Understanding Dental Implants

"Understanding Dental Implants..." by Dr. Gregory K. Boyajian, CDT, MDT, DDS, Prosthodontist INTRODUCTION Dental implants have received a great deal of attention over the past few years. One reason for this could be the economy. During recessions, it is common for health professionals to be retrained in new skills and to return to school for higher education. With the decrease of patient appointments, many dentists have taken the opportunity to expand their skills and their knowledge and learn more complex procedures, like dental implants, in hopes of it being financially rewarding for their practice. The purpose of this article is to provide you with simple and unbiased information about dental implants. I promise you – there will be no gloom, doom, or sugar coating here. Just the facts. HISTORY More than a century ago, American dentists “experimented” with putting metal inserts in human jaws to anchor artificial teeth to them. Much like the Wright brothers’ contribution to aviation, those dentists paved the way for dental implants. Although it wasn’t successful and the failure rate was extremely high, the implant was born. Now, it’s a vital service offered to the public in specialty and general dental practices. DENTAL IMPLANT The term does not mean, “to insert an artificial tooth where the natural tooth used to be.” Dental implants, in reality, are highly engineered screw-like metallic structures that are surgically inserted into the jawbone and underneath the gum. This totally submerged implant is designed to accept a metal or ceramic post that emerges through the gum. Over this post, an engineered crown (tooth) is placed on top of it either via a small screw and/or with cement. Like Cosmetic Dentistry, Dental Implantology is NOT a recognized specialty by the American Dental Association. Dentists can limit their services to only “do implants,” but they are not permitted to use a prestigious “Specialist” title. WHEN TO USE DENTAL IMPLANTS In general, dental implants are used to replace missing teeth and/or to anchor removable teeth for more retention (other uses include facial reconstruction due to trauma). They could be used in any situation where candidates need successful results like better function, comfort and health, or for aesthetic purposes. Patients must be good candidates for this surgical procedure, both orally and systemically. A consultation combined with an education in dental implants is necessary prior to commitment. A well-informed patient must know and understand the pros and cons, specifically for his/her condition. Patients who are new to this treatment are encouraged to seek a second opinion. Be aware for false promises such as that they are “forever” or they are “permanent.” I understand that it’s natural to share concerns with friends, family members and loved ones, but this is not the type of procedure to be discussed for opinions, to do so is unwise because dental implant questions need to be answered by knowledgeable, skilled professionals in this field. Seeking information from retired doctors or from professionals with limited experience and background in this field is a poor choice. OPTIONS Naturally, dentists recommend procedures they are comfortable with, putting the patient’s health at the top of their list. Providing different recommendations for replacing missing teeth is not a simple task. Multiple factors must be taken into consideration because the patient’s general health and oral condition are not the only requirements for a successful result. A comprehensive treatment plan must be made based on the patients’ short and long term needs. Most individuals, when seeking dental implants, want to have their own teeth back so they can eat, smile and enjoy life again. PROCEDURE Without going into details, there are numerous sources that describe the procedure. These sources are often found on the Internet or on a dentist’s website. Sometimes they include an animation that’s done in a simple and straightforward way, but do not cover everything because they do not want to elevate an individuals anxiety. For an example, they may refer to “pain” as “discomfort.” In my opinion, it’s best to read about implants from good sources, which are made toeducate the public and not to persuade. It’s like a building a house – first, the land must be suitable to build on, then the house has to be designed by an expert before laying the foundation. After deciding what type, size, length and the width of the implant to use, the operator will use a surgical guide or a special computerized program to ensure the proper angulations and depth are achieved. Impinging on adjacent natural teeth or other critical anatomic structures must be avoided. After placing the implant, the gum is closed to create a natural healing environment where the jawbone grows toward the implant and penetrates its surface. If this does not happen, the implant should be removed. Dental implants are not simply “glued” to the jaw. The surface of the implant is bio engineered to naturally adhere to the bone, which is why titanium metal is preferred. It’s complex oxidized surface, strength, light weight, abundance and machinability prove that this metal is the best choice. Other materials have been used in the past such as ceramic dental implants, which have been reintroduced to Dentistry, but this time they are made with Zirconium Oxide, nonmetallic, white materials that are desirable in the front of the mouth for aesthetic reasons. As with any “new” system, time will tell if it makes a big impact in the ever expanding dental implant market. TIMETABLE “You can have your implant and tooth,” reminds me of the popular saying, “You can have your cake and eat it (too).” Yes, it can be done, but this “can be done” is not the answer. “Should it be done,” is the correct way of thinking. Assuring the success of the implant in bone must be the highest priority. If this is compromised, then the rest of the procedure is weak and worthless. Expediting healing is possible, to a point, but natures way of accepting the implant requires TIME. This fact is supreme - deviation from it is unwise. All of this depending on the patients age, health and nutrition. Prior to initiating the implant(s) procedure, a detailed plan must be created that’s suitable for the practitioner and patient alike. Usually, “temporary” teeth are made during the implant healing period. This is done to allow the jawbone to accept and embrace the dental implant, depending on factors such as: - Location of the implant in the mouth - Type of implant - If “artificial” bone is used before or during the surgery IMPLANTS and DENTAL TEAM The scientific protocol for successful implants came to the United States from Europe in 1982 by the introduction of the osseointegration from Professor Br?namark of Sweden (see photo below), a world-renowned orthopedic surgeon. The protocol called for teams of THREE to accomplish the treatment: an oral and maxillofacial surgeon to insert the implant, a dentist to carry on with the rest of the procedure and a dental technician to assist with the surgery. While this is ideal, it’s not always practical. Today, implant dentistry can be done by periodontists and general dentists, as well. There are many dentists, and many who are good and do both the surgical phase (placing the implant) as well as the restorative phase (providing the tooth) with the help of a laboratory technician. Few, have an in-house lab. And the unsung hero of this team is the dental hygienist, who is professionally trained in the art and science of maintaining the health of the mouth, and thus, the longevity of the implant.

During my post doctoral residency at the University of Florida, I had the privilege to interview Professor Br?namark during his visit to the United States. The interview was published in the "Official Dental Laboratory Journal," entitled "Trends and Techniques." IMPLANT vs. CONVENTIONAL CROWNS The part of the tooth that is under the gum is called the “root,” and the part that we see above the gum is called the “crown.” A dentist can use a removable one or a fixed one to replace a missing tooth. A fixed crown is preferred, but it requires using the adjacent teeth on either side to anchor the tooth, which is why it often times requires three teeth to do and why individuals object it. Unfortunately, this issue gets blurred because there are dentists who won’t replace a missing tooth with an implant and others who are more flexible. Implant or no implant, this topic should be addressed in the dental office with respect to the American Dental Association’s (ADA) Current Standard of Care. As always, with the patients best interest in mind - long and short term - evaluate risk and benefit, taking into consideration the patient’s physical, emotional and financial realities will lead to a mutual understanding, trust and respect. IMPLANTS vs. REMOVABLE TEETH “Fixed” teeth are always preferred over “removable” teeth. Dentists too, would like to give patients fixed teeth, but this is not always possible. Patients, who refuse this unpleasant reality of life, make the mistake of searching for a doctor to “receive dental implants.” If general health is not a factor, but the bone volume needed is not adequate enough, then a Bone Grafting (Augmentation) procedure can make it possible for patients to have fixed teeth and free themselves from unnatural, removable ones. This way of having implants should be left to surgical specialists who will work with the dentist (and Lab) in order to give the patient naturally beautiful teeth that function like “normal” teeth. Note, simple and complex situations should be treated differently and no one should, “bite more than they can chew”. (Fitting phrase, right?) WHAT IS “ALL ON FOUR?” It’s a procedure that originated in Europe. Popularized in Italy and now spreading like wild fire in America, it relies on the Cross Arch Stabilization method, which means the upper and the lower jaw must receive a full arch (horse shoe shape) dental prostheses-bridge. Teeth are then anchored to four implants in the anterior part of the mouth. Note, this requires removal of ANY existing teeth (good or bad) for this procedure. I question this philosophy since tooth preservation has been a noble mission in our profession. This treatment is offered in many parts of the U.S., and usually with a heavy marketing budget backing it – many times, highlighting the positive sides of the procedure and downplaying the negative during consultations. The dentist’s professionally trained staff are often the ones used to “sell the case.” They will tell you that you can, “have all your teeth in one day, go home and eat your dinner,” and to “no longer worry.” It is in my 40+ years of experience that this procedure is NOT always the best choicebecause there are many negative sides to it. Proper planning and proper sequencing will expedite the treatment, however this is not always the popular choice. ARE IMPLANTS FOREVER? No, nothing on earth is. Even the sun has a “lifespan!” “Are dental implants permanent?” Again, no! The word permanent in dentistry relating to dental implants has been replaced with the word fixed in order to distinguish it from the phrase,removable teeth. Implant longevity vs. Crowns is a debatable issue. Readers should be careful from jumping to conclusions. And this topic of longevity is very important and should be discussed with dentists. CONCLUSION Dental implantology is a surgical procedure that’s followed by a restorative one. This is how dentists refer to dental implants. Today, dental implants can be done and highly successful when a comprehensive examination and treatment plan are done utilizing the use of C Scan Radiology, in order to assure no trauma is caused to the anatomic structures of the mouth, namely the maxillary sinus of the upper jaw (maxilla) or to the lower jaw’s two main nerves – the inferior mandibular nerve and the incisive nerve, which are both branches of the trigeminal cranial nerve (commonly known as the, “dentistry’s nerve”). This article was written in simple terms in order to inform the dental patient. More reading and consultation is highly recommended. Dr. Gregory Boyajian is a practicing Prosthodontist in Palm Beach, Florida. Visit www.smilepalmbeach.com for more information about his practice.