INTRODUCTION TO DENTAL IMPLANTS
What is a dental implant?
A dental implant is a screw-like metal component (typically titanium) embedded within either the lower jaw bone (mandible) or within the upper jaw bone (maxilla).
A dental implant is composed of 3 main elements:
- An artificial root embedded within the jaw bone
- Abutment – attaches to the head of the implant and sits above the gumline (creating a stable platform onto which the prosthetic is added)
- Prosthetic tooth / bridge / partial denture / full denture
The dental implant provides a permanent structure capable of supporting either an individual prosthetic crown or several prosthetic teeth in the form of bridge work or a denture.
Depending on the type of restoration work being carried out, more than one prosthetic tooth may be supported by a singular dental implant.
The dental implant is fitted in a surgical procedure that normally takes less than one hour to complete.
A period of healing – usually spanning 3-6 months – is observed before a second stage of surgery is carried out to fit the prosthetic.
However, ‘one-stage’ or ‘same-day’ implants may be offered to patients who meet certain criteria, including sufficient general health, sufficient oral health, and adequate bone density.
Most surgical procedures for dental implants are carried out under local anaesthetic.
However, where a patient requires multiple dental implants, the dentist may recommend carrying out the procedure under IV sedation for patient comfort.
Prior to any dental implant work being carried out, the patient must undergo an assessment.
This assessment will likely involve an X-ray, and a CBCT scan (digital 3D imaging).
Using these results, the dentist will also consider the Occlusal Vertical Dimension (OVD) – this is the term used to describe the space available between the upper teeth and lower teeth, position of adjacent teeth, bone quality, and anatomical structures including the position of the sinus (maxilla) and nerves.
What are the benefits of dental implants?
Patients may benefit from dental implants in several ways that can be broken down into practical benefits and psychological benefits.
Practical benefits of dental implants include:
- Enhanced Usability – dental implants offer ‘set and forget’ convenience (unlike removable dentures that must be removed/replaced each day)
- Enhanced Levels of Oral Health – where necessary, the procedure involves building the surrounding bone and soft tissues (halting and reversing any deterioration)
- Enhanced Speech Delivery – dental implants are embedded into the bone and do not move/slip when speaking (eliminating mumbled speech)
- Enhanced Mastication (ease of chewing) – dental implants are fixed into the bone and do not slip or move around when eating food
Psychological benefits of dental implants include:
- Enhanced Self-Esteem – dental implants can create a ‘Hollywood’ smile that results in greater self confidence during personal interactions
- Enhanced Visual Appearance – dental implants have the visual appearance of well looked after natural teeth (resulting in peace of mind that people will not realise the teeth are prosthetic)
- Enhanced Comfort (compared to alternatives) – dental implants do not agitate the gums (e.g. removable dentures may cause friction issues)
What materials are used in a dental implant?
Although dental implants are increasingly available in a variety of formats. The most common type of dental implant is comprised of three sections:
- Dental Implant
The screw-like dental implant is typically made using titanium or a titanium alloy as this material is known for delivering optimum results in terms of integrating with the bone - Abutment
The abutment is more or less completely housed within the prosthetic tooth and may be made from a variety of materials such as titanium or stainless steel - Crown (prosthetic tooth / bridge / denture)
The crown is the visible prosthetic tooth and may be constructed from a variety of materials including ceramic compounds and porcelain
In many cases, the abutment and the crown form a single unit known as screw retained implants. These are always preferential for patients. However, depending on implant position, screw retained implants may not always be possible.
How long will dental implants last?
There are two long term factors that will ultimately determine the lifespan of a dental implant.
First, attention to oral hygiene and following the approved dental implant care plan (provided by the dentist) will help to reduce the build up of potentially harmful deposits such as calculus and plaque.
Second, patients that choose to attend the recommended number of annual dental reviews will benefit from ongoing professional advice and maintenance.
Neglected dental implants will likely accumulate both hard and soft deposits, which can lead to infection within the gum, pain, bleeding, and bone deterioration.
Where the proper guidelines are followed, dental implants are expected to last multiple decades.
How many prosthetic teeth can be supported by a single implant?
Prosthetic teeth do not necessarily require the support of individual dental implants in a 1:1 ratio.
The dentist will decide whether an area of jaw bone is a viable implant area based on factors such as bone density and whether there is room for a prosthetic tooth between any existing teeth/implants.
A reasonably healthy adult that is missing a single tooth can expect the treatment to involve a single dental implant, to which a single prosthetic tooth is fitted (filling the hole left by the missing tooth).
Where two or more consecutive teeth are missing, the dentist may elect to embed dental implants in the most suitable areas of jaw and fit a bridge or partial denture.
All of the options will be outlined in a treatment plan (this is the plan put forward by the dentist following the completion of all initial eligibility checks).
Can anyone have a dental implant?
The answer to the question of whether anyone can have dental implants comes down whether the patient has agreeable levels of general health and oral health.
Health and patient safety are the primary considerations and can be carefully managed.
Oral health conditions are equally important. The implant site suitability, general oral hygiene, and number of teeth to be replaced are all considerations when determining implant suitability.
The first point to mention is that dental implants can only be installed in bone that has stopped growing or has almost stopped growing.
This means that the treatment is only available to adults and teenagers typically aged 18+. In many cases, braces may also be considered as part of planning to fill a space.
Conditions that may affect the body’s natural healing process (such as haemophilia) must also be taken into consideration.
Where such health concerns are present, the patient may not qualify for the dental implant procedure.
Also, patients that have received radiation therapy to the head/neck may also experience deteriorated levels of bone density – meaning surgery on the bone is not advised.
The dentist will ask all relevant questions regarding a patient’s medical history prior to recommending and installing dental implants.
TYPES OF DENTAL IMPLANT
Different types of dental implants have been developed in order to provide optimum outcomes on an individual basis.
For example, patients with multiple tooth loss and lowered bone height may not qualify for an ‘endosteal’ implant and will likely require a customised ‘subperiosteal’ solution.
What is an endosteal implant? (within-the-bone implant)
An endosteal implant is a type of dental implant that screws into the upper or lower jaw bone and subsequently grafts or ‘bonds’ with the bone over a typical healing period of 3-6 months.
This type of dental implant procedure requires sufficient bone density both in order to house the implant and to provide enough bone material around the implant that grafting may take place.
What is a subperiosteal implant? (on-top-of-the-bone implant)
A subperiosteal implant consists of an elongated metallic arch that is moulded to envelop a length of exposed jaw bone.
The frame is firmly attached to the jaw bone. The gum is sewn back in place, concealing the base of the implant – posts protruding from the implant sit above the gumline.
Individual crowns, bridges, or dentures may be fitted to these posts.
This type of procedure is preferred in cases where the patient presents a lowered bone height that would otherwise serve to decrease the success rate of endosteal implants.
What are transosteal implants? (through-the-bone implant)
A transosteal implant can only be used in the lower jaw (mandible).
This is because the method involves drilling holes through the jaw.
A metal plate is attached to the underside of the jaw. Implants that look like screws are threaded through the holes in the jaw and are screwed into the metal plate.
The heads of the screws (showing above the gum line in the mouth) can subsequently be used as fixing posts to which a bridge or denture may be attached.
Transosteal implants may result in scarring. The method is generally reserved for cases that cannot be solved with other more mainstream dental implant solutions.
What are the alternatives to dental implants?
Compared to alternative solutions, dental implants are generally seen as a more desirable long dental treatment regarding tooth loss.
This is because dental implants are fixed into place and do not move, representing excellent long-term value for money and removing the need to take teeth out at night etc.
However, where a patient does not wish to undergo the surgical procedures involved in installing dental implants, alternative treatments are available.
Tooth supported fixed bridge
The tooth supported fixed bridge is one of the most common alternative tooth replacement options compared to the dental implant procedure.
The bridge itself will usually consists of at least three conjoined prosthetic teeth – the outer teeth are hollow, the central tooth is solid.
The dentist will shape the two natural teeth in the mouth located either side of the missing tooth. The bridge’s two outer teeth can now be fitted onto these supports.
Typically, a bridge is seen as a medium term solution as some deterioration of the surrounding tissue and jaw bone is expected due to the difficulties associated with cleaning a bridge and the risks to the natural teeth.
Partial denture (removable)
A removable partial denture consists of one or more prosthetic teeth attached to a plastic or metal base (normally cobalt-chrome) that sits in the roof of the mouth.
Not as expensive as the alternatives, this type of tooth restoration does generally provide a convincing cosmetic result but offers lowered overall biting/chewing functionality.
Also, due to the exposed nature of the gum, some deterioration of both the soft tissue and the jaw bone is expected to develop over time.
Complete denture (removable)
A complete removable denture is a cost-effective multiple tooth restoration solution.
The denture fits onto the gum and can be held in place using the gums and musculature. The denture can be supported further with a designed denture adhesive.
Results vary in terms of functionality, with most people experiencing some movement of the denture. This can result in clicking sounds when speaking and some difficulty when eating.
A complete denture may last from 10 – 15 years. Patients should be advised, however, that soft tissue deterioration and a lowered bone density in the jaw can occur over this time period.
Resin-bonded bridge
A resin bonded bridge is a type of bridge that does not require any reduction / shaping of the natural teeth adjacent to the missing tooth.
Instead, the bridge consists of a central solid prosthetic tooth that is attached to thin metal wings. These wings are glued into place on the natural adjacent teeth.
A resin bonded bridge may be seen by some patients as a more desirable bridge option because the procedure does not involve filing down any teeth.
However, a resin-bonded bridge does not perform to the same standards as a tooth supported fixed bridge and will likely require a higher degree of maintenance.
HOW MUCH DO DENTAL IMPLANTS COST
The ultimate cost of dental implants comes down to the work required to achieve the best result for each individual patient.
For example, patients with existing complications affecting the gums and teeth may be required to undergo intermediate to extensive preparatory work such as gum grafts and bone grafts.
Likewise , patients may be able to benefit from making significant savings where several prosthetic teeth (i.e. bridge work or dentures) are fitted in a ratio of two or more teeth per implant.
Following an assessment of the patient’s individual circumstances, the dentist is best placed to advise each patient on the overall cost of a personalised dental implant procedure.
How much is a single tooth dental implant?
The cost of a single tooth dental implant can be broken down into the assessment phase of the treatment and the surgical phase of the treatment.
These costs may vary from dentist to dentist, and are given here as a guide only.
General assessment phase costs
- Exam: €50
- X-ray: €20 – €50
- CBCT scan: €150
- Hygiene Treatment where required: €75 (per 30 mins)
General surgical phase costs
- Sedation: €250 (Optional)
- Single implant placement: €1300
- 2nd stage surgery: €100
- Implant Crown: €1200
In some cases, where the bone level or condition may not be optimal, patients may opt for bone grafting to improve treatment outcomes.
What is the cost of full mouth dental implants?
The cost of full mouth dental implants will vary depending on the individual circumstances of the patient, and will be outlined by the dentist on an individual basis.
For example, patients who require bone grafts and other preliminary work can expect increased costs.
For an idea of general individual costs that may be associated with full mouth dental implants, please see the cost listings above.
Can I spread the payments?
Different dentists may offer different finance options in terms of spreading the cost of dental implants.
For the best outcome, patients are advised to consider any finance options put forward by the dentist.
Typically, the dentist will be best placed to offer advice on low interest finance arrangements available to patients relating to the dental implant services that are offered.
DENTAL IMPLANT PROCEDURE & CONSULTATION PERIOD
Consultation procedure – How will I know if I am suitable for dental implants?
Providing that the adult wishing to undergo the dental implant procedure is able to demonstrate adequate levels of both general health and oral health, the consultation procedure may proceed.
X-rays will be taken of the patient’s mouth and a model will be made of the teeth. This will confirm certain details of the patient’s dental issues.
A Cone Beam Computed Tomography (CBCT) scan is another diagnostic tool that may be used at this stage.
The CBCT scan provides a topographical (3D) image of mouth. This allows the dentist to measure bone density and acquire exact positioning of the teeth and other structures.
Where bone density is not sufficient, the dentist may recommend treatments that aim to enhance bone thickness, creating a viable dental implant site.
Conditions such as osteoporosis, diabetes, and haemophilia can result in poor healing rates.
Such conditions will be considered by the dentist as to whether the chances of success are significantly affected.
What if I require a bone graft?
A bone graft may be required in situations where the patient has suffered bone loss or bone deterioration in the proposed site of the dental implant.
Deterioration of the bone generally occurs as a result of gum disease – where unhealthy bacteria is allowed to accumulate at gum level, infections may eat into the tooth and supporting bone.
Although alternative techniques are available that can help to build bone density, a bone graft is one of the main options.
A bone graft, or ‘onlay graft’, is a surgical procedure that usually involves preparing the graft site and introducing a healthy portion of bone taken from the patient.
‘Allografts’ from donors may also be a viable option in many cases – called Cadaver Bone.
Autogenous grafts of Bovine derivative offer options and are commonly used (there are also synthetic versions of bone that are used).
The type of graft material used will be determined by the surgeon in consultation with the patient based on the expected performance and implant requirements.
Depending on the size of the graft and the natural speed at which the patient is able to heal, a period of 6 – 12 months is typically observed following surgery before the dental implant procedure can continue.
Are there any alternatives to a bone graft?
In the case of low bone density, a dental implant would not be advised as the site would be unlikely to heal in a full and correct manner.
The dentist may advise a bone graft in order to boost the quantity and quality of bone available.
However, some patients may prefer to avoid going through a bone graft procedure, where surgery is required in order to take healthy bone from the patient’s own body (typically from the hip or leg).
In this case, alternative bone graft materials are available:
- Bovine graft (cow bone)
- Porcine graft (pig bone)
- Synthetic materials
New bone may require anything from 6 – 12 months to heal.
A ‘guided tissue regeneration’ technique may also be used. This involves encouraging new bone cells to grow by placing a barrier between the bone and the soft tissues in the mouth.
This technique was developed as soft tissue grows faster than bone and may grow into any available space, blocking bone growth.
The barrier is absorbed by the body and does not need to be removed.
What can cause bone loss?
There are several circumstantial factors that may contribute towards bone loss in a patient.
For example, if a patient has experienced the loss of a tooth (either due to trauma or as part of a previous dental treatment plan), the bone at the extraction site may have already begun to thin.
This not uncommon process is known as bone reabsorption, as the previously high density but now unneeded bone is reabsorbed by the body.
In cases of individuals who have experienced multiple tooth loss, this process may result in a lowered bone height, meaning dentures become ill-fitting over time.
Dental implant procedure explained
The surgical procedure will typically consist of two stages.
Under normal circumstances, the procedure is carried out under local anaesthetic. However, sedation may be preferred in cases of multiple implants.
- Stage 1 – Placing the dental implant
The dentist will make an incision within the gingiva (gum). This exposes the target area of jaw bone.
A hole is made into the bone – this process may involve the use of several drill bits of increasing diameter. The purpose of this hole is to house the implant.
Next, the dental implant is screwed into the hole. The gum is closed back up with sutures.
The bone is given time (roughly between 3 – 6 months) to grow new cells around the implant – a process known as ‘osseointegration’. This ensures the implant cannot move.
Where the treatment is carried out in order to replace essential teeth (either for chewing food or for filling a gap in a smile), temporary teeth may be attached to the implant straight away assuming the implant achieves enough stability- called Primary Stability.
This temporary solution is called early loading and is only intended as a stop gap. Once the bone has fused to the dental implant, the temporary teeth are replaced by the permanent prosthetic teeth.
- Stage 2 – Fitting the prosthetic teeth
Using a variety of methods (including CBCT scanning technology), the dentist will decide when the bone has healed and is ready for second stage surgery (typical expected time frames are 3 – 6 months).
The dentist will make an incision in the gum, exposing the implant site.
Next, a tubular ‘healing cap’ is attached to the head of the implant. The healing cap sits slightly above gum level. The gum is sewn around the healing cap and is given time to heal.
When the healing is complete, the healing cap is removed, leaving a perfectly formed ‘hole’ in the gum that will house and support the prosthetic crown.
A ‘post and core’ – called an abutment – is threaded into the implant and fixed into place.
The abutment protrudes above the gum line and forms the platform onto which the crown is permanently cemented.
What type of anaesthetic is used during the dental implant procedure?
The medical professional tasked with performing the dental implant procedure is best placed to advise patients on the different types of anaesthetic available.
However, common types of anaesthetic that may be used (either as a singular solution or in combination) during the dental implant procedure include:
Local Anaesthetic
Local anaesthetics are used to numb an area of the body. This means that the patient does not lose consciousness.
The effect of the local anaesthetic will become obvious to the patient (in the form of loss of feeling in the area) usually within a few minutes of the anaesthetic having been administered.
A local anaesthetic prevents the nerves in an area of the body from sending signals to the brain.
The patient will not be able to feel pain in the anaesthetised area, but may be able to feel some pressure or the sensation of motion when attempting to move the numbed body part.
The effects of the local anaesthetic will gradually wear off within a few hours. After this time, the patient can expect a return to full bodily sensation in the area.
Conscious Sedation
Conscious sedation differs from a general anaesthetic in that the patient remains awake throughout.
This means that, although the patient is unlikely to be able to recall the surgical procedure in detail, the patient does have the ability to respond to the surgeon during the treatment.
This can be beneficial to the surgeon where the treatment is due to take longer than an hour as the patient may be more easily monitored.
The procedure involves injecting a sedative into a vein. An anaesthetist will monitor the heart rate and blood oxygen levels.
A local anaesthetic is also used at the site of the proposed implant (the patient is unlikely to recall/feel this process, as the sedation from the injection will have already taken hold).
WHAT ARE THE DIFFERENT IMPLANT PROCEDURES
Depending on determining factors such as bone density, bone height, and the area of the mouth in which the implant is to be inserted, different types of implant procedures may be required.
What is a one-stage implant?
As the name suggests, a one stage implant is a type of dental implant procedure that involves only one surgical procedure.
This means that the implant is embedded within the jaw bone and the tooth or the abutment is immediately attached to the implant (the abutment is usually added during a second surgical procedure).
The one-stage implant procedure therefore presents the option of installing a temporary crown right away – under certain circumstances, the permanent crown may be fixed in place.
A one-stage implant is favoured in cases of both cosmetic importance (i.e. to fix a gap in a smile) and where the bone housing the implant will have time to heal without the stress of chewing.
What is a two-stage implant?
The two-stage implant procedure involves two surgical procedures.
First, the dentist will make an incision in the gum to expose the jaw bone. A hole is drilled in the bone, and the implant is torqued into place.
The gum is sutured over the top of the implant, giving the bone time to heal (this can take up to around 3-6 months).
Once the bone has healed around the implant, the dentist will reopen the implant site and introduce the either a healing cap (allowing the gum to form into the desired shape) or the abutment.
The two-stage procedure is more common in cases of non cosmetic importance (i.e. hind teeth) where the bone must be fully healed around the implant so as to cope with the pressure of chewing.
This also means that the two-stage procedure is preferred where bone density is poor, ensuring that the implant is given time to graft to the available bone.
What are same-day implants?
Same day implants are used in cases of multiple tooth loss. Several implants are installed during a single surgical procedure, with the option of attaching a temporary or permanent bridge / denture.
Typically, a permanent bridge will replace a temporary arrangement following a suitable period of healing (i.e. once the bone has healed around the multiple implants).
This type of procedure is favoured in cases of patients who have suffered multiple tooth loss – the singular procedure means that the patient does not need to undergo many individual procedures.
What is an immediate implant?
The dentist may elect to carry out an immediate implant where an unhealthy tooth is scheduled for extraction and the bone density is sufficient to support the implant immediately.
This means that the patient will undergo both the tooth extraction procedure and the initial stage of the dental implant procedure in a single surgical procedure.
This procedure is not recommended where insufficient bone density would result in a poor result (i.e. procedures to increase bone density at the implant site may be required following tooth extraction).
Immediate implant & early loading
The immediate implant and early loading procedure involves removing an unhealthy tooth, embedding the dental implant into the removal site, and fixing in place both the abutment and crown.
This results in the removal of an unhealthy tooth and installing a full implant and crown on the same day.
Factors such as the patient’s general health, oral health, and bone density at the site of the proposed implant will help to determine whether a patient is a suitable candidate for this type of procedure.
Given the potential heightened risk involved with the immediate implant and early loading procedure, the dentist will likely also ascertain whether there is a strong desire for an immediate cosmetic result.
The procedure will only go ahead in cases where the dentist is satisfied that all of the above factors are met.
Dental implant aftercare
The dentist will advise each individual patient on the appropriate dental implant aftercare procedure relevant to the work that has been carried out.
A typical plan of after care will involve regular visits to the dentist or dental hygienist, where the condition of the soft tissue surrounding the implant site will be inspected for signs of potential issues.
The density of the bone will also be monitored to ensure that the graft between the bone and the implant is taking place within expected time frames.
The overall ongoing integrity of the dental implants will also come down to basic oral hygiene on behalf of the patient.
Brushing with a soft bristle toothbrush (or switching to a sonic toothbrush), flossing or using a water flosser, and regularly swilling with mouthwash will likely be advised by the dentist.
