Dental Implants

What Are My Tooth Replacement Options?

If you are missing one or more teeth and choose to have it or them replaced, several treatment options are available.

• A ‘flipper’ is a removable plastic tooth that is inexpensive but fragile and temporary.
• A cast partial denture also is removable but is precision cast in metal for longer service life. Wire clips help hold it in place.
• A fixed bridge is cemented into place using crowns or "caps" on the teeth adjacent to the open space for support. Crown placement usually requires removing or reducing the outer layer of the tooth. In some cases, a ‘Maryland’ bridge, a fixed bridge that does not need crowns, is glued onto the back of the teeth adjacent to the space so that minimal tooth structure is removed.
• Complete dentures or ‘plates’ are the traditional solution for people who have lost all their teeth in one or both jaws. The success of a complete denture depends upon the individual’s jaw size and shape, his or her oral habits, and his or her adaptability. Some people adapt well to dentures, while others are not able to adapt.

Dental implants can be used to provide support for the replacement of one tooth or all of an indivi-dual’s teeth. After years of research and clinical trials, we can now provide this option in addition to the traditional treatments just described. Implant-supported teeth can be cemented, screw-retained, or removable and can be made attractive, stable, and comfortable for almost any patient.

What Is A Dental Implant?

The best way to describe a dental implant is to compare it to a real tooth. A natural tooth consists of a root and a crown. The part of the tooth that you see and eat with is called the crown. Beneath the crown is the root, which anchors the tooth through the gum tissue to the jawbone. When you lose a tooth, you lose both the root and the crown. To replace a tooth, we first have to replace the root. Essentially, a dental implant is a new root. This titanium root is fitted into a socket that we create in your jaw, replacing the lost root of your natural tooth.

Dental implants come in various shapes and sizes and have different types of surfaces. The actual implant selection will depend on a variety of factors related to your specific treatment needs and the most appropriate one(s) will be used. Once an implant has been placed in the jaw, the bone around the implant will need to heal for up to six months, depending upon how hard the bone is. When this initial phase of healing is completed, a support post called an abutment will be placed on the implant itself and then a new crown will be placed on top. If all of your teeth are missing, a variety of treatment options are available to support the replacement teeth.

How Are Dental Implants Placed?

Usually, the office procedure to place a dental implant takes about an hour for one implant and no more than two or three hours for multiple implants. The placement process consists of the following steps:

If indicated, you will be given medication such as antibiotics prior to the surgery. You may be offered sedation with nitrous oxide ("laughing gas") or intravenous medications. Then, a local anesthetic will be administered to numb the areas where the implant(s) will be placed.

• After you are comfortable, a small incision is made into the gum tissue, revealing the bone into which the implant will be placed.
• Using special instruments, a space (socket) is created in the bone into which the implant will be placed.
• The titanium implant is then inserted into the socket.
• Finally, if necessary, sutures will be used.

Once the implant is inserted, it is completed in one of two ways: First, the gum tissue will be closed (or sutured) over the implant, allowing the implant to heal for up to six months. Then a second procedure, called "uncovering surgery," will be performed after a local anesthetic has been used to numb the gum tissue. Next, the gum is moved out of the way, the implant located, and a healing cap placed into it. The gum tissue is then sutured around the healing cap. Generally, after two to four weeks, you will return to have the healing cap removed, the abutment (or support post) placed, and impressions made in order for the final crown (replacement tooth) to be fabricated. This is called a "two-stage" or "two-step" approach to implant placement and is the more traditional approach. For more aesthetically important areas, we may ask that you wait up to 12 weeks to begin the final restorative process. During this time, you will be fitted with temporary teeth. Occasionally, impressions are made at the time the implant is placed in order to have a crown ready when the implants have healed.

After the implant is placed, the area will need to heal for as long as six months. How long your mouth will need to heal will be determined by a variety of factors. Follow-up care (one to four appointments) is usually needed to ensure that your mouth is healing well and to determine when you are ready for the restorative phase of your treatment.

An alternative approach is called the "single-stage" or "one-step approach," in which a healing cap is added at the same time as the implant is placed and the gum tissue is sutured around it. If the entire process occurs during one step, a second surgery to place the healing cap is unnecessary. Because only one surgical appointment usually is all that is needed, both patients and doctors often prefer this approach. However, it is not always the best method for placing implants. We will use the most appropriate approach to meet your particular needs.

On occasion, it may be necessary to perform a "soft tissue graft" to obtain stronger, more easily cleaned and natural appearing "gum" tissue in the area around the implant. This process involves moving a small amount of gum tissue from one part of your mouth to the area around the implant. Most often, it is a brief and relatively comfortable procedure.

When Are The Implants Placed?

Approximately three months after the tooth is removed, the implant is placed where the missing tooth was located. Once a tooth is removed, if your socket walls of bone are intact and fairly thick, your body will grow new bone to replace or refill the empty socket. Your socket will usually be completely filled in with bone by the time you are ready for placement of your implant (about three months later). Occasionally, it is possible to take out the tooth and place the implant at the same time. This may involve a little more risk, but it simplifies the process—you won’t have to wait three months for the bone to refill the socket. Again, there are times when this is appropriate and other times (when infection or other problems with the bone are present) when immediate implant placement is not the best treatment.

If your tooth has been missing for some time, the adjacent bone is likely to grow thinner because the root of the tooth itself has stimulated the bone. Once the tooth root is removed, the bone loses this stimulation and starts to disappear. As much as one third of your jaw’s thickness can be lost in the year following tooth extraction. If you are missing quite a bit of bone, you may need to have additional bone grafted into the area so that the implant will be supported adequately when it is placed.

Do I Have Enough Bone?

Again, if after tooth extraction the walls of the socket are very thick, they will usually fill with bone in three months. However, if the walls of your socket are very thin (such as in your upper and lower front teeth), then this type of healing will not be as predictable. After waiting three months for the bone to fill in, you may have only a very thin ridge of bone. Sometimes, a bone graft is placed at the time of tooth extraction to help your body fill in the socket with bone. This step will maintain the width or volume of bone you will need for implant placement. It is most commonly performed on thin-walled extraction sockets, especially in such visible areas as the front of the mouth.

If your tooth was removed many years ago, then your bony ridge may be extremely thin and you may not have enough bone left for implant placement. In this case, a bone graft can be placed next to the thin bone and allowed to heal for three to nine months. After the graft has fused to your pre-existing bone, the ridge will be re-entered and the implant placed. Usually bone grafting is a relatively comfortable procedure. Many different bone-grafting materials are available, including your own bone.

You also may need bone grafting if the sinus cavities in your upper jaw are very large or very low and extend into the tooth-bearing areas. This often occurs when teeth in the back of a person’s upper jaw have been removed many years before, and the amount of bone available for implant placement is thus limited. This condition requires what is called a "sinus grafting procedure." Most often, it is performed in the office with local anesthesia and perhaps sedation. During this procedure, the membrane that lines the sinus will be located and elevated. Bone will then be added to restore the bone height and ensure that dental implants of an adequate length can be placed. This procedure often can be performed at the time of implant placement.

How Many Implants Do I Need?

Most frequently, one implant per missing tooth is placed. Because many of the larger teeth in the back of your jaws have two or three roots, the most common approach is to replace missing back teeth with larger implants or more than one implant per tooth, especially if there has been moderate bone loss or if there is evidence of excessive biting force.

What If I’m Missing All Of The Teeth In My Lower Jaw?

If you are missing all of the teeth in your lower jaw, you may consider a number of treatment options. Although many patients have no problem wearing an upper denture, some find it difficult to wear lower dentures.

The first option is to have two implants placed in your lower jaw and a denture made that snaps onto these implants. This option allows your lower denture to be more stable while chewing than without implants. This is a viable option if your jaw’s support ridge is big enough. There will still be movement of your lower denture, however, and you can still get sore spots if any food particles, especially seeds, are caught under it. As with all removable replacement teeth, you still will need periodic appointments for denture adjustment.
A second option involves placing four to six implants, depending on your jaw size or shape, into your lower jaw. After healing is complete, the implants are connected with a custom-made support bar. Your denture will be made with special retention clips inside that attach onto the support bar, allowing the denture to snap firmly into place. This is called an "overdenture." The advantage of this option is that it is much more stable than the first option, allowing very little denture movement. Your denture still will be removable for easy cleaning and maintenance.

A third option involves placing five or more implants in your jaw and attaching a permanent denture. Your denture is held in place by screws or clasps that secure it to the support posts or bar. It doesn’t touch the gum tissue, which allows you to clean under the denture without removing it. This denture will replace all your missing lower teeth and will not be removed except at maintenance visits. Although cleaning under your denture without removing it is more time consuming and requires more dexterity, many patients who want a permanent denture prefer this option.

The final option is to have all your teeth individually replaced so that they will appear to be growing out of your gum tissue and will most closely resemble the appearance of your natural teeth. This option usually requires eight or more implants. Separate abutments or support posts for each one of these implants will be made and crowns for each missing tooth will be placed. The teeth are then frequently joined together for strength and support. Overall, this is the most costly option, because (among other reasons) it requires the most implants. In addition, your options may be limited by the current size and shape of your jawbone

What If I’m Missing All Of My Upper Teeth?

A similar range of treatment options is also available for your upper jaw. However, because the bone is not as hard as that in the lower jaw, people often need more implants to support their replacement teeth.

Depending upon the number of implants to be placed, it may be possible to eliminate the need for covering the roof of your mouth with the denture. This option will allow you to better taste your food and to better sense food temperature, and it will make your denture feel more natural. You will still have a removable denture, which makes cleaning the support bar and denture much easier. If you want a restoration that is similar to your natural teeth and therefore not removable, you probably will need eight to ten implants placed. This is followed after healing by the placement of the abutments and crowns.

What Can I Use For Teeth While The Implants Are Healing?

Many options are available, and they are tailored to your specific needs. If you need a replacement tooth while the implants are healing, temporary removable teeth or a temporary bridge can be made. If all your teeth are missing, we can usually modify your present complete denture or make you a new temporary denture. If you would prefer nonremovable teeth during the healing phase, temporary transitional implants usually can be placed along with the permanent implants, and temporary teeth may be made and inserted the same day.

What Are The Potential Problems?

Although it is natural to be concerned about the pain that may be caused by these procedures, most patients do not experience severe or significant postoperative pain. Pain medication and antibiotics will be prescribed for you to make your recovery as easy as possible. Occasionally, some people develop postoperative infections that require additional antibiotic treatment. In addition, there is a chance that the nerve in the lower jaw, which provides sensation to your lower lip and chin, may be affected. If you are missing quite a lot of bone, it might be difficult to place an implant without infringing on the nerve space. Although we take great care to avoid this nerve, occasionally it is irritated during the procedure, resulting in tingling, numbness or a complete lack of sensation in your lip, chin or tongue. Although these altered sensations will usually resolve with time, they can be permanent and/or painful. If you notify us of postoperative numbness as soon as possible, it will allow us to manage your care in the most appropriate way.