like a screw, usually made from titanium. It mimics the root of the natural tooth.
Complete treatment involves two phases: the surgical phase (placement of the dental implant) and the prosthetic phase (placement of teeth on implants).
During a small surgery (usually under local anesthesia) the dental implant is placed in the bone of the jaw, where it remains undisturbed for a period of 6-24 weeks. The implant is either not visible during this period or only the top of the implant is visible.
In this period, the bone grows in tight contact with the dental implant, an event we call "osseointegration".
After osseoointegraion is achieved, the implant is restored with a metal or ceramic abutment which can be used to support a crown, a bridge or another dental prosthesis which replaces one or more missing teeth. This is the prosthetic restoration.

2. Which are the main treatment options for replacing the missing teeth?

There are several options for replacing missing teeth. Each treatment option has its own indications and contraindications.


Implants

Implants can be placed in the area where the teeth are missing. Then single crowns or a bridge can be fixed on to the implants. Implants can replace single or multiple teeth, or support prosthesis for people who have no teeth at all.



Tooth supported bridge

Teeth/tooth adjacent to missing teeth can be prepared to carry a bridge and provide support for the replacement of the missing teeth. This involves slicing teeth under local anesthesia, followed by preparing a bridge in the lab. The bridge is cemented on to the teeth and replaces the lost teeth. A certain number of healthy teeth are required in order to support a fixed bridge.


Removable prosthesis on teeth (Partial denture)

A tooth supported removable prosthesis may also be an option for replacing adjacent missing teeth. However, these are not fixed in the mouth and often might be less comfortable to wear, while a period of adaptation is required.


Full denture

When there are no teeth present, a full denture can be made which is supported by the alveolar ridge (remaining bone and soft tissues). The comfort and stability of such a denture depends greatly on the amount of bone left and can be difficult if there is little bone left.
Sometimes, the stability of a full denture can be greatly improved by introducing some implants to provide anchorage.

3. Are dental implants safe?

Dental implants have been in use for more than 30 years and have been proven safe and effective at replacing missing teeth. Millions of people have benefited from treatment with dental implants, while today we achieve osseointegration in more than 98% of the implants placed.
Allergic reactions or rejections of the dental implant are very rare. Titanium is one of the most tissue-accepted metals, and has negligible metal toxicity.
Nevertheless, placement of the dental implants requires a surgical intervention, which might be contraindicated in patients with certain health conditions or medications.
Implant surgery, like every surgical procedure can have complications. Depending on the local anatomy and proximity to sensitive structures (e.g. nerves, arteries, sinus), careful planning is required and often detailed radiographic examinations in order to prevent injury. Your dentist will discuss with you in detail if any risks exist in your case.

4. Are dental implants appropriate for everyone?

Most people who are in good general health are good candidates for treatment with dental implants and can enjoy a predictable and highly successful outcome. Establishment of optimal gingival health and effective oral hygiene is however a prerequisite for implant treatment, as bacterial plaque and inflammation of the gums are major threats for the success of implant treatments. Certain systemic conditions might increase the risk for failures or complications, although not directly prohibit implant treatment.
For example:
Patients with Diabetes Mellitus are strongly advised to achieve proper metabolic control prior to implant treatment.
Smokers have increased risk for implant complications. Smoking cessation is recommended before implant treatment takes place in order to increase the success rate.
Patients with a history of Periodontitis are more susceptible to implant inflammation and must maintain an optimal hygiene and regular visits to the dentist for checkups.
Sometimes the local anatomic conditions might complicate implant treatment or increase risks for failures. Some people do not have enough healthy natural bone to support dental implants, or anatomical structures such as nerves and the sinus cavity might be in close proximity.
Certain radiographic examinations such as Computer Tomography might be needed to identify the residual bone quality and quantity and decide if an implant is the best option and what type of procedure will be required.

Figure 11. Horizontal loss of bone after the tooth extractions.

5. How long time does an implant treatment require?

The timeframe of an implant treatment depends greatly on the type of reconstruction and individual conditions such as each patient's restorative needs, medical and dental histories, the condition of the jawbone, and the technique and materials used. The duration might vary from 2-3 months in simple cases to more than a year in complex reconstructions.
After an initial consultation, your implant dentist should provide you with a treatment plan including the estimated amount of time required to complete the treatment. Implant treatment usually comes once complete oral health is present or established. Often the treatment with dental implants might be delayed because of other existing conditions that need to be treated first such as periodontal disease, caries, periapical inflammations etc.
The usual implant treatment procedure consists of two parts: implant installation surgery and prosthetic restoration. If you need to extract a tooth, a healing period of at least 6-12 weeks, most likely will be required before implant surgery is possible to replace this tooth. In exceptional cases, extraction of the tooth and placement of the implant can happen in the same day, which is called immediate placement.
Once placed, implants require an undisturbed healing time of 6 to 12 weeks before placement of the prosthesis. Manufacturing of the prosthesis itself might require from 2-6 weeks, depending on the complexity. Multiple appointments are almost always necessary.
Under specific circumstances, implants may be restored (have a prosthesis placed) on the same day the implant is inserted. This is known as immediate loading.

Figure 12. Most common procedure of implant treatment.

6. Is implant surgery painful?

In the great majority of cases, implant surgery is well tolerated with mild post-surgical discomfort.
Local anesthetic is in most cases enough to ensure that no discomfort is felt while implants are being placed.
Post-surgical pain usually responds well to over-the-counter painkillers such as Paracetamol. According to a study conducted with patients in our clinic (5) after straightforward implant surgery, half of the patients needed painkillers on the first day, while one out of 4 patients still took painkillers on the 4th day. By the 6th day, only one in ten patients used painkillers.
Minor discomfort in most cases is transitory and can be controlled after the surgery. Most common post-surgical complications are swelling, pain, hematoma and bleeding. There are very few major risks associated with implant surgery and although they can potentially occur, they are rare.
Implant=Straight forward Implant Surgery; Implant+GBR= Implant placement with simultaneous bone augmentation surgery
Figure 13. Patient-reported swelling scores post-surgery in a scale 0-10 (no swelling- very much swelling), day 1 to day 14. Figure 14. Patient-reported pain scores post-surgery in a scale 0-10 (no pain- very much pain), day 1 to day 14.

7. What is my commitment once I receive implants?

Implant Prostheses require effective oral hygiene and frequent examinations, in order to prevent or detect any early potential problems.
In most cases, as a minimum, an annual check-up appointment will be required so that the prosthesis and the peri-implant tissues are examined and also are professionally cleaned by your dentist or hygienist. In certain patients with increased risk, more frequent appointments are often recommended.
Moreover, effective practice of oral hygiene with brushing and flossing twice a day is essential. As Implant prostheses are often different in structure than teeth, sometimes effective oral hygiene might require special types of brushes or devices, which your dentist or hygienist can demonstrate.
Figure 15. Use of dental floss Figure 16. Interproximal brush

8. Do implant supported prostheses look like natural teeth?

Implant prostheses are of many types and can vary from single crowns replacing one missing tooth to extensive restorations that cover the whole jaw. At present, we have a wide variety of aesthetic techniques and materials which in many cases result in very high aesthetics with dental implants. Often, crowns on dental implants will appear very natural and quite similar to your real teeth.
The final esthetic outcome however, greatly depends on the kind of reconstruction as well as the local conditions (availability of bone and gums). In some cases, additional procedures to improve soft tissue might be required if an optimal aesthetic outcome is necessary. In other cases, a small compromise in the aesthetics is necessary in order to achieve healthy and sustainable treatment outcomes.
At present, there are protocols available that can help your dentist assess the aesthetic risks in your case and give you a reliable opinion on how likely we are to achieve a high aesthetic outcome and if any special procedures will be required. If aesthetics is your major priority, please discuss with your dentist on the possibilities to achieve a highly aesthetic outcome in your case.
Figure 17. Single implant with implant crown Figure 18. Full arch implant supported fixed dental prosthesis

9. Do implant supported prostheses function as natural teeth?

Dental implants remain fixed in the bone and allow for normal function. Patients with fixed prostheses on dental implants enjoy comfortable chewing that is very close to this of natural teeth. Your ability to enjoy a meal and experience taste and texture is the same as when you have natural teeth.
Crowns on dental implants will feel very natural only after a couple of weeks and in most cases quite similar to your real teeth. Normally, you will not be able to feel that you have a dental implant.
However, natural teeth are surrounded by the periodontal ligament which offers very precise perception during mastication. Implants are deprived of periodontal ligament, so in case that you no longer have natural teeth remaining in the mouth, your sensation of pressure while chewing might be significantly reduced.
Patients with removable prosthesis (overdenture) on implants will enjoy a high stability of the denture. Such overdentures however often have an extensive coverage of the palate or mandible and might reduce your perception of taste as well.

10. How long do dental implants last?

Implants have a high success rate, but it is still a relatively new treatment and thus documentation beyond 10 years is scarce. Nevertheless, there are reports that have assessed their performance over a period of more than 35 years. The most recent studies indicate that about 90% of implants placed are still in function after ten years.
Even with a long-term survival, implants are not always free of complications. Complications can occur either in the technical parts (screws, abutments, porcelain crown etc) or in the tissues surrounding implants (inflammation - peri-implantitis).
The technical parts of implant prosthesis have a certain life span and it is reasonable to expect that within a period of 5-10 years, some parts such as abutment screws or porcelain crown might need repairs or replacement.
The tissue complications however such as chronic inflammation around implants is difficult to manage once established, therefore prevention is the best strategy. Prevention of inflammation related complications is possible through effective oral hygiene and long-term health of peri-implant tissues depends greatly on how well they are cleaned and maintained

11. Why do you have to come to the dentist frequently?

Dental implants are as susceptible to bacterial inflammation as your natural teeth. Therefore, effective cleaning is required. Special brushes may be used to facilitate this, along with dental floss.
Your dentist will put together a maintenance program that is appropriate for your individual needs. As a minimum, an annual check-up is likely to be recommended, but more frequent supportive therapy could be necessary if you have any increased risk for example if you have lost teeth due to periodontitis.
Smoking can significantly increase the risk of inflammation and bone loss around implants. Therefore, smoking cessation is an important step in order to achieve good overall oral health and to reduce bone loss around dental implants, as well as around the natural teeth.

Figure 21. Radiograph of a patient with peri-implantitis. Observe the bone loss around the two last implants.

12. Can things go wrong after the end of the treatment?

At present, osseointegration is very predictable and between 98% and 99% of the implants placed will successfully osseointegrate. However, problems or complications can be encountered shortly or long after the implants are successfully restored. The majority of these complications can be managed effectively if they are detected early.


Bone loss

Bone loss can occur around implants. Regular check-ups by your implant dentist will ensure that such a condition is diagnosed early and adequately managed.


Infection / Inflammation

Bacterial plaque might lead to chronic inflammation around implants which is known as peri-implantitis and can result in continuous bone loss around implants. Poor oral hygiene is the main cause for such infections and once established they can be very challenging-to-treat problems. Bacterial infection, is however preventable through good hygiene and professional cleaning by your dentist or a hygienist. Poor systemic health such as uncontrolled diabetes and smoking are known to increase the risk of peri-implantitis.


Complications relating to the prosthesis

Technical complications such as mechanical fracture of crowns, bridges, prosthetic screws, or loosening of screws, are not uncommon, especially for prostheses that have been more than 5 years in function. This type of complications can be increased in patients with parafunctional babits (bruxism or clenching) or unstable occlusion. And in most cases, they are dealt effectively with replacement of damaged components.


Implant fracture

Fracture of implants occurs rarely (in less than 1 % of cases). This type of complication usually results in patients with parafunctional habits (bruxers or clenchers) or unstable occlusion, as well as with other kinds of overload.