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Dental Implants

Written by Dr. Daniel Cho - Medically reviewed by Dr. Daniel Cho -

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Humans have a limited ability to regenerate lost body parts and teeth are no exception. Luckily, teeth are one of the few body parts that can be replaced that are just as effective in all practical regards as natural dentition. Patients often tell me that they forget they have a dental implant, as they feel and function very closely to teeth. While implants are generally the treatment of choice for edentulism or non-restorable teeth, they may not be the best fit for some people. Many situations are unique and require special considerations to ensure if implants are truly the right option.

Table of contents

What are Dental Implants?

Implants are a biocompatible root form that fuses to the jawbone via osseointegration. They replicate missing teeth and very closely mimic the appearance and function of natural dentition. Implants also have a very high long term success rate, as shown by many studies7https://www.sciencedirect.com/science/article/pii/S0307904X1000257X8https://web.p.ebscohost.com/abstract9https://www.sciencedirect.com/science/article/abs/pii/S0901502714000976.  While there are several types of implants, the most common today are endosteal implants.  A key process to the success of dental implants, osseointegration was described as early as half a century ago by Branemark1Brånemark, P-I., et al. “Intra-osseous anchorage of dental prostheses: I. Experimental studies.” Scandinavian journal of plastic and reconstructive surgery 3.2 (1969): 81-100.. In short, osseointegration is the connection of bone directly to the implant surface2https://www.hindawi.com/journals/bmri/2016/6285620/. The degree of success of an implant is based on the amount of bone loss and amount of bone to implant contact, where constant research aims to continually improve the already high success rates. Once integrated, implants form the foundation upon which various oral prosthetics connect to. The most common prosthetic is a single implant crown, designed to replace a tooth extracted due to disease or trauma. Other common prosthetics include implant bridges, overdentures, hybrid prosthetics and full arch prosthetics.

Components of a Dental Implant

There are a few key components that make up dental implants. They include the dental implant itself, the abutment, and the various types of prosthesis. For simplicity sake, we will focus on a single implant crown.

  • Dental implant – as previously mentioned, this is the root form that is embedded into the maxilla or mandible. Implants are made of a medical grade titanium alloy or zirconia. Zirconia is a biocompatible ceramic

Requirements for a Dental Implant

There are several requirements for a patient to be clinically eligible for implants. First and foremost, the patient must be healthy enough to undergo the surgery. With healthy patients, the primary requirement is sufficient bone to completely encase the implant in vital bone. There must be adequate bone in the buccal-lingual and incisal-apical dimension. If there isn’t sufficient bone, the jaws must be augmented by various types of bone grafting (Link to grafting page). The size range of full sized implant sizes generally ranges from 3.0mm to 6.0mm in diameter and anywhere from 6mm to 13mm in length, although smaller and larger implants in both dimensions exist. 

In addition, there needs to be enough space for the crown itself in the inter-arch and interproximal dimension. This space can be reduced due to a collapsed vertical dimension of occlusion (VDO) or if the space is occupied by another tooth that has drifted into the edentulous space. If there isn’t enough space, the existing teeth must be moved via orthodontics to ensure enough room for the crown. 

Additionally there are several risk factors that affect the survival rate of implants. Several health related risk factors include10https://web.s.ebscohost.com/abstract11https://www.sciencedirect.com/science/article/abs/pii/S0266435611004268:

  • Age
  • Diabetes
  • Smoking
  • History of head and neck radiation
  • Menopause
  • Hormone replacement therapy
  • Zone of keratinized gingiva
  • Width of implants
  • Presence of pathology

There are several studies that have shown that there is not a significant correlation between osteoporosis and early implant failure12https://www.sciencedirect.com/science/article/abs/pii/S090150271731484413http://www.quintpub.com/userhome/omi/omi_8_2_Dao_2.pdf14https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4363814/. However treatment for osteoporosis can lead to severe complications such as bisphosphonate related osteonecrosis of the jaw (BRONJ)15https://www.sciencedirect.com/science/article/abs/pii/S027823911000268516https://journals.lww.com/jcraniofacialsurgery/Abstract/2016/05000/Medication_Related_Osteonecrosis_of_the_Jaw_Around.33.aspx. The difficulty in implantology is balancing the grafting and prosthetic needs with the risk factors and placement of the largest sized implant without damaging any major structures.

Pros and Cons of Dental Implants

While implants are considered the gold standard to treat edentulism, they, like all treatments, are not foolproof and not for everyone. There are several other options to replace missing teeth that may be a better treatment option such as fixed partial dentures (bridges) and various removable prosthetics (dentures).

Other situations to call your dentist are abnormally painful symptoms after treatment. Most often this is after surgical treatment such as an extraction. When there is radiating pain that is not manageable with the recommended or prescribed postoperative analgesic medication, you may have a complication that requires medical intervention. In these situations, you should call your dental office to see if these symptoms are abnormal and if additional treatment is necessary.

Dental Implant Pros

Implants perform exceedingly well in oral reconstruction and rehabilitation. The esthetics, occlusion, phonetics, masticatory ability, and satisfaction rank highly amongst patients17https://onlinelibrary.wiley.com/doi/abs/10.1034/j.1600-0501.2003.140116.x18https://web.p.ebscohost.com/abstract. They are also a versatile treatment option when combining implant therapy with various types of prosthesis such as dentures, resulting in higher patient satisfaction19https://web.p.ebscohost.com/abstract20https://www.researchgate.net/profile/Merete-Bakke/publication/10997274_Masticatory_Function_and_Patient_Satisfaction_with_Implant-Supported_Mandibular_Overdentures_A_Prospective_5-Year_Study. In addition to excellent function, implants also displayed a high long term success rate ranging from around 85% to as high as 95% over 5 – 10 years in multiple studies21https://www.sciencedirect.com/science/article/abs/pii/S027823910300726222https://europepmc.org/article/med/2261189923https://www.sciencedirect.com/science/article/abs/pii/S030057121930049124https://link.springer.com/article/10.1007/BF01133326. The evidence points towards implants being one the most effective and longest lasting treatment option.

Dental Implant Cons

Although implants have shown to be an extremely effective treatment option, there are several hurdles to pass prior to treatment. Many people are simply not good candidates for an implant surgery. The following must be satisfied prior to surgery:

  • Healthy surgical candidate 
  • Sufficient bone depth and width
  • Sufficient prosthetic space
  • Ability to pay for surgery

The patient must be healthy enough to undergo surgery. The ASA classification is a good guideline where ASA class I and II are good surgical candidates as opposed to ASA class III or higher. Unhealthier patients aren’t precluded from surgery, however there are additional risks. In addition to being healthy enough for surgery, the patient must have adequate bone height and depth for the implant. If they lack bone in either dimension, they must be able and willing to undergo additional grafting to augment the ridge. When an appropriate amount of bone exists, there must also be adequate space in the edentulous site to place the prosthesis. If there isn’t enough room for an implant crown, the implant itself is useless since the crown cannot be attached to the implant. Lastly, the patient must be able to pay for the implant treatment itself, including any necessary grafting. While wiggle room exists with these requirements, there are clear boundaries that cannot be crossed no matter how much the patient or dentist wants to.

What Types of Dental Implants Exist?

There are three styles of dental implants: endosteal, transosteal, and subperiosteal.

  1. Endosteal Implants: This is the most common type placed today. Common shapes include cylindrical, with or without threads, and a blade. The most common shape used is a cylindrical with threads and resembles a wood screw. The entirety of the implant body is placed within bone, with the top of the implant either at or just below the level of bone. 
  1. Transosteal Implants: This style of implant completely transverses the jaw with an entry and exit point in the jaw. Due to traveling through the jaw itself, the surgery is more complex and invasive. There are major nerves and vessels to avoid when the implants are being placed. There is often a metal plate on the opposing end of the implant. The size of the implant and complexity of the surgery prohibits this style of implant for use to replace small 1-3 teeth edentulous areas. Due to the precise nature of the surgery, custom sized implants may be required which in addition to the complexity of the surgery, results in a much more expensive surgery.
  1. Subperiosteal Implants or Epiosteal Implants: This style of implant rests on top of the jawbone itself and does not cross the cortical plate. A framework rests on top of the jawbone but under the periosteum and gingiva. Posts protrude through the gingiva to attach to various prosthetics, most often being dentures. The main advantage is the bypassing grafting and this style may be good for patients with severely atrophic mandibles. However as with transosteal implants, this style is not as common as endosteal implants.

What are Dental Implants Made Out of?

The two primary materials used are titanium and zirconia. While other materials have been used, titanium has been shown to be a superior material and is the most common material used. More recently zirconia has been showing great promise for those who cannot use titanium.

  1. Titanium implants: Titanium has evolved to be the material of choice for structural replacements in the human body. While previous materials included stainless steel, gold and cobalt-chromium, titanium has proven to be a superior material of choice

What are Dental Implants Used for?

Implants are used as the foundation for a myriad of prosthetics. Once osseointegrated, they serve as the anchor for the following treatments:

  1. Single tooth implants – The most common use for implants is to replace a single tooth at a time. This is also more common than the other treatment options as a single person can have multiple single tooth implants over a lifetime. If either the maxilla or mandible is completely edentulous, it does not make sense to place 14 separate individual implant crowns when there are other much more effective treatment options.
  2. Implant supported bridge – This treatment is the same concept as described in the dental crown except the abutments are implants instead of natural dentition. The number of teeth this treatment option replaces is three but it can replace more. However as the number of teeth being replaced increases, so do the risks of failure due to the Law of Beams and Ante’s Law. 
  3. Implant supported overdentures – Described in detail on our dentures page, this treatment option is also known as ‘snap-in dentures’. It uses traditional dentures and attaches it to implants when restoring an entirely edentulous jaw. By anchoring dentures to a solid structure, it solves the primary weakness of dentures: lack of stability and retention. This holds the dentures firmly in place, which is especially problematic on the lower jaw. This treatment option is incredibly effective and greatly increases patient satisfaction

What is the Process of Getting Implants?

When no bone augmentation is needed, the treatment for dental implants is a relatively straightforward process. The actual surgery itself takes anywhere from 15 minutes to a couple hours, depending on the type of implant treatment and grafting that is required at the time of placement. A large portion of the work is completed prior to the surgery during the planning phases. A 3D image of the jaw is taken using cone beam computerized tomography (CBCT) technology. The CBCT scan allows the surgeon to view the jaw in its entirety to see major structures such as nerves, blood vessels, and sinuses. The scan itself has a high degree of accuracy34https://link.springer.com/article/10.1007%2Fs10278-010-9339-9, allowing for accurate planning. Once properly planned and the risk factors have been minimized, the surgery can proceed.

Implants are placed in one of two situations – either in an edentulous site or immediately after a tooth has been extracted. In either situation, the critical principles remain the same. After the patient is comfortable and has been properly anesthetized:

  1. The jawbone is adequately visualized which may or may not require placing a gingival flap.
  2. An initial pilot hole is made into the jaw, ensuring proper depth and orientation in 4 directions: mesial, distal, lingual, buccal.
  3. Subsequently larger drill sizes are used to widen the osteotomy site.
  4. Once the osteotomy site is an appropriate size, the implant is slowly torqued into place.
  5. Depending on the stability of the implant, either a healing cap or cover screw is placed and torqued down.
  6. If additional grafting at the time of implant placement is needed, it is completed at this time.
  7. If reflected, the gingival flap is approximated in a tension free manner to ensure adequate blood flow.
  8. The implant must heal and integrate for a period of time prior to loading the implant. This time frame is most often 3 months. Depending on the type of prosthesis, the implant may be immediately loaded.
  9. Once osseointegration has occurred, if a healing cap isn’t already present, it is placed during a process called second stage implant uncovering. This very minor procedure is often referred to as the 2 stage implant process and takes a few weeks for the gingival tissues to recontour and heal.
  10. A digital or analog impression is taken and sent to the lab to fabricate the crown.
  11. Once the implant crown is made, it is placed onto the implant via either a screw or cement. A few important aspects of the crown are checked then the entire process is done!

During the osteotomy process, copious irrigation (typically saline) is used to prevent any overheating. Additionally, throughout the process various radiographs (x-rays) are taken to ensure correct angulation of the osteotomy. 

This process is for a single edentulous site and very similar to a multi-tooth edentulous site. However as previously mentioned, there are other uses for implants. While the implant placement process is essentially the same, the prosthetic side will vary depending on the type of restoration being completed.

What is the Healing Process After Implant Surgery?

As previously mentioned, the healing process typically takes 3 months after surgery for the implant to heal and fully integrate. This process can be extended if an implant cannot be placed immediately after extraction. This occurs if the surgeon has reason to believe immediate implant placement will fail, resulting in excessive bone loss. A few of the reasons may include remaining pathology such as an abscess, inadequate blood supply, or a traumatic extraction resulting in fracture of the cortical plate – most often the buccal plate. If this occurs, it is most predictable to graft the site and wait 3-5 months for healing of the edentulous site. Once the site has fully healed and adequate bone turnover has been verified via CBCT, the implant can be placed, initiating the 3 month waiting prior to loading. A few exceptions to delayed loading implants are full arch cases and occasionally anterior implants for esthetic reasons. However there must be 100% patient compliance with immediately loaded implants as any movement will inhibit proper osseointegration. 

How Much Time do I Need to Take Off After Implant Surgery?

While the recovery time varies on a multitude of factors, typically a patient can return to light to normal duties after a few days. Typically after a week or so, a patient can return back to regular activities with the exception of strenuous exercise. The following are a few variables that typically increase the recovery time:

  • Extraction of a tooth prior to implant placement (immediate implant treatment).
  • A more traumatic extraction.
  • Complicated health history – (e.g. diabetes).
  • Age.
  • Multiple implants/extractions necessitating a bigger surgery.
  • Level of sedation.
  • Grafting required at the time of surgery.
  • The patient’s occupational required level of physical exertion. For instance a construction worker may need more time to recover than a desk worker due to the higher required levels of physical exertion.

A good general rule of thumb is the more complicated the surgery, the longer the recovery time will be. The opposite is also true: a single implant placement in an already edentulous site in a healthy ASA I-II patient may return to normal duties the very next day. I have had multiple patients tell me they felt completely fine the next day and didn’t need any analgesics. I even had one patient tell me he forgot he had the surgery the previous day and completed some overdue yard work. If you have any concerns about the recovery time, contact your dental office to get a better idea of how much time you may need.

How Painful are Dental Implants?

Many patients feel anxious prior to any implant surgery, often believing it to be extremely painful. However the pain experienced following the surgery is typically mild32https://aap.onlinelibrary.wiley.com/doi/abs/10.1902/jop.2007.060032 and can be easily managed with short term NSAID analgesics33https://link.springer.com/article/10.1007/s00784-021-03859-y. Most patients generally agree that dental extractions are more uncomfortable than a standalone implant surgery. As the complexity of surgery increases, so does the post operative discomfort. For instance an uncomplicated single implant may rank at a 0-2 on the pain scale whereas a full arch with extractions may be up to a 7-8. These are generalizations as the pain tolerance from patient to patient will vary greatly. If you have any concerns or questions, contact your local dental office.

How Much do Implants Cost?

The cost will vary upon many factors, however depending on the surgery and prosthetic, implants can cost anywhere from $3,000 – $8,000+ for a single implant, up to $25,000 – $40,000 for an all on X (full arch) procedure on a single jaw. Keep in mind these estimates have a wide range and your experience will vary. These estimated costs cover the surgery as well as the prosthetic costs. These estimates may or may not cover any grafting, sedation, or extractions that are may be required for implant therapy. Contact your local dental office to find out more information.

Does My Insurance Cover Implants?

Although implant insurance coverage will vary greatly between plans, if implants are covered, they are commonly covered at 50-80%. Insurance plans often cover the prosthetic costs (the abutment and implant crown) but they may or may not cover the surgical placement of implants. Other factors to keep in mind are the remaining benefits. If the average single implant costs $5,000 and is covered at 50%, then the insurance should cover $2,500 of the costs and your out of pocket should be $2,500. However if the insurance plan only has $1,000 of total benefits, they will only cover a total of $4,000 even though they cover 50% of the $5,000 on paper. This results in an out of pocket expense of $4,000, not $2,500. Additionally keep in mind insurance plans may have a missing tooth clause which states that the insurance will not cover any missing teeth prior to that plan. This means if you had a tooth extracted 5 years ago and you started with your current plan 2 years ago, a missing tooth clause means the plan will typically not cover ANYTHING to replace that missing tooth. Lastly, keep in mind that insurance plans may also have a waiting period which states that some services, typically major, will not be covered for a period of time. That time frame is usually 12-24 months, meaning if you start an insurance plan with the intention of utilizing coverage for certain services, you may not be able to do so until as much as 2 years later. It is critical that you understand your own insurance plan so there are no surprises. Contact your local dental office if you have any questions.

Frequently Asked Questions

How much do dental implants cost?

While the actual cost varies from many factors such as locality, grafting, insurance coverage, and treatment by a specialist or general dentist, a single implant typically costs between $3,000 – $8,000.

How much does a full set of teeth implants cost?

There are variables that will influence the cost, however a full arch case typically costs anywhere from $20,000 -$40,000 per arch. If you need top and bottom, it will cost twice as much.

When does implantation occur?

Implantation occurs when there is adequate bone and no diseased tissue in or near the implant site.

When does implantation bleeding occur?

Implantation bleeding occurs during the actual surgery. However your surgeon will not dismiss you if there is any active bleeding.

What does implantation bleeding look like?

Implantation bleeding looks like oozing blood seeping from the implant site. This is typically not an issue due to advanced hemostatic techniques as well as proper suturing.

How long does implantation bleeding last?

Bleeding from surgery is controlled prior to being dismissed from the office.

References

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