What are Dental Implants?
Dental implants are tooth root shaped titanium devices, which are placed into the bone once occupied by a tooth. Once positioned, under sterile conditions at the practice, bone fuses to the implant surface in a process known as osseointegration. The procedure is carried out under local anaesthetic and although some soreness afterwards can be expected, this is usually minimal.
Once integrated a healthy implant can virtually be considered as permanent. At this stage, which can be anything from six weeks to six months after the implant is placed, it is uncovered and a special post called an abutment is attached. A porcelain crown or bridge can then be made for the post and subsequently cemented into position. In some situations a post and provisional crown can be attached to the implant at the time of the surgery.
The main advantages of dental implants are that if kept healthy they are permanent and the adjacent teeth are not touched in any way. Dental implant treatment is extremely predictable with success rates in excess of 95% and is now seen as the ideal solution and first choice for replacing missing teeth.
The 3 phases for dental implant treatment are as follows: -
Phase I - Diagnosis and treatment planning
Our first task at the consultation is to try to understand the nature of your problem and to decide if this can be managed with implants. We consider the possible alternatives, your medical and oral health, and begin to form an outline proposal for treatment. We can be clear about potential costs at this stage - no nasty surprises down the line.
If you decide that implants are for you we may carry out further diagnostic procedures at this stage - models, further x-rays, CT scans and photographs can be taken of your mouth to assist with our diagnosis and second stage consultation, and it also allows the technician to get involved in your case, and to make a surgical guide template if one is needed. The template shows us the ideal positions of the proposed dental implants during surgery, but may not be necessary for simple placements.
Our laboratory can also make wax mockups of the ideal teeth shape for the final crowns, which can be used at the consultation for diagnosis of your appearance and to make provisional restorations.
Phase II - Implant Surgery
The dental implants are placed very carefully into the appropriate positions as planned. The procedure is carried out under local anaesthetic under strict sterile conditions.
Healing is rapid and any swelling, discomfort or pain is usually minimal and easily managed with over-the-counter painkillers. You will be provided with everything you need at the implant surgery appointment.
Phase III - Implant Restoration
Depending on how the implant has been left, buried in the gum or protruding through, the next stage involves exposing the implant and fitting a special attachment, which enables us to take accurate impressions of the implant position. This may involve exposing the implant with a second minor surgical procedure, with impressions being taken after a further short period for the gum to heal, usually 2-3 weeks.
We then have the restoration made and posts (abutments) connected. We can fit transitional, temporary crowns or healing abutments at this visit, which help the gum ‘heal’ into the ideal position.
The definitive porcelain crowns are cemented (or screwed) into place, after a try-in to check the colour, shape and fit.
What are the Surgery stages?
Although implants are usually used to replace missing teeth we frequently use them to replace a tooth that is diseased or damaged. This introduces two important variables in the surgical process that have a direct bearing on the timing of the treatment which then takes place over two, three or sometimes four stages.
Despite all the available diagnostic tools and procedures it is impossible to predict with absolute certainty how surgery will proceed. Everybody and every case is different, and sometimes we find situations at the surgery site that dictate a change in approach, and by implication, the timing for our plan.
Fortunately this usually only leads to a slight delay in the plan which will be fully explained, but it is important to respond to findings appropriately, and if it’s not possible to place the implant, for example if we find infected material at the implant site, it is better to deal with the complication and delay the implant than insert the implant into a compromised site.
Possible surgical options are as follows:
What are Biomaterials?
On occasions we use biomaterials to boost bone volume around an implant site. These materials can also ‘plump’ out soft tissue to create a more natural appearance of the gum and the crown.
We use bone substitute materials of bovine origin (Bio-Oss), which are gradually replaced by your own bone over a period of time, and on occasion we may need to protect this with a porcine derived collagen membrane (Bio-Gide), which is used to cover and protect the graft materials during healing.
Use of these biomaterials is supported by many long-term studies where they have proved to be reliable for repairing or filling small defects in bone. If you have any objection to their being used please let us know, but we will discuss them further if it becomes likely that some use will be required.
What are the Benefits and Risks of Treatment?
As well as the benefits, we have discussed the risks that are associated with this treatment. You should be aware that on occasion an implant may fail. There is a risk of failure of approximately 1% to 5% depending on specific circumstances. Generally an implant can be replaced should it fail but occasionally additional or alternative procedures may be necessary.
An implant can fail at any time, immediately after surgery, or later when it has been restored. The reasons for failure are not always clear, but it is usually possible to correct the problem by removing the implant and starting again after a period of healing.
There is also a risk of accidental damage to adjacent anatomic structures, such as teeth, nerves and sinus spaces, although with accurate planning this should be avoidable. There is a very low risk of failure of implants after the first year in function as long as your health, both general and around the implant is maintained and no excessive forces are exerted. Excessive forces may result in some of the component parts fracturing.
You should also be aware that implants and teeth are subject to normal wear and tear as time goes on and, depending upon the amount of wear, the need to replace the crown may arise.
There is a risk of gum recession around the implants. Although this may not affect its survival it may require additional hygiene treatments or treatment for aesthetic reasons.
The day of surgery - what can I expect?
On the day you are having your implant placement you will be given a time to arrive at the practice. This won’t be when you go into the surgery, but will allow time for you to take your antibiotics and relax ahead of the surgery. We will be busy preparing the surgery and equipment for the appointment.
On entering the surgery you will notice the difference immediately - the equipment and preparation for sterile working are completely different to normal dental surgery, and once we get you numb we will all be gowned up to maintain a sterile working environment.
For your part you will be asked to rinse with an antiseptic before we start and you will have a sterile drape placed over you that will keep the area clean and tidy.
Implant surgery - how is it done?
The surgery itself involves raising a small flap of gum to expose the implant site. Then by using drills of increasing size the hole into which the implant will go will be formed. Once we are happy with the alignment and depth of the hole an implant of matching size will be selected and placed. The final tightening involves using a hand wrench that makes a bit of noise and pressure, but is done to ensure precise placement and orientation of the fitting surface of the implant.
Once placed we make the decision on how to cap the implant off - usually achieved with a healing stud (a bit like after having an ear pierced), which we call a healing abutment. The gum is then closed with sutures around the stud.
Healing of the bone normally takes 3-4 months after which the implant becomes integrated with the bone. If we have placed any bone chips (Bio-Oss) this will have been replaced by immature bone by this stage.
Once the implant is integrated with the bone we can then proceed with the final restoration.
Surgery Aftercare - what will I need to do?
When the surgery is completed you will still be numb, and may be so for 1-3 hours. Our concerns at this stage are to allow things to settle undisturbed. We need the formation of good healthy blood clot and for none of this to be disturbed or washed away.
We ask you to observe these simple rules:
The review appointment
Someone from the surgery call you the day after surgery to check all is well, and we will see you after a week to remove your sutures. You will the have an appointment to review progress at 6 weeks, and the second at 12 weeks, when impressions will be taken to start the final restoration process.
The final restoration
The range of restorations is vast depending on the case, but the procedure for this stage is roughly the same either way.
First, the healing abutment is unscrewed exposing the head of the implant. Next, an impression abutment is screwed into place and an impression is taken over it - the impression abutment duplicates the fit surface of the implant in the impression and allows precise location of the restoration in the gum.
The technician pours the model in plaster and creates the final restoration.
Do I need to take Antibiotics?
It is generally accepted and standard protocol that antibiotics should be taken before implant surgery to reduce the potential for infection at the implant site. The usual antibiotic of choice is amoxicillin, taken as a drink just before the operation. For anyone who is allergic or has a problem with amoxycillin we give clindamycin. Clindamycin has to be taken as a few tablets as it is not available in powder form.
The second and final dose of antibiotic is taken 8 hours after the first.
For those few individuals who refuse to take an antibiotic we regret to say that we cannot cover the implant with our usual guarantee. The risk of implant failure is very low but if antibiotics are declined and failure occurs for any reason a charge will be made for any repeat treatment.
Do I need Sedation?
For most implant procedures the treatment is no more difficult to tolerate than having a filling. The procedure is carried out under local anaesthetic, and apart from feeling some vibration from the drill and some pressure during the placement, the procedure it is quite comfortable.
For anyone who remains anxious about the procedure, you can ask your GP about oral sedatives - a dose of 30mg temazepam the night before to help with sleep and a further 30mg 1 hour before surgery is usually sufficient to take the edge off any nerves and allow the surgery to go ahead without difficulty. You cannot drive after oral sedation and we ask that you bear this in mind when making arrangements for the day.
We also offer a full intravenous sedation service, and if this is the only way this treatment could be acceptable to you. You will be advised of any associated costs and precautions if this is the case.
What maintenance will my implant need?
As you should now be aware it is essential that the implants are monitored and maintained after completion of treatment.
After the initial period it is recommended that you attend the practice at regular intervals for examinations and maintenance.
You will need to maintain a high standard of hygiene around the implants and, if necessary and recommended, see our hygienist every three months. (All treatment plans exclude costs for hygiene and annual review appointments).
Implant restorative treatment at the practice is guaranteed for a period of five years but only if recommended maintenance appointments are attended.
Are there any medical problems that affect implant treatments?
There is some evidence in the literature and scientific studies that smoking increases the risk of implant failure. The risk increases by about 3 times, but is still relatively low. As long as the gum condition is good we can proceed.
Medication - Bisphosphonates
These drugs affect bone metabolism and are used to treat osteoporosis and other conditions. If there is any doubt about the risk of treatment we will recommend an alternative course of treatment for you.
Medication - Steroids
Long-term steroids can affect the healing and immune response in patients, but are not an absolute contra-indication to implant treatment. They can also affect bone, and that may have a bearing on healing times and loading considerations.
Medication - Anti-coagulants
Aspirin 75mg daily dose is not a problem, and warfarin is also not a problem as long as the INR is below 3.0. We may need to see your INR records if you are on warfarin, so please bring them with you.
Diabetes - Type 1
As long as the glycaemic control is good and gum health is good, then implants can be done with caution.
Diabetes - Type 2
As with Type 1 - as long as the gum health is good and the diabetes is being controlled well, implants can be done with few complications.
In order to be confident about the success of implants good gum health is very important. Although the connection between an implant and bone is different to that between teeth and bone, implants can suffer from poor oral hygiene and develop inflammation. This results in bone loss around the implant, and while this might not result in failure of the implant it can become unsightly, especially if towards the front of the mouth.
An assessment of the gum condition will be made as part of the consultation process for implant treatment, and we may recommend treatment with our hygienist ahead of confirming suitability for treatment.
Fees and Finance
As you are aware the fees for implant treatments are relatively high, due in large part to the cost of the implants, components and laboratory charges. Our estimates are provided for you giving as much information as possible. As you will appreciate the findings at the time of operation can force decisions that affect costs - such as with the use of biomaterials. Where this is anticipated you will be advised accordingly.
Just as the implant treatment is staged, so will be the payments due for your treatment. Please refer to the estimate and payment schedule provided with details of the fees.
Due to the high cost of components and laboratory work for the surgery and restoration stages we ask that you make arrangements to settle your account on or before the day of your surgery and restoration fitting appointments.
This will be confirmed to you closer to the date, and your co-operation with this is much appreciated.
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