Dental implant

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Dental implant
Intervention

A Straumann-brand root-form endosseous dental implant placed in the site of the maxillary left permanent first molar with bone graft used to elevate the sinus floor
ICD-9-CM23.5-23.6
MeSHD003757
 
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Dental implant
Intervention

A Straumann-brand root-form endosseous dental implant placed in the site of the maxillary left permanent first molar with bone graft used to elevate the sinus floor
ICD-9-CM23.5-23.6
MeSHD003757

A dental implant is a "root" device, usually made of titanium, used in dentistry to support restorations that resemble a tooth or group of teeth to replace missing teeth.

Virtually all dental implants placed today are root-form endosseous implants, i.e., they appear similar to an actual tooth root (and thus possess a "root-form") and are placed within the bone (endo- being the Greek prefix for "in" and osseous referring to "bone"). The bone of the jaw accepts and osseointegrates with the titanium post. Osseointegration refers to the fusion of the implant surface with the surrounding bone. Dental implants will fuse with bone; however, they lack the periodontal ligament, so they will feel slightly different from natural teeth during chewing.

Prior to the advent of root-form endosseous implants, most implants were either blade endosseous implants, in that the shape of the metal piece placed within the bone resembled a flat blade, or subperiosteal implants, in which a framework was constructed to lie upon and was attached with screws to the exposed bone of the jaws.

Dental implants can be used to support a number of dental prostheses, including crowns, implant-supported bridges or dentures.[1] They can also be used as anchorage for orthodontic tooth movement. The use of dental implants permits undirectional tooth movement without reciprocal action.

Contents

History [edit]

The Maya civilization has been shown to have used the earliest known examples of endosseous implants (implants embedded into bone), dating back over 1,350 years before Per-Ingvar Brånemark started working with titanium. While excavating Maya burial sites in Honduras in 1931, archaeologists found a fragment of mandible of Maya origin, dating from about 600 AD. This mandible, which is considered to be that of a woman in her twenties, had three tooth-shaped pieces of shell placed into the sockets of three missing lower incisor teeth. For forty years, the archaeological world considered that these shells were placed after death in a manner also observed by the ancient Egyptians. However, in 1970 a Brazilian dental academic, Professor Amadeo Bobbio studied the mandibular specimen and took a series of radiographs. He noted compact bone formation around two of the implants which led him to conclude that the implants were placed during life.

In the 1950s research was being conducted at Cambridge University in England to study blood flow in vivo. These workers devised a method of constructing a chamber of titanium which was then embedded into the soft tissue of the ears of rabbits. In 1952 the Swedish orthopaedic surgeon, P I Brånemark, was interested in studying bone healing and regeneration, and adopted the Cambridge designed ‘rabbit ear chamber’ for use in the rabbit femur. Following several months of study, he attempted to retrieve these expensive chambers from the rabbits and found that he was unable to remove them. Per Brånemark observed that bone had grown into such close proximity with the titanium that it effectively adhered to the metal. Brånemark carried out many further studies into this phenomenon, using both animal and human subjects, which all confirmed this unique property of titanium.

Dr. Leonard Linkow placed his first dental implant in 1952, four months after he graduated from dental school. By 1992, Dr. Linkow had placed over 19,000 dental implants and stopped counting. He retired from private practice in 2002 leaving a body of work that included 12 books and 36 patents. Many implant dentists refer to Dr. Linkow as the father of modern implant dentistry.[2]

Meanwhile an Italian medical doctor called Stefano Melchiade Tramonte, understood that titanium could be used for dental restorations and after designing a titanium screw to support his own dental prosthesis, started to use it on many patients in his clinic in 1959. The good results of his clinical studies on humans were published in 1966.[3] This was the worldwide start of a mainly practitioners based development. New materials and many different and sometimes strange technical solutions have been applied in the jaw area.[4]


Although Brånemark had originally considered that the first work should centre on knee and hip surgery, he finally decided that the mouth was more accessible for continued clinical observations and the high rate of edentulism in the general population offered more subjects for widespread study. He termed the clinically observed adherence of bone with titanium as ‘osseointegration’. In 1965 Brånemark, who was by then the Professor of Anatomy at Gothenburg University in Sweden, placed his first titanium dental implant into a human volunteer.

Contemporaneous independent research in the United States by Stevens and Alexander led to a 1969 US patent filing for titanium dental implants.[5] Also to mention is the american engineer T. D. Driskell.[6] His groundbreaking work can still be found again in the products of Bicon implant system.

Over the next fourteen years Brånemark published many studies on the use of titanium in dental implantology. The hybrid bridge on Brånemark implants was a concept of good clinical results. Bad (red/white) aesthetics was the reason of low acceptance by dentists and patients. In 1978 he entered into a commercial partnership with the Swedish defense company, Bofors AB for the development and marketing of his dental implants. With Bofors (later to become Nobel Industries) as the parent company, Nobelpharma AB (later to be renamed Nobel Biocare) was founded in 1981 to focus on dental implantology. To the present day over 7 million Brånemark System implants have now been placed and hundreds of other companies produce dental implants. The majority of dental implants currently available are shaped like small screws, with either tapered or parallel sides. They can be placed at the same time as a tooth is removed by engaging with the bone of the socket wall and sometimes also with the bone beyond the tip of the socket. Current evidence suggests that implants placed straight into an extraction socket have comparable success rates to those placed into healed bone.[7] The success rate and radiographic results of immediate restorations of dental implants placed in fresh extraction sockets (the temporary crowns placed at the same time) have been shown to be comparable to those obtained with delayed loading (the crowns placed weeks or months later) in carefully selected cases[8]

Till 1990 restrictions of free trade and rules of FDI prevented the leading european implant companies for example Straumann to enter the US and Canadian market. This changed after the studies of the ITI team. [9]

Some current research in dental implantology is focusing on the use of ceramic materials such as zirconia (ZrO2) in the manufacture of dental implants. Zirconia is the dioxide of zirconium, a metal close to titanium in the periodic table and with similar biocompatibility properties.[10] Although generally the same shape as titanium implants, zirconia, which has been used successfully for orthopaedic surgery for a number of years, has the advantage of being more cosmetically aesthetic owing to its bright tooth-like colour.[11] However, long-term clinical data is necessary before one-piece ZrO2 implants can be recommended for daily practice.[12]

Composition [edit]

A typical implant consists of a titanium screw (resembling a tooth root) with a roughened or smooth surface. The majority of dental implants are made out of commercially pure titanium, which is available in 4 grades depending upon the amount of carbon and iron contained.[13] More recently grade 5 titanium has increased in use. Grade 5 titanium, Titanium 6AL-4V, (signifying the Titanium alloy containing 6% Aluminium and 4% Vanadium alloy) is believed to offer similar osseointegration levels as commercially pure titanium. Ti- 6Al-4V alloy offers better tensile strength and fracture resistance. Today most implants are still made out of commercially pure titanium (grades 1 to 4) but some implant systems are fabricated out of the Ti-6Al-4V alloy.[14] Implant surfaces may be modified by plasma spraying, anodizing,[15] etching, or sandblasting to increase the surface area and osseointegration potential of the implant. Recent studies have suggested that the chemical modification of the implant surface by polyelectrolyte coating [16] or nanoscale roughness manipulation [17] enhance cell proliferation and differentiation and promote osseointegration.

Training [edit]

There is no specialty recognized by the ADA for dental implants in the United States. Implant surgery may be performed as an outpatient under general anesthesia, oral conscious sedation, nitrous oxide sedation, intravenous sedation or under local anesthesia by trained and certified clinicians including general dentists, oral surgeons, periodontists, and prosthodontists.

The legal training requirements for dentists who carry out implant treatment differ from country to country. In the UK, implant dentistry is considered by the General Dental Council to be a postgraduate sphere of dentistry. In other words it is not sufficiently covered during the teaching of the university dental degree course and dentists wishing to practice in dental implantology legally need to undergo additional formal postgraduate training. The General Dental Council has published strict guidelines on the training required for a dentist to be able to place dental implants in general dental practice.[18] UK dentists need to complete a competency assessed postgraduate extended learning program before providing implant dentistry to patients.

The degree to which both graduate and post-graduate dentists receive training in the surgical placement of implants varies from country to country,[19][20][21] but it seems likely that lack of formal training will lead to higher complication rates.[22]

In the United States, there are two surgical specialties available for dental graduates to gain multiple years of surgical training in placing dental implants; Oral and Maxillofacial Surgeons and Periodontist. United States Oral and Maxillofacial Surgeons are required to complete an additional 4 years of post-dental training or 6 years if a medical degree is obtained, and Periodontal Surgeons are required to complete 3 years of additional post-graduate training. <http://www.aaoms.org/conditions.php><http://www.ada.org/495.aspx><http://www.perio.org/consumer/periodontist2.htm>However, with increasing competition and marketing by major implant manufacturers, dentist seeking to learn how to place and/or restore dental implants can take a weekend or week-long implant training courses available through most major manufacturers. These hands-on courses rely on simulated models and patient examples to emphasize treatment planning, case selection, implant placement protocol, restorative techniques, and marketing strategies. <http://www.ditcusa.com><http://www.zimmerdental.com/education/><http://www.nobelbiocare.com/en/training-education/course-directory/default.aspx><http://www.straumann.com.au/au-index/courses.htm><http://iird.com>Ultimately, patients are responsible for researching the qualifications of their treating provider that can impact their final surgical and restorative outcome.<http://www.ada.org/sections/newsAndEvents/pdfs/tips.pdf>

Surgical procedure [edit]

Surgical planning [edit]

Prior to commencement of surgery, careful and detailed planning is required to identify vital structures such as the inferior alveolar nerve or the sinus, as well as the shape and dimensions of the bone to properly orient the implants for the most predictable outcome. Two-dimensional radiographs, such as orthopantomographs or periapicals are often taken prior to the surgery. Sometimes, a CT scan will also be obtained. Specialized 3D CAD/CAM computer programs may be used to plan the case.

Whether CT-guided or manual, a 'stent' may sometimes be used to facilitate the placement of implants. A surgical stent is an acrylic wafer that fits over either the teeth, the bone surface or the mucosa (when all the teeth are missing) with pre-drilled holes to show the position and angle of the implants to be placed. The surgical stent may be produced using stereolithography following computerized planning of a case from the CT scan. CT guided surgery may double the cost compared to more commonly accepted approaches.

Basic procedure [edit]

In its most basic form, the placement of an implant requires a preparation into the bone using either hand osteotomes or precision drills with highly regulated speed[23] to prevent burning or pressure necrosis of the bone. After a variable amount of time to allow the bone to grow on to the surface of the implant (osseointegration), a crown or crowns can be placed on the implant. Unlike conventional dental implants, Mini dental implants may be loaded immediately and still have a high survival rate (94%).[24][25] The amount of time required to place an implant will vary depending on the experience of the practitioner, the quality and quantity of the bone and the difficulty of the individual situation.

Detail procedure [edit]

At edentulous (without teeth) jaw sites, a pilot hole is bored into the recipient bone, taking care to avoid the vital structures (in particular the inferior alveolar nerve or IAN and the mental foramen within the mandible). Drilling into jawbone usually occurs in several separate steps. The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length). Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline or water spray keeps the temperature of the bone to below 47 degrees Celsius (approximately 117 degrees Fahrenheit). The implant screw can be self-tapping, and is screwed into place at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone). Typically in most implant systems, the osteotomy or drilled hole is about 1mm deeper than the implant being placed, due to the shape of the drill tip. Surgeons must take the added length into consideration when drilling in the vicinity of vital structures.

Surgical incisions [edit]

Straumann guide pin in place to visualize positioning, angulation and depth prior to implant placement. Implant is being placed as a flapless procedure because it was clinically and radiographically evident that there is adequate bone in all dimensions.

Traditionally, an incision is made over the crest of the site where the implant is to be placed. This is referred to as a 'flap'. Some systems allow for 'flapless' surgery where a piece of mucosa is punched-out from over the implant site. Proponents of 'flapless' surgery believe that it decreases recovery time while its detractors believe it increases complication rates because the edge of bone cannot be visualized.[26][27] Because of these visualization problems flapless surgery is often carried out using a surgical guide constructed following computerized 3D planning of a pre-operative CT scan.

Healing time [edit]

The amount of time required for an implant to become osseointegrated is a hotly debated topic.[28] Consequently the amount of time that practitioners allow the implant to heal before placing a restoration on it varies widely. In general, practitioners allow 2–6 months for healing but preliminary studies show that early loading of implant may not increase early or long term complications.[29] Minimally invasive methods of early dental implant placement reduce the cost of installed implants and shortens the implant-prosthetic rehabilitation time with 4–6 months.[30] If the implant is loaded too soon, it is possible that the implant may move which results in failure. For conventional implants, the subsequent time to heal, possibly graft, and eventually place a new implant may take up to eighteen months. For this reason many are reluctant to push the envelope for healing.

One-stage, two-stage surgery [edit]

When an implant is placed, either a 'healing abutment', which comes through the mucosa, is placed or a 'cover screw' which is flush with the surface of the dental implant is placed. When a cover screw is placed, the mucosa covers the implant while it integrates then a second surgery is completed to place the healing abutment.

Two-stage surgery is sometimes chosen when a concurrent bone graft is placed or surgery on the mucosa may be required for aesthetic reasons. The latter is usually important where an implant is placed in the "aesthetic zone". This allows more control over the healing and as a result the predictability of the final result. Some implants are one piece so that no healing abutment is required.

In carefully selected cases, patients can be implanted and restored in a single surgery, in a procedure labeled "Immediate Loading". In such cases a provisional prosthetic tooth or crown is shaped to avoid the force of the bite transferring to the implant while it integrates with the bone.

Surgical timing [edit]

There are different approaches to place dental implants after tooth extraction. The approaches are:

  1. Immediate post-extraction implant placement.
  2. Delayed immediate post-extraction implant placement (2 weeks to 3 months after extraction).
  3. Late implantation (3 months or more after tooth extraction).

According to the timing of loading of dental implants, the procedure of loading could be classified into:

  1. Immediate loading procedure.
  2. Early loading (1 week to 12 weeks).
  3. Delayed loading (over 3 months)

Immediate placement [edit]

An increasingly common strategy to preserve bone and reduce treatment times includes the placement of a dental implant into a recent extraction site. In addition, immediate loading is becoming more common as success rates for this procedure are now acceptable. This can cut months off the treatment time and in some cases a prosthetic tooth can be attached to the implants at the same time as the surgery to place the dental implants. Because one of three implants requires a minimum addition of bone tissue, surgical techniques for underlying bone augmentation are currently under a large scale development.[31]

Most data suggests that when implants are placed into single rooted tooth sites with healthy bone and mucosa around them, the success rates are comparable to that of delayed procedures with no additional complications.[32]

"Fast and fixed" are similar surgical concepts whereby implants are placed on the same day and a fixed prosthesis is attached to them. This allows the patient to leave with a fixed solution as opposed having to make do with a removal temporary prosthesis whilst the implant osseointegrates with the bone. This concept is appropriate for completely edentulous jaws where either the teeth are to be extracted or have already been removed.

Use of CT scanning [edit]

CT scan of the lower jaw. This shows eight dental implants superimposed over the lower jaw in areas of maximum bone and four teeth that will be extracted.[33]

When computed tomography or, more specifically, cone beam computed tomography or CBCT (3D X-ray imaging) is used preoperatively to accurately pinpoint vital structures including the inferior alveolar canal, the mental foramen, and the maxillary sinus, the chances of complications might be reduced as is chairtime and number of visits.[34] Cone beam CT scanning, when compared to traditional medical CT scanning, utilizes less than 2% of the radiation, provides more accuracy in the area of interest, and is safer for the patient.[35] CBCT allows the surgeon to create a surgical guide, which allows the surgeon to accurately angle the implant into the ideal space.[36]

Complementary procedures [edit]

Sinus lifting is a common surgical intervention. A dentist or specialist with proper training such as an oral surgeon, periodontist, general dentist or prosthodontist, thickens the inadequate part of atrophic maxilla towards the sinus with the help of bone transplantation or bone expletive substance. This results in more volume for a better quality bone site for the implantation. Prudent clinicians who wish to avoid placement of implants into the sinus cavity pre-plan sinus lift surgery using the CBCT X-ray, as in the case of posterior mandibular implants discussed earlier. Sinus lift is done to reestablish bone to your upper jaw, in the missing tooth area of molars and premolars. This allows for dental implants to be placed in the bone of the upper jaw.[37]

Bone grafting will be necessary in cases where there is a lack of adequate maxillary or mandibular bone in terms of front to back (lip to tongue) depth or thickness; top to bottom height; and left to right width. Sufficient bone is needed in three dimensions to securely integrate with the root-like implant. Improved bone height—which is very difficult to achieve—is particularly important to assure ample anchorage of the implant's root-like shape because it has to support the mechanical stress of chewing, just like a natural tooth.

Typically, implantologists try to place implants at least as deeply into bone as the crown or tooth will be above the bone. This is called a 1:1 crown to root ratio. This ratio establishes the target for bone grafting in most cases. If 1:1 or more cannot be achieved, the patient is usually advised that only a short implant can be placed and to not expect a long period of usability.

A wide range of grafting materials and substances may be used during the process of bone grafting / bone replacement. They include the patient's own bone (autograft), which may be harvested from the hip (iliac crest) or from spare jawbone; processed bone from cadavers (allograft)Which is demineralised; bovine bone or coral (xenograft); or artificially produced bone-like substances (calcium sulfate with names like Regeneform; and hydroxyapatite or HA, which is the primary form of calcium found in bone) or calcium phosphosilicate which is available in a mouldable putty form. The HA is effective as a substrate for osteoblasts to grow on. Some implants are coated with HA for this reason, although the bone forming properties of many of these substances is a hotly debated topic in bone research groups. Alternatively the bone intended to support the implant can be split and widened with the implant placed between the two halves like a sandwich. This is referred to as a 'ridge split' procedure.

Bone graft surgery has its own standard of care. In a typical procedure, the clinician creates a large flap of the gingiva or gum to fully expose the jawbone at the graft site, performs one or several types of block and onlay grafts in and on existing bone, then installs a membrane designed to repel unwanted infection-causing microbiota found in the oral cavity. Then the mucosa is carefully sutured over the site. Together with a course of systemic antibiotics and topical antibacterial mouth rinses, the graft site is allowed to heal (several months).

The clinician typically takes a new radiograph to confirm graft success in width and height, and assumes that positive signs in these two dimensions safely predict success in the third dimension; depth. Where more precision is needed, usually when mandibular implants are being planned, a 3D or cone beam radiograph may be called for at this point to enable accurate measurement of bone and location of nerves and vital structures for proper treatment planning. The same radiographic data set can be employed for the preparation of computer-designed placement guides.

Correctly performed, a bone graft produces live vascular bone which is very much like natural jawbone and is therefore suitable as a foundation for implants.

Considerations [edit]

Chrome-cobalt disc with bridges and crowns for dental implants manufactured using WorkNC Dental CAD/CAM

For dental implant procedure to work, there must be enough bone in the jaw, and the bone has to be strong enough to hold and support the implant. If there is not enough bone, more may need to be added with a bone graft procedure discussed earlier. Sometimes, this procedure is called bone augmentation, or guided bone regeneration. Mini dental implants are particularly useful in the endentulous arch with minimal remaining bone facio-lingually.[38] In addition, natural teeth and supporting tissues near where the implant will be placed must be in good health.

In all cases careful consideration must be given to the final functional aspects of the restoration, such as assessing the forces which will be placed on the implant. Implant loading from chewing and parafunction (abnormal grinding or clenching habits) can exceed the biomechanic tolerance of the implant bone interface and/or the titanium material itself, causing failure. This can be failure of the implant itself (fracture) or bone loss, a "melting" or resorption of the surrounding bone.

The dentist must first determine what type of prosthesis will be fabricated. Only then can the specific implant requirements including number, length, diameter, and thread pattern be determined. In other words, the case must be reverse engineered by the restoring dentist prior to the surgery. If bone volume or density is inadequate, a bone graft procedure must be considered first. The restoring dentist may consult with the oral surgeon, periodontist, or another trained general dentist to co-treat the patient. Usually, physical models or impressions of the patient's jawbones and teeth are made by the restorative dentist at the implant surgeons request, and are used as physical aids to treatment planning. If not supplied, the implant surgeon makes his own or relies upon advanced computer-assisted tomography or a cone beam CT scan to achieve the proper treatment plan.

Computer simulation software based on CT scan data allows virtual implant surgical placement based on a barium impregnated prototype of the final prosthesis. This predicts vital anatomy, bone quality, implant characteristics, the need for bone grafting, and maximizing the implant bone surface area for the treatment case creating a high level of predictability. Computer CAD/CAM milled or stereolithography based drill guides can be developed for the implant surgeon to facilitate proper implant placement based on the final prosthesis' occlusion and aesthetics.

Treatment planning software can also be used to demonstrate "try-ins" to the patient on a computer screen. When options have been fully discussed between patient and surgeon, the same software can be used to produce precision drill guides. Specialized software applications such as 'SimPlant' (simulated implant) or 'NobelGuide' use the digital data from a patient's CBCT to build a treatment plan. A data set is then produced and sent to a lab for production of a precision in-mouth drilling guide.[39]

Success rates [edit]

Dental implant success is related to operator skill, quality and quantity of the bone available at the site, and the patient's oral hygiene. The consensus is that implants carry a success rate of around 75%[40]

One of the most important factors that determine implant success is the achievement and maintenance of implant stability.[41] The stability is presented as an ISQ (Implant Stability Quotient) value. Other contributing factors to the success of dental implant placement, as with most surgical procedures, include the patient's overall general health and compliance with post-surgical care.

Dental implants can help stop periodontal diseases from forming. This is because gaps formed by missing teeth can cause periodontal disease and infections that may affect a person’s ability to eat or speak. It is very important to fill in any gaps to prevent the adjacent and opposing set of teeth from shifting positions or causing further damage to the mouth.[42]

Failure [edit]

Failure of a dental implant is often related to the failure of the implant to osseointegrate correctly with the bone, or vice-versa. A dental implant is considered to be a failure if it is lost, mobile or shows peri-implant (around the implant) bone loss of greater than 1.0 mm in the first year and greater than 0.2 mm a year after.

Dental implants are not susceptible to dental caries but they can develop a condition called peri-implantitis. This is an inflammatory condition of the mucosa and/or bone around the implant which may result in bone loss and eventual loss of the implant. The condition is usually, but not always, associated with a chronic infection. Peri-implantitis is more likely to occur in heavy smokers, patients with diabetes, patients with poor oral hygiene and cases where the mucosa around the implant is thin.[43]

Currently there is no universal agreement on the best treatment for peri-implantitis. The condition and its causes are still poorly understood.[44]

Failure may also occur independently of the causes outlined above. Implants, like any other object, suffer from wear and tear. If the implant(s) in question are replacing commonly used teeth, then these may suffer from wear and tear and after years may crack and break up, although this is a very rare but dramatic occurrence. Scanning electron microscopy (SEM) helps to investigate failures.[45] These fractures can be checked using the finite element method. An improved design by CAD is one of the necessary standards in modern dental implant engineering.[46]

In the majority of cases where an implant fails to integrate with the bone and is rejected by the body the cause is unknown. This may occur in around 5% of cases. To this day we still do not know why bone will integrate with titanium dental implants and why it does not reject the material as a 'foreign body'. Many theories have been postulated over the last five decades. A recent theory argues that rather than being an active biological tissue response, the integration of bone with an implant is the lack of a negative tissue response. In other words, for unknown reasons the usual response of the body to reject foreign objects implanted into it does not function correctly with titanium implants. It has further been postulated that an implant rejection occurs in patients whose bone tissues actually react as they naturally should with the 'foreign body' and reject the implant in the same manner that would occur with most other implanted materials.[47]

Contraindications [edit]

There are few absolute contraindications to implant dentistry. However, there are some systemic, behavioral, and anatomic considerations that should be assessed.

Particularly for mandibular (lower jaw) implants, in the vicinity of the mental foramen (MF), there must be sufficient alveolar bone above the mandibular canal also called the inferior alveolar canal or IAC (which acts as the conduit for the neurovascular bundle carrying the inferior alveolar nerve or IAN).

Failure to precisely locate the IAN and MF invites surgical insult by the drills and the implant itself. Such insult may cause irreparable damage to the nerve, often felt as a paresthesia (numbness) or dysesthesia (painful numbness) of the gum, lip and chin. This condition may persist for life and may be accompanied by unconscious drooling.

Uncontrolled Type II diabetes is a significant relative contraindication as healing following any type of surgical procedure is delayed due to poor peripheral blood circulation. Anatomic considerations include the volume and height of bone available. Often an ancillary procedure known as a block graft or sinus augmentation are needed to provide enough bone for successful implant placement.

There is new information about intravenous and oral bisphosphonates (taken for certain forms of breast cancer and osteoporosis, respectively) which may put patients at a higher risk of developing a delayed healing syndrome called osteonecrosis. Implants are contraindicated for some patients who take intravenous bisphosphonates.

The many millions of patients who take an oral bisphosphonate (such as Actonel, Fosamax and Boniva) may sometimes be advised to stop the administration prior to implant surgery, then resume several months later. However, current evidence suggests that this protocol may not be necessary. As of January 2008, an oral bisphosphonate study reported in the February 2008 Journal of Oral and Maxillofacial Surgery, reviewing 115 cases that included 468 implants, concluded "There is no evidence of bisphosphonate-associated osteonecrosis of the jaw in any of the patients evaluated in the clinic and those contacted by phone or e-mail reported no symptoms."[48]

The American Dental Association had addressed bisphosphonates in an article entitled "Bisphosphonate medications and your oral health,"[49] In an Overview, the ADA stated "The risk of developing BON [bisphosphonate-associated osteonecrosis of the jaw] in patients on oral bisphosphonate therapy appears to be very low...". The ADA Council on Scientific Affairs also employed a panel of experts who issued recommendations [for clinicians] for treatment of patients on oral bisphosphonates, published in June 2006. The overview may be read online at ada.org but it has now been superseded by a huge study—encompassing over 700,000 cases—entitled "Bisphosphonate Use and the Risk of Adverse Jaw Outcomes." Like the 2008 JOMS study, the ADA study exonerates oral bisphosphonates as a contraindication to dental implants.[50]

Bruxism (tooth clenching or grinding) is another consideration which may reduce the prognosis for treatment. The forces generated during bruxism are particularly detrimental to implants while bone is healing; micromovements in the implant positioning are associated with increased rates of implant failure. Bruxism continues to pose a threat to implants throughout the life of the recipient.[51] Natural teeth contain a periodontal ligament allowing each tooth to move and absorb shock in response to vertical and horizontal forces. Once replaced by dental implants, this ligament is lost and teeth are immovably anchored directly into the jaw bone. This problem can be minimized by wearing a custom made mouthguard (such an NTI appliance) at night.

Postoperatively, after implants have been placed, there are physical contraindications that prompt rapid action by the implantology team. Excessive or severe pain lasting more than three days is a warning sign, as is excessive bleeding. Constant numbness of the gingiva (gum), lip and chin—usually noticed after surgical anesthesia wears off—is another warning sign. In the latter case, which may be accompanied by severe constant pain, the standard of care calls for diagnosis to determine if the surgical procedure insulted the IAN. A 3D cone beam X-ray provides the necessary data, but even before this step a prudent implantologist may back out or completely remove an implant in an effort to restore nerve function because delay is usually ineffective. Depending upon the evidence visible with a 3D X-ray, patients may be referred to a specialist in nerve repair. In all cases, speed in diagnosis and treatment are necessary.

Market [edit]

In the United States and the United Kingdom, there is no exclusive specialty in 'implantology'.

Any practitioner who carries out implant treatment, whether in the surgical insertion or the final provision of the prosthesis, must be adequately trained. Legal training requirements differ between countries.

In 2008, in the UK the General Dental Council (GDC) laid down strict training requirements[52] for dentists involved in dental implantology. Any dentist in the UK who wishes to train in the field of dental implantology must take part in an extended learning program which covers a detailed theory syllabus, as approved by the GDC,[53] in addition to formal supervised surgical training and mentoring. Dentists must not take part in implant dentistry in the UK until they have been approved by the training provider as having passed a formal competency assessment. Failure to comply with the GDC regulations may result in a dentist being removed from the Dental Register and hence losing the right to practice dentistry in the UK.[54]

The fast growing demand for prosthetic solutions based upon dental implants caused the birth of hundreds of different brands available on the market, about 150 in the UK[55] and more than 300 in Italy,[56] but only a very few of these have enough documentation and clinical practice for being recognized worldwide.[56] According to a study published in the Clinical Implant Dentistry and Related Research, only three brands of implants were tested by at least two independent (not sponsored) clinical researches,[57] which should push the patients to ask for more information before accepting any treatment, and to demand for a real implant passport.[56]

Prices [edit]

Due to high prices of implants - complete implant with a crown & an abutment in UK can cost more than £2,000 - many Britons are choosing to travel abroad for their treatment. In 2009, there were 60,000 patients who went abroad, out of which 43% had a dental treatment completed abroad.[58] In the U.S., $2,000 for the implant itself, in addition to $300 – $400 for evaluative xrays, in addition to the cost of the crown is not uncommon. If you want to replace full or partial teeth sets, the cost of dental implants can rise to as much as $40,000 in the United States.[59]

See also [edit]

References [edit]

  1. ^ Anh, M-R; An K-A, Choi J-H, Sohn D-S (2004). "Immediate loading with mini dental implants in the fully edentulous mandible". Implant Dent 13 (4): 367–372. PMID 15591999. 
  2. ^ Four Linkow textbooks online.
  3. ^ Annali di Stomatologia - Su alcuni casi particolarmente interessanti di impianto endosseo con vite autofilettante - Vol XV - Aprile 1966
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  5. ^ US patent 3579831, Stevens, Irving J.; Alexander, Jerry, "Bone Implant", issued 1971-05-25 
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