Dental Implants



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What Are Implants?

Implants are devices that replace the roots of missing teeth. They are used to support crownsbridges ordentures. Implants are surgically placed in your jawbone. Most of the time, implants feel more natural and secure than other methods of replacing missing teeth, such as dentures.

There are many reasons it's important to replace missing teeth:

  • Having all of your teeth can make you more self-confident. You don't worry that people notice that you have teeth missing.
  • When teeth are lost, the area of the jawbone that held those teeth starts to dissolve. Over time, you can lose a great deal of bone. Then, you may need a bone graft to build up your jawbone before your dentist can place implants or make a denture that fits properly.
  • Tooth loss affects how well you chew and what foods you are able to eat. Many people who have missing teeth have poor nutrition, which can affect overall health.
  • The loss of teeth can change your bite, the way your teeth come together. Changes in your bite can lead to problems with your jaw joint, called the temporomandibular joint.
  • Losing teeth can lead to changes in your speech. This also can affect your self-confidence.

There are several types of implants, including:

  • Root form
  • Subperiosteal
  • Mini

Root-form implants are the most common type used today. A root-form implant is made of titanium. It looks like a small cylinder or screw. After an implant is placed in the jawbone, a metal cylinder called an abutment eventually is attached to it. The abutment serves as a base for a crowndenture or bridge.

The key to the success of all implants is a process called osseointegration. This is how the bone in the jaw grows into and around the implant. Titanium is a special material that the jawbone accepts as part of the body.

The ability of titanium to fuse with bone was discovered by accident. In 1952, a scientist named Per-Ingvar Brånemark was using titanium chambers screwed into bones as part of his research. He was trying to learn about how bone healed after an injury. When he tried to remove the titanium chambers, he found they had become integrated with the bone.

Dr. Brånemark then did further research into how titanium implants might work. In 1965, the first root-form implants were placed in people. Other types of implants also have been used for the last 30 to 40 years. Many implant systems are available from various dental manufacturers.


Studies indicate that surgical placement of root-form implants is successful more than 90% of the time. When these implants fail, the problems usually occur within the first year after surgery. After that, only about 1% of all implants fail each year.

Implants have become increasingly popular since the American Dental Association (ADA) endorsed them in 1986. Between 1986 and 1999, the number of implant procedures tripled. An ADA survey found that the average number of implants placed by a dentist who does the procedure was 56 per year in 1999, compared with 18 in 1986.

It is now estimated that more than half a million implants are placed every year in the United States.

Implants vs. Alternatives

Depending on your particular problem, implants can be more expensive than the alternatives (denture or bridge). A basic implant plus a crown can cost between $2,000 and $5,000. The fees will depend on many factors and vary considerably. Only a few insurance companies cover this cost. You should always check with your insurer.

The upfront cost for implants can be more than for other types of restorations. But the investment can pay off in the long run. You may not need an implant for every missing tooth. Your dentist can discuss how many implants you will need.

Other benefits of implants include:

  • Feel — Because implants are imbedded in your bone, they feel more like your natural teeth than dentures.
  • Convenience — You will not need to worry about denture adhesives or having your dentures slip, click or fall out when you speak.
  • Nutrition — You may be able to chew better with implants. Chewing can be difficult with regular dentures, especially ones that don't fit perfectly. A regular upper denture also covers your palate, which can reduce your sense of taste.
  • Self-esteem — Because implants are so much like your natural teeth, you will think about them less. Your self-esteem and confidence will be improved because you will not have to worry about denture problems or people noticing that you have missing teeth. Regular dentures also can affect your speech. This can make you less self-confident when talking.

Who Is an Implant Candidate?

If you're interested in replacing a missing tooth or teeth, dental implants may be an option for you. Most people are good candidates for implants. A good candidate should have the following:

  • Healthy gums
  • Enough bone to anchor the implants in the jaw — Some people who have lost bone in their jaw still can get implants, but first the bone must be rebuilt using special procedures.
  • A commitment to taking very good care of the implanted teeth and surrounding gums — Dailybrushing and flossing are essential. Regular visits to the dentist for follow-up are also important.

Some people may not be good candidates for implants. They include:

  • Young people whose jawbones have not stopped growing
  • Pregnant women
  • Heavy smokers — Smoking hinders healing in the mouth. It can reduce the likelihood of a successful implant.
  • Alcohol or substance abusers who are not prepared to follow the dentist's instructions after placement of the implant, such as no smoking, and returning for follow-up. They also may be less likely to take good care of their teeth and gums, including the new crown over the implant.
  • People who have received high-dose radiation treatment of the head or neck
  • People with chronic diseases or systemic problems, including:
    • Uncontrolled diabetes
    • Connective-tissue diseases
    • Hemophilia
    • Significant immune deficiencies
    You still may be a good candidate for implants even if you have one of these conditions. It depends on the extent and severity of the condition.
  • People who take certain medicines, such as steroids or drugs that suppress the immune system
  • People who severely grind or clench their teeth — These habits can place too much pressure on the implants and increase the risk of failure.

Your dentist can evaluate you to see if you would be a good candidate for implants.

Being Evaluated

Implant therapy involves a team. A dental specialist places the implant or implants. This is usually an oral surgeon or a periodontist. Then a restorative dentist takes over. This is usually a general dentist or prosthodontist. The restorative dentist will make the crownsbridges or dentures that the implant or implants will support.

Your first step is to make an appointment with one of these professionals for an evaluation. He or she will coordinate your treatment with the other members of the implant team.

Your initial evaluation will include an examination of your mouth and teeth and a thorough review of your medical and dental histories. Your mouth will be X-rayed. You might also have a computed tomography (CT) scan. This will provide information on the amount of bone in your jaw and its shape and where the nerves and sinuses are.

Finally, you and your dentist will discuss the options available to you. You will talk about the procedure, and its cost and possible complications. Your dentist will work with you to develop a treatment plan for your needs and preferences.

Types of Implants

Today, most dental implants are made of titanium. This metal has special qualities that make it useful for implants.

Titanium develops a thin film on its surface that protects it from corrosion. It is resistant to acids, salt solutions and oxygen, among other things. Titanium also is almost completely nonmagnetic. It is extremely strong for its weight.

Perhaps most important, the body does not reject titanium implants as foreign objects. When implants are placed in bone, the bone grows around the implant. The process is called osseointegration.

Titanium implants come with many types of surfaces. The surface is altered to improve the likelihood of osseointegration. The methods used to alter the surface include:

  • Acid etching
  • Sandblasting
  • Plasma spraying
  • Treatment with a laser

There are several types of implants. Root-form implants are by far the most popular. Subperiosteal implants and mini-implants are also used. Blade-form and Ramus-frame implants are used rarely.

Your dentist decides which type of implant to use based on the quality of the bone in your jaw and the type ofcrownbridge or denture that will be placed on the implant.

Root-Form Implant

Root-form implants are called endosseous or endosteal implants. This means that they are placed in the bone. They look like screws, thick nails or cones, and come in various widths and lengths. A metal cylinder called an abutment is attached to the implant once it's solidly integrated into the jawbone. The abutment serves as a base for a crowndenture or bridge. For root-form implants to be successful, the bone needs to be deep enough and wide enough to provide a secure foundation.

Root-form implants can be inserted in two stages or one stage. The two-stage process is the traditional way. In this procedure, the implant is "buried" under the gum tissue in bone for three to four months. Then it is exposed during a second surgical procedure. In a single-stage procedure, the implant is placed in the bone and remains exposed in the mouth.

Subperiosteal Implant

The subperiosteal implant may be used only in the lower jaw when you have no lower teeth and don't have enough bone for root-form implants. The subperiosteal implant is a custom-made metal frame that sits precisely on top of the bone, but under the gums. The frame includes metal spokes (abutments) that push through the gums into the mouth.

The first stage of making the implant is to make a model of your jaw. This is done in one of two ways. Sometimes an impression is taken of the bone after the tissue has been cut open. In other cases, the model is based on a computed tomography (CT) scan of the jaw. A dental lab will then use the model to make the implant.

At your second visit, the jawbone is exposed and the subperiosteal implant is placed. The tissue is stitched closed and the overdenture is temporarily cemented onto the protruding frame. The stitches can be easily removed a week later, since the overdenture does not usually sit directly on the gum. This overdenture can be either a series of crowns all connected (bridge) or a framework with acrylic and teeth (denture). It may remain temporarily cemented so the dentist can always adjust it.


These small implants are usually about 2 millimeters in diameter. This is almost half the size of many traditional root-form implants. Mini-implants consist of only one piece.that screws into the bone and also extends above the gum line. They are placed in the same way as larger root-form implants. Crowns are often seated over the mini-implant right away. People often can walk out of the office and have functional, normal-looking teeth right after they are placed.

This type of implant can be used for small teeth, front teeth, pre-molars or missing teeth that are located in a narrow area. They also can be used to stabilize lower-jaw dentures. They are sometimes used when there is too little bone to place a larger implant. They also can be placed temporarily next to full-size implants. The mini-implants can hold crowns so it's possible to chew while waiting for the full-size implants to become integrated with the bone. Once this occurs, the mini-implants are removed and crowns are placed on the full-size implants.

Placing Dental Implants

When you get implants, more than one dental professional may treat you. An oral surgeon or a periodontist will place the implants in your jawbone. A prosthodontist or general dentist will make your crownsbridges ordentures, which will look like natural teeth. The dental specialist who places your implants will coordinate your treatment with your general dentist or prosthodontist. He or she will decide what implants to use, how many you need and where they should be placed.

There are different types and manufacturers of implant devices. Therefore, the approach your dentists use may differ from the description presented here. The following describes the steps that a dentist typically takes when placing an implant.

Before Placing an Implant

Most people are good candidates to get dental implants. You must have enough bone in your jaw to allow an implant to be placed in the jawbone. You should be free of periodontal disease. Implants are not recommended for:

  • Smokers
  • People who have autoimmune diseases or take medicines used for these conditions
  • People who have had radiation therapy to the head and neck
  • People with uncontrolled diabetes

A dental professional will examine you and determine if you are suitable to get implants.

Some people want implants to replace teeth that have been missing for years. Others may need implants to replace teeth that were extracted recently because of severe decayperiodontal (gum) disease, infection or injury. In some cases, the teeth can be extracted and the implant placed at the same time. However, if you have a severe infection in a tooth root or your gums, your dentist may wait a few months after removing the teeth to allow the area to heal.

If you do not have enough bone to support an implant, you may be able to have the bone in the area built up. This is a common procedure called bone grafting or augmentation. If a bone graft is done, you will need 4 to 12 months to heal before having the implants placed in your jawbone. You can wear dentures or a bridge during this time, so you won't be without teeth.

Placing the Implants

Most implants are placed using a two-step process, although some newer implants can be placed in one step. What follows, is a description of how the two-step process works.

First surgery 

You may be given antibiotics and pain medicine to take before the surgery. Your dentist will use local anesthesiafor the procedure and will offer you sedation if you want it. You can be sedated by taking medicine by mouth, or through an intravenous line. This is a needle attached to a small tube placed in a vein in your arm.

To place the implants, the surgeon first will make an incision (cut) in your gums to expose the bone. He or she then will drill a hole in the bone and place the implant in the hole. The surgeon probably will take an X-ray of the area to make sure the implant is where it should be. The surgeon will then stitch your gum closed over the implant.

The time required for this procedure depends on:

  • The number of implants
  • Whether or not you get a bone graft at the same time

In most cases, placing a single dental implant requires about one hour. You will feel some pain after this procedure. The level of discomfort depends on the person, but generally it has been described as relatively mild.

If the implant is placed in the front of your mouth, your dentist will give you a temporary denture or bridge so that you do not have to be without teeth. He or she will discuss options with you before the surgery.

After the surgery, your surgeon will give you antibiotics and pain medicine. You also will get instructions to follow. These will include:

  • Don't spit, suck on straws or smoke. This can dislodge blood clots and slow healing.
  • Eat only soft food to avoid injuring your gums.
  • Don't try to clean the implant area for the next one to two weeks, but clean the rest of your mouth normally. Your dentist may give you an antibacterial rinse to help keep the area clean.

You will return to the surgeon 7 to 10 days later to have your stitches removed.

After the implant is placed in your jaw, you will have to wait several months for the bone to bond with the implant. This usually takes 3 or 4 months in the lower jaw and 5 or 6 months in the upper jaw. During this time, the head of the implant usually remains hidden under your gum.

Second surgery 
After the implants have integrated with (attached to) the surrounding bone, you are ready for the second surgery. After giving you local anesthesia, your surgeon will make a small cut in the gum. This exposes the implant. This surgeon will remove a protective screw from the implant and replace it with a metal healing cap (collar). The healing cap looks like a small metal cylinder that sits above your gums in the area where your tooth would be. It maintains the space so that the gum heals correctly around the implant.

In a very small percentage of cases, the implants will not successfully integrate with the bone. If this happens, your dentist can do one of the following:

  • Remove the implants and immediately replace them with slightly wider ones.
  • Remove them and allow the area to heal for several months before making a second attempt.

Some dentists are now using one-stage implants. These implants are placed in the jaw and remain exposed in the mouth so that no second surgery is needed.

Generally, you will go to your dentist or prosthodontist two or three weeks after the second surgery to start the process of having your crown, bridge or denture made.

Complications From Surgery

Any surgery carries the possibility of complications. Problems that can occur with implant surgery include:

  • Bleeding
  • Infection
  • Injury to nerves, sinuses (located above your upper teeth) or the nasal cavity

When implants are used to replace lower teeth, your dentist could nick the nerve that runs through the jawbone during drilling. This can cause pain or numbness. If numbness occurs, it usually affects the lower part of the lip and chin or one side of the tongue. It can last for several months until the nerve heals. In some cases, it may be permanent.

In the upper jaw, there is the possibility of drilling through the jawbone into one of your sinuses or nasal cavity. This could result in an infection. To avoid this, special X-rays are taken before your surgery to help the surgeon determine where the nerves, sinuses and nasal cavity are located.

Implant Failure

Implant surgery is successful more than 90% of the time.

Occasionally, an implant fails to integrate with the surrounding bone. This is usually discovered at the second stage surgery when the implant is uncovered and the surgeon finds it is loose. In this case, the "failed" implant has to be removed. Another implant can be placed either immediately or at a later visit.

Sometimes implants fail to integrate with surrounding bone after the first stage of surgery. Potential reasons include:

  • Surgical trauma
  • Infection around the implant
  • Smoking — This appears to decrease blood flow to the healing gums and bone, which could interfere with the bonding process.
  • Lack of healthy bone — If there is not enough bone for the implant to remain stable, the implant may move around within the bone and integration will not occur.
  • Titanium allergies — These are extremely rare.
  • Excessive or uneven force on the implants because of the way the teeth come together during chewing and speaking (the bite).

Problems also can develop years after implants are placed. For example, just like natural teeth and gum tissue, the gum around implants can become infected by bacteria. This leads to a form of periodontal disease called periimplantitis. If left untreated, this condition can cause bone loss. Then the implant can become loose and have to be removed. Generally, this situation can be treated in a way very similar to treatments for periodontal disease affecting natural teeth.

Another type of complication that can happen over time is breakage. Either the implant or the implant-supported restoration (crown, bridge or denture) can break. This usually happens if your bite (the way your teeth come together) is not aligned properly. If your bite is off, too much force might be placed on the restoration or implant. Broken restorations often can be repaired. However, a fractured implant has to be removed.

A implant that breaks or fails because of an infection can be replaced with a new implant.

Single-Tooth Implants

When Is This Used?

Single-tooth implants can be used in people who are missing one or more teeth. An implant is surgically placed in an opening that your dentist makes in the jawbone. After the implant integrates (attaches) to your bone, it acts as a new "root" for the crown that will replace your missing tooth. A crown (cap), which is made to look like a natural tooth, is attached to the implant and fills the space left in the mouth by the missing tooth.

For this procedure to work, there must be enough bone in the jaw. The bone has to be strong enough to hold and support the implant. If there is not enough bone, it may need to be added with a procedure called bone augmentation. In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health.

How Does It Work?

An implant-restored tooth consists of several parts.

The implant, which is made of titanium, is placed in the upper or lower jawbone.

The abutment can be made of titanium, gold or porcelain. It is attached to the implant with a screw. This part connects the implant to the crown. It is shaped like a natural tooth that has been cut down to receive a crown.

The restoration (the part that looks like a tooth) is a crown. It usually is made of porcelain fused to a metal alloy (PFM). It also can be all metal or all porcelain. The crown is screwed or cemented onto the abutment. If the crown is screwed to the abutment, the screw hole will be covered with restorative material such as tooth-colored filling material (composite).

The Implant Process

The time frame for completing the implant and crown depends on many factors. When the traditional method of placing an implant is used, the shortest time frame for a complete implant is about five months in the lower jaw and six months in the upper jaw. This includes surgeries and placing the permanent crown. However, the process can last a year or more, particularly if bone needs to be built up first.

In the traditional method, two surgeries are required, with three to six months between them. During the first surgery, an incision is made in the gum where the implant will be placed. A hole is drilled in the bone, the implant is placed into the hole in the bone, and the incision is stitched closed.

At the end of the healing period, a second surgery takes place. It involves making a new incision to expose the implant. A collar, called a healing cap, is screwed onto the top of the implant. It helps the surrounding gum tissue to heal. After a few weeks, the healing cap is removed. The abutment is screwed into the implant and used to support the crown.

A one-stage procedure is now used sometimes for implants. In this procedure, your dentist can place the implants, abutments and a temporary crown or bridge all in one visit.

Initial consultation 
Before any work is done, you will visit either a specialist called a prosthodontist or a general dentist who has had advanced training in the placement and restoration of implants.

Your dentist will do a comprehensive examination. During the exam, he or she will review your medical and dental history, take X-rays, and create impressions of your teeth and gums so that models can be made. In some cases, the dentist also may order a computed tomography (CT) scan of your mouth. This scan will help your dentist determine how much jawbone is available to hold the implants in place. It also will show the location of structures such as nerves and sinuses (located above your upper teeth) so they can be avoided during surgery.

If the X-rays show that your jaw does not have enough bone to hold an implant, the dentist can discuss options for building up the bone. These may include bone grafting or bone distraction. Grafting involves taking bone from another source and adding it to your jaw. A graft could be your own bone, from your mouth, chin or hip. Processed cadaver bone or cow bone also can be used. Bone distraction is a surgical procedure at the site where more bone is needed. It causes the body to grow more bone by slowly pulling apart the existing bone using pins and screws.

If you need one of these procedures, it will take about 4 to 12 months for the bone to be ready for the implant.

First surgery - implant placement 
Month 1 (if no bone grafting is necessary) 
Month 5 (if bone grafting is necessary)

Once you have enough bone to successfully hold an implant, you will schedule the first surgery, which involves placing the implant or implants in your jaw. A periodontist or an oral surgeon usually does this surgery, and uses a plastic surgical guide made by your prosthodontist or general dentist. A surgical guide fits over your existing teeth and extends over the area where teeth are missing to show where the implants need to be placed.

Although there are several types of implants, the most popular type is a root-form implant designed to serve as the root of the tooth. The implant is placed in the jawbone in the space created by the missing tooth.

After the first surgery, the specialist will wait four or five months if implants were placed in the lower jaw, and six or seven months if they were placed in the upper jaw. During this time, the bone and the implants fuse.

Second surgery and placement of healing collar and/or temporary crown 
Month 4 or 5 (no bone grafting, lower jaw) 
Month 6 or 7 (no bone grafting, upper jaw) 
Month 8 or 9 (bone grafting, lower jaw) 
Month 10 or 11 (bone grafting, upper jaw)

Once the implants have become fused with the bone, you can schedule the second surgery. Your dentist will confirm whether the implant is ready for the second surgery by taking an X-ray. This surgery is simpler than the first. A new incision is made to expose the heads (tops) of the implants.

A collar, called a healing cap, is placed on the head of the implant after it is exposed. This guides the gum tissue to heal correctly. The collar is a round piece of metal that holds the gum away from the head of the implant. The collar will be in place for 10 to 14 days. If you previously had a removable partial denture, your dentist may adjust it so you can use it during this time.

After the stitches and collar are removed, final impressions are made of the abutments for each tooth. These impressions will be used to make models that will look exactly like your mouth. A dental technician will use these models to make the temporary and final crowns.

An abutment and temporary crown are placed on the implant. (C) The abutment is screwed onto the implant and tightened, using special equipment so that it won't come loose. After the abutment is attached to the implant, the temporary crown is placed on the abutment. In some cases, you may get the abutment and temporary crown immediately after the implants are uncovered during the second surgery, and you won't need a healing cap.

The temporary crown will be in place for four to six weeks. The gums will heal around it and will look like the gums around your natural teeth. The temporary crown is made of softer material than the permanent crown. The softer material helps to cushion and protect the implant from the pressure of chewing, and gives the jawbone the opportunity to gradually get stronger.

Placement of permanent crown 
Month 5, 6 or 7 (no bone grafting, lower jaw) 
Month 7, 8 or 9 (no bone grafting, upper jaw) 
Month 9, 10 or 11 (bone grafting, lower jaw) 
Month 11, 12 or 13 (bone grafting, upper jaw)

While you are wearing your temporary crown, the permanent crown will be made. It may take two to three weeks, or less, to make a permanent crown. The crown can be created from a model of your teeth and gum tissue that includes the abutment.

The crown can be either cemented or screwed to the abutment.

Crowns held in place by cement may look better because there is no screw hole in the crown to be seen. However, crowns held in place by a screw are easier for your dentist to remove if he or she needs to reach the implant or the tissue around the implant.

Caring for Your Implants

You care for your implants the same way you care for your natural teeth. It is important to brush and floss daily. If you have any problems, see your dentist before your six- month recall visit.

What Will X-Rays Show?

On an X-ray, you will be able to see the implant in the bone, the abutment and the crown. Your dentist can look at how the implant, abutment and crown fit together and make sure that there are no problems.

Possible Complications

In addition to the risks of surgery, there is the possibility of the implant failing. An implant can fail if an infection develops, which is rare, or if the bite (the way the teeth come together) has not been properly adjusted. In addition, clenching or grinding teeth can put a lot of pressure on the implant. This may cause bone loss, and cause the implant to break or fail.

You should be aware that when implants are used to replace lower teeth, a nerve that runs through the jawbone sometimes can be injured when the bone is being drilled or the implant is being placed. This can cause numbness or tingling. If this happens, it usually involves the lower part of the lip and chin or one side of the tongue. The numbness can be temporary, until the nerve heals, or it can be permanent. However, it is not common for the nerve to be injured. X-rays and computed tomography (CT) scans can help your dentist to see where the nerve is located and minimize the possibility of injuring the nerve.

In the upper jaw, there is a risk of drilling through the jawbone into one of your sinuses (located above your upper teeth) or nasal cavity, which could cause an infection. To avoid this, special X-rays are taken before your surgery to help your surgeon to determine where your nerves and sinuses are located.

What Can You Expect From Your Implant?

Single-tooth implants will work and look like your natural teeth. However, for some patients, it will be difficult to make the implant look exactly like your natural teeth. In some cases, your implant will not be placed straight, but will be inserted on an angle in the bone because of the amount of bone that you have and the amount of bone that is needed to place the implant properly.

A crown placed over an implant that is at an angle may not appear as natural as your own tooth. However, it will typically give you a very good result. Another situation in which it may be difficult to match the appearance of a natural tooth is when the crown is made more bulky to close a space. Studies so far have shown that these implants can last as long as 25 years.