02 Nov All you need to know about dental implants by Professor Jose Nart
At Nart Dental Clinic Barcelona dental implants are placed by Professor Jose Nart Molina, a reference and opinión leader in implantology at a European level, who is also a teacher and researcher in oral implantology. His clinical cases are shown at the most important congresses in implantology in the world (EAO, AAP, SEPA, Osteology, Quintessence), and his research on dental implants is published in the scientific journals with the greatest scientific impact (JCP, COIR, JP, CIDRR, CLOI, IJPRD).
The protocols used at Nart Dental Clinic Barcelona combine the best planification, materials and patient´s consideration. The commitment is to carry out the simplest, quickest, least painful and efficient treatment, using the world’s leading brand of implants.
Is it necessary to have a dental implant if I am missing a tooth?
Generally speaking, we place dental implants to replace the loss of 1 or more teeth. We can replace all the teeth except for the wisdom teeth.
It is important to replace the lost teeth to maintain the masticatory function avoiding digestive problems, and to avoid the movement of the back teeth into the space or the top or bottom tooth with which you would chew as they get extruded (move up or down). We also recommend replacing the lost teeth with implants to maintain the bone and the position of the gum and aesthetics.
It is an international scientific consensus, due to the high level of success and satisfaction after treatment, that dental implants are the best option for replacing our lost teeth, avoiding the grinding of healthy neighbouring teeth as we would do with a bridge, or the discomfort and overloading of neighbouring teeth that a removable prostheses would generate.
What is a dental implant?
An implant is a device made of titanium, but it can also be made of zirconium, which placed inside the bone is used to screw a tooth on.
The dental implant and the bone are joined by a process called osseointegration that takes 6 to 8 weeks. When the implant and the bone are joined, the implant acts like a female and we proceed to make the crown or tooth and screw it onto it. We can also make bridges or prostheses for all the teeth if more than 2 or more teeth are missing.
How many implants can I have in one day?
You can have as many implants as you need in the same surgery. The insertion of dental implants nowadays is a very minimally invasive procedure and in the majority of cases it generates very little discomfort and rarelypost-operative inflammation.
How many implants do I need to replace all my teeth?
In general, a patient who has lost all his teeth needs 6 implants in the upper part and 6 implants in the lower part in order to replace the lost teeth with a fixed prosthesis. It is true that in some situations 4 implants in the upper part and 4 implants in the lower part could be enough to replace all the teeth. On other occasions in older patients we could stabilise a lower denture with only 2 implants.
Does it hurt to get a dental implant?
The insertion of a dental implant should not hurt as it is carried out under local anaesthetic. Furthermore, the post-operative period of the following 2 or 3 days should not generate any pain or discomfort either, and in most cases the patient is expected to need only 1 or 2 painkillers after the placement of 1 or several dental implants. The patient should understand that dental implant surgery is minimally invasive by making a very small incision in the gum after planning the intervention in the 3D CT. Of the more than 2000 implants placed by Dr. Nart in the last 4 years, 95% of the patients only needed 1 or 2 analgesic or anti-inflammatory tablets. In cases where we have to perform bone or gum regeneration at the same time as placing a dental implant, the use of anti-inflammatories will be extended by 2 or 3 days, but not beyond that.
Which specialists can place dental implants?
All dentists can place dental implants. Although it is true that those who have specialist training in implantology or implants have higher success rates, fewer complications and better maintenance of dental implant treatments over time. The trained or specialist in periodontics and implants have the training and capacity for the surgical part of the treatment (the placement), to have adequate gingival around, to diagnose and treat the diseases of the dental or peri-implantary implants, and to carry out the maintenance of the healthy implants in the long term.
Is a dental implant forever? How long does it last?
The success of dental implants in the short term is around 98%, the long term success varies depending on the type of prosthesis on the implant and the results at 15 and 20 years of follow-up show a success between 92 and 96%, depending on the brand of implants placed.
There are patients with a higher risk of losing implants in the short term and among them smokers, diabetics, those with poor oral hygiene, those who have not been treated for periodontitis, as well as those allergic to amoxicillin. Those who are more at risk of losing implants in the long term are smokers, those who do not go to the dentist for professional maintenance every 6 months, those who have poor hygiene and those who have on their implants non hygienic prostheses, which do not allow access to hygiene.
Is there any patient who cannot have a dental implant?
The only patients who could not have dental implants would be those allergic to Titanium to whom we would recommend Zirconium implants. Allergy to Titanium has been described in an invaluable percentage.
Patients who smoke should reduce or quit smoking, and diabetics should have their glycaemia controlled with glycated haemoglobin below 6.8%. Patients taking oral bisphosphonates should evaluate with their physician the risk-benefit of continuing or suspending their treatment. Also, recently irradiated patients will have to wait for some time to have their implants placed.
Can I refuse a dental implant?
Dental implants are not rejected, they can fail initially before the teeth are placed or they can fail late once the teeth are already on the implants.
The initial or early failure is usually associated with an infection or some surgical difficulty such as limitations in the quantity and quality of the bone, stability in the implants, incorrect planning of the implants or absence in the preparation of the patient. Late failure is usually associated with infection of the dental implants, called periimplantitis, or situations of overloading the dental implants through their prostheses. It is worth remembering that both early and late failures are exceptional situations due to the very high success rate offered by dental implants today, although it is clear that dental implant treatments must be very carefully planned, correctly executed and properly maintained over time.
The patient should also know that if an implant fails it can be placed a second time and according to the available scientific studies the success rate of the second implant is still over 90%.
How do you know if the implant is well integrated or attached to the bone?
Traditionally, it takes between 3 and 4 months to place a tooth on an implant. The integration of the implant was checked by means of an x-ray by tapping the implant itself and listening to a matt sound. Nowadays, the implant-bone connection or osseointegration can be measured with an apparatus by means of resonance (ISQ values). This device provides values on a scale from 0 to 100, and the existing scientific evidence indicates that implants are successful with values above 65. Values above 65 are usually obtained 6-8 weeks after the placement of the implants (for some brands of implants).
How long should I wait to put my teeth on the implants?
For many years it was usual to wait between 3 and 6 months before being able to put teeth on the implants. Today the process of integration of the implant into the bone has been greatly accelerated thanks to the new surfaces of the dental implants. In most cases the teeth can be placed from 6 to 8 weeks after the placement of the implants.
Are all implants the same?
The reality is that not all implants behave in the same way. Very few brands of implants report medium or long term results, and we have almost no comparative studies between the different brands. The main differences between the implant brands are: the design, the surface, the connection and prosthetic components, and the composition of these. These 4 factors make the implants behave very differently in terms of success rates, short and long term survival and complications.
How long does it take to place a dental implant?
The surgery of placing an implant is simple and usually lasts about 20 or 30 minutes if it has been planned correctly beforehand.
In situations where we place the implant after the extraction of the tooth, the procedure is a little longer. It is also longer when we have to regenerate the bone or gum at the same time as we place the implant; on these occasions the procedure can take around 60 minutes. If the surgery has been properly planned and the placement of the implants has been done in the CT, the placement of the implants is usually very fast.
It is important to emphasize that the faster and simpler the surgical procedure is, the fewer complications and less postoperative pain there is. Therefore, preparation and planning are essential to make dental implant surgery simple and well executed.
How are dental implants cleaned?
Implants need good oral hygiene, thorough and detailed every 12 hours. The gums around the implants swell very easily and are more vulnerable than the teeth.
Implant-supported prostheses must allow access to hygiene, that is, they must allow the patient to sanitise them 360º around them, ideally with an electric toothbrush and with interdental brushes twice a day. In prostheses that replace all the teeth, the use of irrigators can be added without replacing the interdental brushes. In addition, every 6 months the implant patient should visit the dental clinic for maintenance or professional hygiene.
If the oral hygiene around the implants is not correct the patient will develop mucositis and if this is not treated probably periimplantitis. Periimplantitis is an infection of the gums and the bone around the dental implants caused by bacteria that generate loss of bone and in the end the loss of the implant itself.
Can I work after getting an implant?
The post-operative period after the insertion of dental implants is gentle and does not compromise the daily routine. The vast majority of patients do not need to take anti-inflammatory or analgesic medication. In some particular cases where bone or gum regeneration has been carried out, or where many implants have been placed in the same surgery, a relative rest of 24-48 hours may be recommended.
What if I do not have enough bone to place an implant?
In the immense majority of cases we can place implants even when there is limited availability of bone, using short implants or narrow implants. In situations where even using narrow implants there is little available bone we can regenerate bone at the same time as placing the implant. In those exceptional situations where it is not possible to place the implant regenerating bone at the same time, we will carry out the bone regeneration prior to the placement of the implant and we will have to wait about 4 to 6 months to place them.
In bone regenerations we usually use cow or corpse bone substitutes. These particles are covered by collagen membranes in most cases.
Do I need gum around a dental implant?
Clinical studies show that having keratinized gums around implants is very important for your long term health, and also to obtain an ideal aesthetic in time.
When we have gum around the implants we can brush them better, there is less inflammation, less bleeding and therefore we prevent the diseases of the implants from occurring.
On the other hand, and to obtain the best aesthetic result we need to have a certain thickness of gum so that the appearance of the tooth on the implant is natural.
We can carry out gum grafts at the same time as we place the implants or once they are in place. In the majority of cases this gum will come from the palate or from the area of the patient’s own wisdom tooth.
What will I feel when I have the implant?
The sensation that the patient perceives must be very similar to that of a natural tooth both in chewing and in aesthetics. Teeth on implants allow you to chew and eat in a very similar way to natural teeth, and aesthetically they can be indistinguishable from them. Studies report very high patient satisfaction after having been treated with dental implants, more than 95% of them would repeat the treatment and recommend it.
Images 7 and 8. A central incisor in each photo was fractured and replaced by a dental implant and its ceramic tooth. As can be seen in the photographs, the aesthetics are ideal and cannot be differentiated from the neighbouring natural tooth. With teeth on implants you can also eat in the same way.
What is immediate loading?
It is when we place the implant and the provisional tooth on the implant at the same time or within the first 24 hours. And by protocol at Nart Dental Clinic Barcelona we carry out immediate loading, that is, we place the implants and the provisional teeth at the same time when it is a question of teeth in the aesthetic zone or before, and when we replace all the teeth in the mouth in the upper or lower zone. These provisional teeth placed on the same day as the implant surgery fulfil their aesthetic function, but we do not recommend eating with them for the first month and a half.
We do not usually place provisional teeth in the back teeth at the same time, as eating there during the first month would mean a greater risk of losing the implant.
What is an immediate implant?
An immediate implant is one that is placed at the same time as the extraction of a tooth, i.e. just after the removal of a tooth in the remaining space. When the patient loses a tooth, there is usually bone left on the sides or on the upper/lower part in order to anchor and stabilise the implant. In this way the patient is spared another subsequent surgery, shortening the treatment and the number of visits to the dentist. On the other hand, the placement of the implant after the removal of the tooth can be technically more complex and will need bone and sometimes gum regeneration in the aesthetic zone if we want to achieve the best result.
What is guided surgery?
It is the placement of the implant through or by means of a surgical resin splint that directs the position of the implant in an unalterable way, according to the planning previously carried out in the CT scan or 3D radiography, and therefore guaranteeing its ideal position.
Implant surgery in general must be guided to ensure the best position of the dental implants. This guided surgery can be performed with a closed or open splint, and can be performed by raising the gum a little or through it. Depending on the case, we will choose one or another treatment option.
Do I have to go without teeth or can I take a provisional one after having an implant?
You should always be able to wear a provisional after having an implant. Furthermore, in the case of implants placed in the aesthetic zone you can wear a fixed provisional tooth, screwed to the implant, from the moment of surgery. If you have had implants inserted to replace all the teeth in your jaw, you can also have fixed provisional teeth inserted to replace them all at once. Your aesthetics should not be altered.
If you already have a removable, removable pre-dentures, in many cases you can adapt to a fixed prosthesis on the implants just after insertion.
What are dental implants complications?
The most important complications can be early or late. The early ones include infection or loss, not osseointegration, of the implants during the first 3 months after surgery. It is usually rare if we have planned the treatment correctly and the patient is hygienized and prepared. It can occur more frequently in patients allergic to amoxicillin, and in those who have subjected dental implants to heavy chewing loads during the first month and a half.
Late complications can be mucositis, inflammation of the gum around the implants; periimplantitis, inflammation of the gum and loss of bone around the implants; and loss or failure of the implants due to overloading (squeezing) or loss of osseointegration over time.
Do I have to take antibiotics for the implant surgery?
Currently and according to the scientific evidence available, it is recommended to take 1 gram of Amoxicillin 1 hour before implant surgery, to reduce the possible early infection. There is no evidence that taking the antibiotic after the placement of the implants will help. Nor is there any evidence of indication for antibiotics other than amoxicillin.
If we place implants with bone regeneration we may prolong the antibiotic intake a few days after placing implants.
What are one or two-stage implants?
In the past, implants were placed in two stages; they were covered with the gum on the day of the surgery and the gum was uncovered after 3 months, in another surgical intervention. Nowadays, implants are placed in a single surgical phase which means that a healing cap is placed over the implant and the gum heals around it, saving the patient the second surgery, making the treatment less morbid and longer.