Dental Implants

Dental procedure
Overview

Dental implants may be thought of as replacement tooth roots. Although they are available in many shapes and sizes, depending on the specific problem to be solved, by far the most common type in use today is the “root-form” implant. Dental implants are among the most significant advancements in the history of dentistry for their versatility at replacing one tooth, several teeth—even all of the teeth.

Implants are a viable treatment option for most patients, regardless of how many teeth are missing.


Video: Dental Implants

The process
A cover screw for a dental implant.

A cover screw is used to prevent the gums from growing down into the dental implant while it is healing into the jaw.

Before a dental implant is placed, your dentist will review your medical and dental history thoroughly to rule out any contraindications to the procedure. These are discussed more fully below. If you have replacement joints (for example, total knee replacement, hip replacement, etc.), you may be pre-medicated with specific antibiotics for the procedure. If you have certain types of heart murmurs or replacement heart valves, you may also need to take a specific antibiotic pre-medication prior to the procedure. Due to the risks and complications of infections with dental implants, your dentist may place you on antibiotic medication a day or two prior to the procedure, and for a week or so afterwards.

If you are anxious about dental procedures, your dentist may recommend sedating you for the procedure. There are several methods of relaxing patients for dental treatment, including oral anti-anxiety pills; inhaled anti-anxiety medication like nitrous oxide; and intravenous anti-anxiety medication. Your dental plan may not pay benefits toward sedation.

If you decide to be sedated with oral medication (pills), you will arrive at the dentist’s office with some degree of sedation already having taken effect. This may inhibit your ability to understand the “informed consent” paperwork you will be required to read and sign. Therefore, the dentist will likely have you read and sign the paperwork ahead of the surgical appointment. You will be given an opportunity to discuss any questions you may have ahead of time, so that you are not signing consent forms while under the effects of sedation. If you are sedated, you will also be required to have an escort to and from the dental office.

When you arrive at the dentist’s office for placement of the implant(s), you will rinse your mouth thoroughly with an antiseptic rinse, and wash your face with an antibacterial scrub.

If you are to be sedated by a method other than ingestion of a pill, the sedation procedure will be performed next.

Local anesthetic will be given in the area of implant placement, both to numb the surgical area and to minimize bleeding for good visibility of the implant site. Bleeding from an implant surgical site is normally insignificant anyway, but can be reduced even more by the vasoconstricting ingredients found in certain local anesthetics.

Dental implant abutments are fastened to the fixture with a retaining screw.

A prosthetic abutment is used to attach the dental restoration (crown, partial denture, etc.) to the implant. Shown here is an abutment for a single crown. Dental implant abutments (2) are fastened to the fixture with a retaining screw (1). Implants are also available which incorporate the abutment and implant in one solid piece. Two-piece arrangements offer greater flexibility.

With traditional implant surgery, an incision through the gums is generally made, exposing the underlying bone. Implants are currently available which are designed to be placed without the need for an incision, but they are meeting with mixed success. Your dentist will be able to provide more information on such techniques.

A series of successively larger drills are used to establish and enlarge the hole into which the implant is placed. The hole is called the “osteotomy”. Depending on the type of implant being placed, and the density of the bone, a bone tap (thread forming device) may or may not be used to establish threads in the osteotomy. The implant is then inserted into the osteotomy. A “single-stage” implant is one that extends through the gums, and is not covered by them during the healing and osseointegration period (while the implant is fusing to the bone).

A “two-stage” implant (the traditional kind) will have a very thin cover screw inserted into the implant at the time of placement, and the gums will be closed over it with stitches (sutures). The cover screw keeps the gums from growing down into the center of the implant during the healing phase. Several radiographs may be exposed during the surgery, to allow your dentist to visualize the depth and angulation of the implant as it goes into place.

A transparent view showing a dental implant with ceramic abutment restored with a porcelain crown.

A transparent view of a dental implant (1) with a ceramic abutment (2), restored with a porcelain crown (3). Use of ceramic abutments instead of titanium or gold allows a much more natural-appearing translucent porcelain to be used for the finished restoration. The result can be very difficult to distinguish from the natural tooth.

About four to six months after placement into the jaw (depending on the density of the bone and other factors), the implant will be ready to be restored. There are several variations on implant placement that your dentist will discuss with you. When the implant is ready to be restored, it is uncovered, and a temporary crown may be placed on the implant to sculpt the gums to proper shape. Crowns, fixed bridges and removable dentures are attached to implants by means of “abutments.”

Abutments can be made of white ceramic or metal. The abutment is attached to the implant with a retaining screw. Generally, silicone, wax, or other soft compound will be placed in the head of the retaining screw to keep cement from the crown from filling it. Crown cement dries extremely hard, and can be difficult to remove from the retaining screw if this step is not done.

In the case of single tooth replacement, the final crown will generally be made in a lab and cemented onto the abutment. Implant crowns can also be screw-retained, with the advantage of easy retrievability and the possible disadvantages of bulkiness and compromised esthetics. With screw-retained implants, the screw head extends through to the surface of the crown. Your dentist can help you decide which type would work best for you.

Advantages and benefits

Dental implants offer many advantages:

  • They preserve the tooth-bearing (alveolar) bone.
  • They avoid cutting healthy teeth to support fixed bridgework.
  • They prevent drifting of adjacent teeth, preserving the patient’s normal bite.
  • They restore normal chewing function.
  • They can provide excellent cosmetic results.
  • They are not susceptible to tooth decay (caries).
Disadvantages and risks

Time

The biggest disadvantage of dental implants is the amount of time that must elapse from surgical placement to placement of the final dental restoration. Typically three to six months are necessary to allow the implant time to heal (osseointegrate) into the bone, although the timeline can sometimes be reduced. In appropriate cases, an implant may be placed and restored with a temporary crown the same day, with an increased chance of the implant failing in the first two years.

Cost

Cost can be another concern with dental implants, although given their excellent track record for long term success, is usually justifiable.

General risks

Risks of placing dental implants into the jaws include the usual risks of having a surgical procedure accomplished: pain (usually mild), post-operative infection, bleeding, swelling, and bruising. Most people do not experience severe pain, swelling or bruising.

Nerve injury

Depending on where in the jaws the implants are being placed, other risks may include nerve injury, resulting in partial to complete numbness (which may be temporary or permanent) of the tissues innervated by the injured nerve; sensory changes in the lip, chin or tongue; temporary muscle trismus (inability to open your mouth fully) secondary to swelling; jaw joint pain (normally temporary), and poor healing, which may result in loss of the implant. Most of these complications are avoidable by careful treatment planning and appropriate diagnostic imaging.

Dental implant failure

Although the failure rate of dental implants is low, failures do occur. What defines failure may not always be intuitive. The implant itself may break (very small chance) or may integrate into the bone in an un-restorable position. It may also integrate into the bone in a position that would provide non-ideal function or esthetics. Any of these situations may require surgical removal of the implant at a later date. Failure of the implant to integrate into the bone, while unfortunate and inconvenient is typically not complicated to resolve. In most such cases, the implant may be easily removed, the site grafted with bone, and another implant may be attempted (if desired by the patient), either at the time of implant removal, or two to four months later.

In general, two things cause implants to fail: Heavy bite stresses on the implant (especially if the implant(s) is/are placed into function too soon); and infection. Smoking reduces the prognosis for success with implants, mainly because it impairs good circulation that is essential to good healing and immune response. Bruxing (grinding your teeth) reduces the success rate of dental implants. Implants should not be placed in a patient with active periodontal disease. Poorly controlled diabetes and poor general health are two of the few medical contraindications to the placement of dental implants.

Bisphosphonate medication / radiation

If you take bisphosphonate medications, or have undergone radiation to the head or neck, you may not be a good candidate for dental implants without significant medical interventions. However, there are protocols for altering medications, and methods of avoiding jaw bone necrosis secondary to radiation which may allow dental implants to be considered. You should check with your dentist and primary care physician before ruling them out as an option.

Your unique dental and medical situation may introduce other specific risk factors which you should discuss thoroughly with your dentist and/or physician prior to undergoing implant dentistry. It’s important to understand the risks, benefits and consequences of not replacing your teeth before deciding with your dentist on the most appropriate course of treatment.

Other care that may be needed

Additional procedures which you might require if you elect to have dental implants: bone grafting, crowns, dental bridges, Essix appliances, night guards, removable dentures, sedation in dentistry, simple tooth extractions, and surgical tooth extractions.

Other treatment options

Missing teeth (edentulism) is often treatable other ways. Understanding their individual risks and benefits can help you to make the most appropriate choice for treating your unique condition.

What if I do nothing?

Tooth loss is accompanied by loss of tooth supporting bone (bone resorption), shifting of the remaining teeth to a new position, additional bite stress on the remaining teeth, and improper distribution of biting forces. As a consequence the remaining overloaded teeth (particularly those that have been restored) are more susceptible to chipping, cracking, and being lost themselves. Loss of the back (posterior) teeth produces greater force on the temporomandibular joints (jaw joints), and can cause temporomandibular joint dysfunction (TMD).

In the worst case, tooth loss causes bite collapse (loss of vertical dimension of occlusion), collapse of the lower face height, wrinkling of the facial skin, inability to chew properly, poor nutrition, weight loss (or gain, as the diet changes to soft sugary and fatty foods), digestive problems, cosmetic and confidence issues.

Author: Thomas J. Greany, D.D.S. / Editor: Ken Lambrecht

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This page was last updated on September 22, 2016.

Evidence-based information for dentists and dental school students

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Links to dental and medical journals

Intended for dentists and dental students, ToothIQ.com links to additional information from over 100 U.S. and international dental and medical journals. Disclaimer: Full-text articles are linked to, when available. Some links lead to content requiring payment. Symbyos is not compensated by the organizations or authors whose articles are linked to. Symbyos is not responsible for the content linked to from ToothIQ.com.

Information you may wish to read before making a decision on treatment

Delayed Versus Immediate Loading of Implants: Survival Analysis and Risk Factors for Dental Implant Failure
Susarla, Srinivas M., DMD, MPH, et al.
Journal of Oral and Maxillofacial Surgery
2008 66 (2): 251-255

Outcomes of Placing Dental Implants in Patients Taking Oral Bisphosphonates: A Review of 115 Cases
Grant, Bao-Thy, DDS, et al.
Journal of Oral and Maxillofacial Surgery
2008 66 (2): 223-230

A Decision Tree for Bone Graft Success
Smiler, Dennis G., DDS, MSD
Journal of Oral and Maxillofacial Surgery
2007 65 (9): 88

Graft Techniques to Augment the Implant Site—Methods to Minimize Patient Morbidity
Misch, Craig M., DDS, MDS
Journal of Oral and Maxillofacial Surgery
2007 65 (9)

Guidelines for Flapless Surgery
Sclar, Anthony G., DMD
Journal of Oral and Maxillofacial Surgery
2007 65 (7): 20-32

Immediate Implant Loading: Current Status From Available Literature
Avila, Gustavo, DDS, PhD, et al.
The International Journal of Oral Implantology
2007 16 (3): 235-242

Immediate Occlusal Loading of Implants Placed in Fresh Sockets After Tooth Extraction
Crespi, Roberto MD, MS, et al.
The International Journal of Oral & Maxillofacial Implants
2007 22 (6): 955-962

Not All bone Grafts Are Created Equal—What You Need to Know For a Better Outcome
Danek, Sofamor
Back.com web site
Last viewed: 9/23/2010
2007
Editor’s notes: Scholarly article from the orthopedic literature, with relevance to dentistry. © Medtronic, Sofamor Danek 2007.

Oral Implants in Radiated Patients: A Systematic Review
Colella, Ciuseppe, MD, DDS, et al.
The International Journal of Oral & Maxillofacial Implants
2007 22 (4): 616-622

Orthodontic Movement: Preliminary Results with Standard Branemark Implants
Merli, Mauro, MD, DDS, et al.
The International Journal of Periodontics & Restorative Dentistry
2007 27 (1): 43-49

Schneiderian Membrane Perforation Rate During Sinus Elevation Using Piezosurgery: Clinical Results of 100 Consecutive Cases
Wallace, Stephen S. DDS, et al.
The International Journal of Periodontics & Restorative Dentistry
2007 27 (5): 413-419

Socket Grafting: A Predictable Technique For Site Preservation
Jackson, Brian J., DDS and Morcos, Iyad, DDS
Journal of Oral Implantology
2007 33 (6): 353-364

The Effectiveness of Immediate, Early, and Conventional Loading of Dental Implants: A Cochrane Systematic Review of Randomized Controlled Clinical Trials
Esposito, Marco DDS, PhD, et al.
The International Journal of Oral & Maxillofacial Implants
2007 22 (6): 893-904

The use of temporary anchorage devices for molar intrusion
Kravitz, Neal D., DMD, et al.
The Journal of the American Dental Association
2007 138 (1): 56-64

Clinical Failures and Shortfalls of Immediate Implant Procedures
Hurzeler, Markus B., et al
The European Journal of Esthetic Dentistry
2006 1 (2): 128-140

Clinical measurement and evaluation of vertical dimension
Toolson, L. Brian, and Smith, Dale E.
The Journal of Prosthetic Dentistry
2006 95 (5): 335-339

Consensus Conference on Immediate Loading: The Single Tooth and Partial Edentulous Areas
Wang, Hom-Lay, DDS, MSD, et al.
Implant Dentistry—The International Journal of Oral Implantology
2006 15 (4): 324-333

Dental management of patients receiving oral bisphosphonate therapy: Expert panel recommendations
The Journal of the American Dental Association
2006 137 (8): 1144-1150
Notes: Association Report by American Dental Association Council on Scientific Affairs

Grafting of Extraction Sockets: When and How
Misch, Craig M., DDS, MDS
Journal of Oral and Maxillofacial Surgery
2006 64 (9): 8

Maxillary Molar Sinus Floor Intrusion at the Time of Dental Extraction
Jensen, Ole T. DDS, MS, et al.
Journal of Oral and Maxillofacial Surgery
2006 64 (9): 1415-1419

Predictability of Simultaneous Implant Placement in the Severely Atrophic Posterior Maxilla: A 9-Year Longitudinal Experience Study of 2,132 Implants Placed into 731 Human Sinus Grafts
Peleg, Michael, DMD, et al.
The International Journal of Oral & Maxillofacial Implants
2006 21 (1): 94-102

Short Implants – An Analysis of Longitudinal Studies
Domingues das Neves, Flavio, DDS, MS, PhD, et al.
The International Journal of Oral & Maxillofacial Implants
2006 21 (1): 86-93

The ‘mini’-implant has arrived
Christensen, Gordon J., DDS, MSD, PhD
The Journal of the American Dental Association
2006 137 (3): 387-390

Evidence-based considerations for removable prosthodontic and dental implant occlusion: A literature review
Taylor, Thomas D. DDS, MSD, et al.
The Journal of Prosthetic Dentistry
2005 94 (6): 555-560

Failed Root Canals: The Case for Extraction and Immediate Implant Placement
Ruskin, James D., DMD, MD, et al.
Journal of Oral and Maxillofacial Surgery
2005 63 (6): 829-831d

Maxillary sinus and ridge augmentations using a surface-derived autogenous bone graft
Peleg, Michael, DMD, et al.
Journal of Oral and Maxillofacial Surgery
2004 62 (12): 1535-1544

Physiologic vertical dimension and centric relation
Shanahan, Thomas E. J.
The Journal of Prosthetic Dentistry
2004 91 (3): 206-209

Postextraction Tissue Management: A Soft Tissue Punch Technique
Jung, Ronald E., Dr Med Dent, DMD, et al.
The International Journal of Periodontics & Restorative Dentistry
2004 24 (6): 545-553

Strategies for management of single-tooth extraction sites in aesthetic implant therapy
Sclar, Anthony G., DMD
Journal of Oral and Maxillofacial Surgery
2004 62 (9): 90-105

Occlusion-Based Treatment Planning for Complex Dental Restorations: Part 1
Keough, Bernard, DMD, CAGS
The International Journal of Periodontics & Restorative Dentistry
2003 23 (3): 237-247

Occlusion-Based Treatment Planning for Complex Dental Restorations: Part 2
Keough, Bernard, DMD, CAGS
The International Journal of Periodontics & Restorative Dentistry
2003 23 (4): 325-335

Patient Satisfaction with Mandibular Implant Overdentures and Conventional Dentures 6 Months After Delivery
Thomason, J. Mark, BDS, PhD, FDSRCS(Ed), et al.
International Journal of Prosthodontics
2003 16 (5): 467-473

Comparison of 3 bone substitutes in canine extraction sites
Indovina, Anthony Jr., DDS, and Block, Michael S., DMD
Journal of Oral and Maxillofacial Surgery
2002 60 (1): 53-58

Congenitally missing teeth: Orthodontic management in the adolescent patient
Kokich, Vincent O., DMD, MSD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 121 (6): 594-595

Management of patients with trigeminal nerve injuries after mandibular implant placement
Kraut, Richard A., DDS, and Chahal, Omar, DDS
The Journal of the American Dental Association
2002 133 (10): 1351-1354

Prosthetic rehabilitation of extremely worn dentitions: Case reports
Cura, Cenk, DDS, PhD, et al.
Quintessence International
2002 33 (3): 225-230

The effect of bruxism on treatment planning for dental implants
Misch, C.E.
Dentistry Today
2002 21 (9): 76-81

Time to go for the end-game: mandibular 2-implant overdentures for older people (Editorial)
Heath, R.
Gerodontology
2002 19 (1)

Oral Health Impact on Daily Performance in Patients with Implant-Stabilized Overdentures and Patients with Conventional Complete Dentures
Melas, Fotis, DDS, et al.
The International Journal of Oral & Maxillofacial Implants
2001 16 (5)

Predictable peri-implant gingival aesthetics: surgical and prosthodontic rationales
Kois, J.C., and Kan, J.Y.
Practical Procedures in Esthetic Dentistry
2001 13 (9): 691-698

Predictable single-tooth peri-implant esthetics: five diagnostic keys
Kois, J.C.
Compendium of Continuing Education in Dentistry
2001 22 (3): 199-206

The speaking method in measuring vertical dimension
Silverman, Meyer M.
The Journal of Prosthetic Dentistry
2001 85 (5): 427-431

Using the neutral zone to obtain maxillomandibular relationship records for complete denture patients
Alfano, Stephen G., DDS, LCDR, USNR and Leupold, Richard J., DDS, CAPT, USN
The Journal of Prosthetic Dentistry
2001 85 (6): 621-623

Integrated Electromyography of the Masseter on Incremental Opening and Closing with Audio Biofeedback: A Study on Mandibular Posture
Gross, MD, et al.
International Journal of Prosthodontics
1999 12 (5): 419-425

A classification system for loss of papillary height
Nordland, W.P. and Tarnow, D.P.
Journal of Periodontology
1998 69 (10): 1124-1126

Restoration of the Severely Worn Dentition Using a Systematized Approach for a Predictable Prognosis
Stewart
The International Journal of Periodontics & Restorative Dentistry
1998 18 (1): 47-57

The Interproximal height of Bone: A Guidepost to Esthetic Strategies and Soft Tissue Contours in Anterior Tooth Replacement (PDF, 54K)
Salama, Henry, DMD, et al.
The Journal of Practical Periodontics and Aesthetic Dentistry
1998
Notes: PDF of the article originally submitted to The Journal of Practical Periodontics and Aesthetic Dentistry for the Anthology Edition in 1998.

How occlusal forces change in implant patients: A clinical research report
Dario, Lawrence J. DMD, FACP, FICOI
The Journal of the American Dental Association
1995 126 (8): 1130-1133

The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: a systematic approach to the management of extraction site defects
Salama, Henry, DMD / Salama, Maurice, DMD
The International Journal of Periodontics & Restorative Dentistry
1993 13 (4): 313-333

A classification of marginal tissue recession
Miller, P.D., Jr.
The International Journal of Periodontics & Restorative Dentistry
1985 5 (2)

Endocarditis Prophylaxis Information
American Heart Association web site
Last viewed: 9/23/2010

Fabrication of Essix Retainers: A guide to making clear plastic retainers with provisional replacement teeth in them (PDF, 268K)
No author specified
Dentsply Raintree Essix web site
Last viewed: 9/24/2010
Editor’s notes: Manufacturer’s web site

International Congress of Oral Implantologists—Frequently Asked Questions
International Congress of Oral Implantology web site
Last viewed: 9/23/2010
Editor’s notes: Frequently asked questions, and answers are given.

Background information

Centric relation: A historical and contemporary orthodontic perspective
Rinchuse, Donald J., DMD, MS, MDS, PhD and Kandasamy, Sanjivan, BDSc, BScDent, DocClinDen, MOrthRCS
The Journal of the American Dental Association
2006 137 (4): 494-501

Implant Restoration of External Resorption Teeth in the Esthetic Zone
Block, Michael S., DMD and Casadaban, Michael C., DDS, MD
Journal of Oral and Maxillofacial Surgery
2005 63 (11): 1653-1661

Medical-Grade Calcium Sulfate Hemihydrate (Surgiplaster) in Healing of a Human Extraction Socket—Histologic Observation at 3 Months: A Case Report
Guarnieri, Renzo, MD, DDS, et al.
The International Journal of Oral & Maxillofacial Implants
2005 20 (4): 636-641

Human mineralized bone in extraction sites before implant placement: Preliminary results
Block, Michael S., DMD, et al.
The Journal of the American Dental Association
2002 133 (12): 1631-1638

Orthodontic anchorage with specific fixtures: Related study analysis
Favero, L., MD, DDS, MS et al.
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (1): 84-94

Periodontic and orthodontic treatment in adults
Ong, Marianne M.A., BDS, MS and Wang, Hom-Lay, DDS, MSD
American Journal of Orthodontics & Dentofacial Orthopedics
2002 122 (4): 420-428

Bone and Soft Tissue Integration to Titanium Implants with Different Surface Topography: An Experimental Study in the Dog
Ingemar Abrahamsson, DDS, PhD, Nicola U. Zitzmann, DDS, et.al
The International Journal of Oral & Maxillofacial Implants
2001 16: 323-332

The Palatal Subepithelial Connective Tissue Flap Method for Soft Tissue Management to Cover Maxillary Defects: A Clinical Report
Houry, Fouad, Prof Dr Med Dent, PhD, DDS and Happe, Arndt, Rd Med Dent, DDS
The International Journal of Oral & Maxillofacial Implants
2000 15 (3): 415-418

Restoring Lost Vertical Dimension of Occlusion Using Dental Implants: A Clinical Report
Balshi / Wolfinger
International Journal of Prosthodontics
1996 9 (5): 473-478

Forces and moments on Branemark implants
Rangert, B., et al.
The International Journal of Oral & Maxillofacial Implants
1989 4 (3): 241-248

Dental Implants
American Association of Oral and Maxillofacial Surgeons web site
Last viewed: 9/23/2010
Editor’s notes: A useful link to the dental implants area of the American Academy of Oral and Maxillofacial Surgery web site.

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