Dental Implants FAQ.

Or: If you build it, they will come...

Perhaps more than any other development in the past twenty years, the popularization of implants has revolutionized the science of dentistry today. The fact that it has not made major inroads in the way dentistry is practiced day to day speaks volumes of the public's willingness to embrace new technologies in a "managed care" environment.

Q: What would the criteria be to deem an individual as an inappropriate candidate for dental implants, other than possibly immunosuppressed, diabetic or chronic smoker?

Would having insufficient bone present be taken as a definite refusal or would methods such as osseointegration and guided bone regeneration overcome this?

A: Dental implants are not as new as is commonly believed; early types of endosseous implants have been placed over 100 years ago. Despite that, the total number of man-hours of experience with this type of treatment is relatively small, since it is practiced relatively infrequently when compared with more conventional modalities of prosthetic dentistry. Consequently, the absolute and relative contraindications for implant placement are still not fully known. Several general requirements do apply, though:

  • Implant candidates should be in relatively good health. Immunosuppression, diabetes, other endocrine disturbance, history of head or neck radiotherapy, etc., would make for less than an ideal implant subject.
  • Sufficient bone must be present in a location suitable for placing a fixture where a prosthetic tooth is needed. In other words, a patient not only needs sufficient bone, but it must be in the right place.
  • Vital structures within the bone must not obstruct proper implant placement. This is frequently a consideration when placing implants in the back of the lower jaw, where canals conveying vital nerves and blood vessels course through the center of the jawbone. The upper jaw frequently presents with a maddeningly large sinus in just the wrong place. This latter problem is currently being addressed by surgical sinus lift procedures, where the bottom of the sinus is elevated by the placement of natural or synthetic bone grafts.
  • A patient who doesn't understand the newness of this procedure is apt to have unrealistic expectations; these must be reined in before treatment. Implantology has not had as many years of refinement as the more conventional modes of treatment (e.g., fixed bridgework).

The term osseointegration refers to the way bone closely approximates the walls of the implant fixture, and is inherent in all endosseous implants. It is not a means of improving the chances for success of an inappropriate treatment.

Guided tissue regeneration simply means the use of a non-resorbable (and lately, a resorbable) membrane to prevent the ingrowth of surface tissue (epithelium) into any surgical site. It may be used in conjunction with a bone graft procedure, but is not in itself a means of augmenting insufficient bone.

Suitability for implant placement depends on too many factors to rely on absolute dogma to determine whether a patient qualifies. Likewise, it's far too early in the game to rely on any hard and fast rules. The best that can be done is for the dentist to go with his admittedly limited experience, his gut intuition, and the patient's willingness to incur the uncertainties of a procedure relatively new to the world of dentistry.

Q: Are titanium implants worth the cost? What can go wrong?

A: Are they worth the cost? It depends on whether any benefits they yield are commensurate with their increased cost over more conventional approaches to tooth replacement. In situations where the time-tested approaches are likely to provide satisfactory results, we will generally guide patients in that direction. This is a personal philosophy; you'll hear others.

We think some of the arguments used to advocate superiority of implants are specious and show a lack of ability on the part of the dentist to take the perspective of the patient. For instance, here's one: "a single tooth implant is better and more conservative than a conventional 3-unit fixed bridge. Why drill down two perfectly good teeth if you can do an implant?" Well here's our answer: "Tell us what's conservative about cutting out a chunk of bone from the jaw?" In our experience, patients always dig their fingernails into the upholstery when we use the term "surgery".

That's not to say that implants don't present options in certain situations that cannot be approached in other ways; they are just another tool in a dentist's arsenal. We would caution our colleagues to not be in such a hurry to throw out hundreds of years of steady progress for the cheap, heady rush of "progress".

What can go wrong? Do you really want to read the package insert in every drug you take? Every medicine you take presents a remote chance that it will kill you, you know. It's not likely this will happen with good technique, but you did ask:

  • infection
  • injury to surrounding structures (nerves, arteries, sinuses)
  • bone fractures
  • failure of the implant fixture

These risks may be greater or lesser depending on the proposed location for the implant. Your dentist should fully explain the potential risks before you commit to any treatment, implants included.

Q: I paid five figures for dental implants. The teeth look like they came off a horse: huge and my mouth protrudes. My entire family is shocked; my friends say they look awful. These are full-mouth implants and look like Chiclets. The dentist told me he'd charge me an EXTRA $5,000 to re-do them. I argued with him, mentioning a lawsuit and he said, "ok; I'll order smaller ones and charge you $500 but this time we'll go veeeeery slowly." (as if to punish me further)? I guess I'll have to comply since legal fees would eat me alive, plus the stress of all this. The lab blames the dentist; the dentist blames the lab and myself for "rushing them" since I wanted them before Christmas (still took a year).

Should implants look like this (wearing horse's teeth) and am I being treated fairly?

A: Ideally, implants should not look unattractive. Sometimes compromises need to be made in tooth shape and position, depending on the location of sufficient available bone in which to position implants. If the bone is not sufficient to optimally position the implants, it is sometimes necessary to alter the inclination or position of the prosthetic teeth attached to them.

Treatment planning is key here. Positioning of implants should not be finalized before scoping out the intended position, shape, and size of the prosthetic teeth. If it is determined in advance that it is not possible to position the teeth in optimal position, other options must be examined, or at least the shortcomings of this approach should be fully explained to the patient. Unfortunately, it is not always possible to accurately predict results in advance.

Implant prosthetics is a collaborative effort between the prosthetic dentist and the surgeon, and sometimes the lines of communication are not fully utilized. Culpability is sometimes a shared affair; you should keep this in mind before you heap all the blame on the restorative dentist. Re-doing the work slowly is not punitive, but indicates an extra effort to get things right. Because time is money, you should know that your dentist will incur additional costs in order to make things right. He may be somewhat guilty of not having predicted in advance the extra costs both he and you will suffer, but unpredictability is inherent in the delivery of many aspects of health care. It's not always like hiring a general contractor and signing in advance on a pre-agreed fee; stuff happens. We are sure that despite the extra fee your dentist is charging, he is absorbing more of the cost of re-doing the work than you.

Q: I had a bridge in the front of my mouth that kept getting abscessed and my face would swell. The dentist told me that I would have to have the bridge removed and a partial denture put in. This is what I did, but I don't like the plate in my mouth. What I would like to ask is whether I have any other options. For example, I have heard that now they have posts that they can put teeth on. The dentist also said I have some bone loss.

A: There is a possibility that surgical dental implants (what you are referring to) may be appropriate for you. This will depend on the quantity and quality of the bone where the teeth will be replaced, the relative position of your upper and lower jaws, and the position of your sinuses and nasal cavity relative to the proposed location of the implants.

The fact that you had recurrent infection, and that your teeth were not extracted recently makes it less likely that this strategy will be successful. It doesn't hurt to ask, though. Ask your dentist about whether implants make sense for you; if he does not provide this service, he should be able to refer you to someone who does.

Follow-up Question:

Thank you for your response. After reading it I realized that relative to the implants, I left one fact out. The oral surgeon I was referred to took a panoramic x-ray and has already shown me I do not have enough bone where the implant is to be placed and it would entail bone grafting from my lower jaw and adding another implant rather than only one implant as recommended by my dentist. The oral surgeon is who recommended a full upper denture because he has concerns as to whether the implants would hold. I have become very hesitant now that I am being told the implants will involve bone grafting which everyone I have spoken to tell me is extremely painful and there is a strong possibility even after all the work is completed I still have no guarantee of success. Can you give me a percentage rate of success on the implants and other work?

A: We can only tell you in general terms that upper (maxillary) implants are less successful than lowers; we are not aware of any recent studies citing the statistics. Keep in mind that the statistics have little applicability if the data is collected on cases having favorable preoperative conditions, and your situation is less than favorable. However, the use of bone grafting before surgical implant placement is nothing unusual, and is becoming more common. Additionally, the bone used in grafting does not need to be harvested from your body; there are allografts (demineralized freeze-dried bone from human sources) and xenografts (treated animal bone), as well as synthetic bone substitutes.

We infer much from the industry that lives and dies by the collection of actuarial statistics: the insurance industry. On the application for professional liability (malpractice) insurance, they ask dentists three questions:

  1. Do you render patients unconscious with general anesthesia?
  2. Do you render Temporo Mandibular Joint (TMJ) therapy?
  3. Do you practice surgical implantology?

They ask these questions because these areas are a "red flag" for them. Simply stated, these are the areas where there is the greatest rate of professional liability. We gather that these are also the areas of greatest patient dissatisfaction.

The profession of dentistry is highly competitive and is searching for new niches in which to practice. There is also something of an inferiority complex relative to our more glamorous cousin, Medicine. Dentists are scrambling to appear as "cutting edge" as they can. Our only hope is that the welfare of the patient doesn't get left behind in that rush...

left arrow. Back to FAQ Contents   left arrow. Previous: Fixing Broken Teeth     Next: Oral Hygiene right arrow.