Almost all dental implants used today are made from titanium or titanium alloy, materials that have been shown over many years to be well tolerated by bone. The terms ‘osseointegrated implants’ or ‘endosseous implants’ are widely used to describe dental implants that can develop and maintain a close union with bone in order to support replacement teeth. A dental implant is essentially a substitute for a natural root and is usually screw or cylinder shaped. Each implant is placed into a socket carefully drilled at the precise location of the intended tooth. If an implant has a screw-thread on its outer surface it can be screwed into position and if it does not, it is usually tapped into place. The main aim during installation of any implant is to achieve immediate close contact with the surrounding bone. This creates an initial stability, which over time is steadily enhanced by further growth of bone into microscopic roughness on the surface of the implant. In order to support replacement teeth, dental implants normally have some form of internal screw thread or post space that allows a variety of components to be fitted. Once fitted, these components (the abutment) provide the foundation for long-term support of crowns, bridges or dentures.

All the common forms of tooth replacements, such as bridges or dentures can be replaced by dental implants. If you are missing just one natural tooth, then one implant is normally all that will be needed to provide a replacement. Larger spaces created by two, three or more missing teeth do not necessarily need one implant per tooth, however the exact number of implants will depend upon the quality and volume of bone at each potential implant site. Occasionally, it is even possible to join natural teeth to implants with a conventional bridge. In the upper jaw, bone density is generally poorer than in the lower and if you have no teeth at all, most treatment providers will want to place a minimum of 4 implants to support a complete arch of 10 or more replacement teeth. In the lower jaw, the bone towards the front of the mouth is often very strong and as a direct result, fewer implants may be needed than are required to treat a whole upper jaw. A simple treatment plan to provide 10 or more teeth in the lower jaw might be possible with as few as 2 implants, although it is still more common to use 4 - 6.

If you have good general health, then dental implants will almost certainly work for you. However, habits such as heavy drinking or smoking can increase the number of problems associated with initial healing and thereafter may negatively influence the long-term health of gum and bone surrounding each implant. Remaining teeth might also be compromised making treatment planning less certain. Some dentists will decline to place implants if smoking cannot be reduced or given up altogether. If you have any other complicated medical problems, then speak to someone with relevant experience - it is rare to have health problems that prevent the use of dental implants.

When you first enquire about dental implants it is often in response to an awareness of ongoing dental problems or the recent loss of teeth. Each of these problems will need to be diagnosed and treated in a logical manner, often placing implants in order to establish healthier conditions. Although it is tempting to focus on the more glamorous aspects of teeth supported by implants, basic dental health, which includes the treatment of gum disease, repair of decay and the elimination of abscesses will be just as important for the long-term success of your treatment. If you are aware of bad breath, loose teeth, or have noticed excessive bleeding, particularly when your teeth are cleaned professionally, you may have gum problems. Periodontal (gum) disease is a major cause of bone loss and with reduced bone, dental implant treatment can be more complicated.

Whenever a tooth is lost or extracted a considerable amount of the bone that once surrounded the remaining root portion may disappear. This loss can be particularly rapid during the first few months and is described as ‘bone resorption’. Although the rate and amount of bone resorption is highly variable between individuals, it will always occur to some extent, unless specific care is taken to reduce its effects. Sometimes, the simplest measure to minimise bone loss after an extraction is to place the implant immediately or with the first few weeks. Dentures Many patients report that after a while their dentures become progressively looser and do not fit as well as they once did. Initially, the increased rate of bone loss following extractions is responsible for the observed deterioration of denture fit. Over the long-term it is the direct effect of chewing forces that causes slow resorption of supporting bone. Most people who have had dentures for many years will have needed a reline procedure to compensate for this bone loss. Therefore, the longer dentures are worn the less the amount of bone available for dental implants.

If an implant does not achieve or cannot maintain a rigid fixation with the surrounding bone it will eventually become loose and no longer able to support replacement teeth. Commonly the failing implant causes no discomfort and if there are enough other supporting implants remaining, it may not be necessary to replace it at all. Failures may not always be so easy to deal with and if you embark upon this type of treatment you have to be prepared to deal with this possibility. Most treatment providers will want to achieve rates much less than 5%, however in practice this could mean that 1 in 20 of the implants placed might not survive in long-term function. It is a good idea to discuss how your treatment plan might be affected by the loss of an implant.

For routine cases, from the time of implant placement to the time of placing the first teeth, treatment times can vary between 6 weeks and 6 months. The availability of better bone can be used to decrease treatment time, whilst more time and care must be taken with poorer bone, which can therefore extend treatment times beyond six months. If there is no reason to shorten the duration of your treatment then be prepared to wait - nobody loses an implant from being patient and allowing the bone to osseointegrate with the implant.

During the period after the new teeth are fitted, the success of each treatment stage will be the main factor determining how the implants are performing. Once the implants and surrounding soft tissues are seen to be healthy and the new are teeth comfortable and correctly adjusted, it is the quality of your home care and willingness to attend regular maintenance reviews that will have the most influence on how long they will last. When poorly cared for, implants will develop a covering of hard and soft deposits (calculus and plaque) which is very similar to that found on neglected natural teeth. Untreated, these deposits can lead to gum infection, bleeding, soreness and general discomfort, just as can occur around natural teeth. It could probably be said that implants much like teeth will last for as long as you can keep them clean. Well-maintained implants placed into adequate bone can be expected to last for many years and probably for your lifetime. However, just as you would expect conventional crowns, bridges and fillings to need occasional repairs or replacements during their lifetime, your implant-supported teeth may also have similar maintenance requirements over theirs.

It is accepted practice that you should be given a written summary of your treatment planning discussion(s), highlighting your current dental situation and any alternatives there are to dental implants. This summary should also include an overview of the anticipated treatment stages and give you some idea of how long treatment is likely to take, how many implants are required and what the fees are expected to be. There may well be other issues specific to your case and these would be dealt with accordingly.

Routine dental x-rays show large amounts of detail, but in only two dimensions. From these views it is generally possible to judge the height of bone available for implant placement, however, more advanced imaging techniques are sometimes needed to determine the equally important bone width, which can otherwise only be estimated from clinical examination. Dental CT scans There are now a number of advanced x-ray techniques which allow your jawbone to be looked at in all three dimensions. The most accurate and widely available is known as the CT (computed tomography) scan. Images obtained by CT scanning will normally be able to show all of the information required about your bone, including quantity and quality, but most importantly the presence of anatomical structures that must be avoided. All of these CT scans are undertaken on site at the practice.

Upper jaw In the upper jaw, provided the implants stay within the bone that once supported your own teeth there are really no important risk areas. If you have missing upper back teeth then the shape and location of the maxillary sinus (the region above the roots) can be shown to you. The maxillary sinuses can be seen on most x-rays and are therefore readily avoided. Lower jaw In the lower jaw the most important anatomical structure to be avoided is the ‘inferior dental nerve’. This nerve runs from the area behind the wisdom teeth, passes under the molars and emerges onto the skin of the face in the region where your premolar teeth are or used to be. This is why a normal dental anaesthetic produces a numb lip even when the needle was placed right at the back of the mouth. If this nerve is disturbed or damaged during the placement of dental implants it can lead to temporary or even permanent numbness of the lip on the affected side. This is a rare but important complication. CT scans are generally the best means for identifying the location of this nerve and allow implants to be placed with considerable confidence. However, these are rarely available within a normal dental surgery environment. It will therefore require a visit to a suitable hospital where the scan is generally completed within a few minutes. Whilst CT scans are more expensive than routine dental x-rays, the information they provide is often invaluable for complex treatment planning and knowing where important anatomical structures are located.

Dental implants are routinely placed beside natural teeth and this is generally very safe to do. The only exception to this would be if the natural root was very curved or tilted unfavourably in the proposed path of the implant. This could cause the root to be damaged by the implant, however this can usually be avoided by careful pre-operative planning. If a tooth is inadvertently damaged by the placement of a nearby implant, any resulting problems can generally be resolved by root canal treatment in which the nerve of the natural tooth is removed.

If the teeth being replaced by dental implants are in a clearly visible part of your mouth it is most likely that you will want to have some teeth present whilst the treatment is underway. There are a number of ways that this can be done, ranging from simple plastic dentures to removable bridges. If replacement teeth are used during treatment stages it is important that they do not apply uncontrolled pressure to the underlying implants. You should expect to make a number of visits after the implants are placed and before they are bought into function, for small adjustments to any temporary teeth.

Most patients will be very familiar with the dental anaesthetics used for routine dentistry and will know how effective they are. Implants are placed using the same anaesthesia. Depending upon the complexity of your case, the operation might take anything from 30 minutes for a single implant, to several hours for complex bone grafting and multiple implant placements. Since the surgery normally involves exposing the bone in the area where the implant and/or bone graft is to be placed you can expect some minor swelling and occasionally bruising afterwards. For most patients, any of the simple painkillers you might take for a headache will be all that is needed for a few days. If you experience more discomfort than this, contact your treatment provider who can prescribe a stronger medication. Healing is generally uneventful and any stitches are removed two weeks later. During the first few days you should report any unexpected levels of pain or swelling so that it can be assessed. If in doubt always ask for advice, as early detection of a problem will often lead to a simpler solution. You may also be asked to take a course of antibiotics and to follow some simple procedures such as rinsing with salt water or an antiseptic mouthwash. It is important that you carry out these instructions.

Increasing bone with Geistlich Bio-Oss®/Geistlich Bio-Gide® This explanation sheet describes the material characteristics of Geistlich Bio-Oss® and Geistlich Bio-Gide®. It should be read together with other information you receive from your dentist for your planned treatment. It will assist you in giving your informed consent to the treatment. Why is an explanation necessary? There are numerous materials that are currently available for increasing bone. Your dentist must inform you about the alternative treatment methods and the materials that are available. Geistlich Bio-Oss® Bone replacement material 1. What are the reasons for using Geistlich Bio-Oss®? In your particular case, you do not have enough of your own bone available for the dentist to be able to stabilise a tooth to securely anchor a dental implant. Geistlich Bio-Ossc® will be used to increase your own bone, thus providing the dentist with an adequate amount for the procedure you require. 2. What is Geistlich Bio-Oss®? Geistlich Bio-Oss® is a bone replacement material that is used to increase the body’s own bone. Geistlich BioOss® is composed of the hard, mineral portion of natural bone and has a structure very similar to that of a human bone. It is therefore well accepted by human bone tissue and serves as a guiderail for the new bone growth. The starting material is carefully inspected bovine bone that has undergone treatment with patented processes for purification and sterilisation. Included amongst these processes is the treatment of Geistlich Bio-Oss® at high temperature for more than 15 hours, after which it is highly purified and finally sterilised. In certain procedures, Geistlich Bio-Oss® collagen is used for regenerating bone. This product is the same as the Geistlich Bio-Oss® described above, but has highly purified natural collagen fibres added to it. The collagen is obtained from pigs. 3. What is the function of Geistlich Bio-Oss®? Geistlich Bio-Oss® is a solid scaffold which serves as a guiderail to allow new bone to grow. This scaffolding material enables and facilitates bone formation in the area where the operation is performed. It is inserted into the operation area in the form of grains or small blocks. Your own bone slowly grows in the Geistlich Bio-Oss® material, which at a later time is gradually broken down by the body. 4. Are there alternatives? As an alternative to Geistlich Bio-Oss®, one can use the body’s own bone, which is taken from a different location, for example the chin or hip. However, this procedure requires additional anaesthesia. Once the bone sample is removed from its original site it is then inserted into the operation area. In this procedure, the following must be considered: There is now a second area of operation, which may be associated with additional pain or loss of sensitivity. It is possible that the amount of the newly gathered bone will not be adequate for the intended purposes. Geistlich Bio-Gide® Collagen Membrane 1. What is Geistlich Bio-Gide®? Geistlich Bio-Gide® is a membrane made of collagen that is generally used to cover the bone replacement material. 2. What is the function of Geistlich Bio-Gide®? It has been proven that better healing rates are achieved when the Geistlich Bio-Oss® particles are covered with a membrane (Geistlich Bio-Gide®). Because the tissues of the gum grow more rapidly than the new bone, the membrane protects the Geistlich Bio-Oss® particles from this faster growing connective tissue. This ensures that the underlying bone can heal in an undisturbed fashion. 3. What is Geistlich Bio-Gide® made from? Geistlich Bio-Gide® is composed of highly purified natural collagen obtained from pigs. 4. Does the Geistlich Bio-Gide® membrane have to be removed in a second procedure? No. The collagen membrane becomes completely broken down by the body, hence a further operation to remove it is unnecessary. Are there any independent quality controls? The manufacturing processes of Geistlich Bio-Oss® and Geistlich Bio-Gide® are subject to a Quality Assurance System based on international guidelines (ISO 9001/EN 46001). These processes are checked once every year by acknowledged, independent testing institutes and international authorities. Geistlich Bio-Gide® and Geistlich Bio-Gide® are medical devices that satisfy the safety standards and conditions required by European Union (CE - certification) and the US Food and Drug Administration (FDA) Do side-effects occur? As with almost natural and artificial materials incomparability and allergic reactions are possible and can never be fully excluded. However, because of the high degree of product purity such reactions have been limited to a few mild individual cases. If you experience any reactions, tell your dentist or doctor.

One-stage implant The implant is placed into a new, healing or healed extraction site and is visible above the gum immediately after placement. The advantage of this method is that a second surgical stage is not necessary to expose the implant. The implant will not normally be ready to support a tooth for several weeks or months. Two-stage implants The implant is placed into a new, healing or healed extraction site and then covered by a layer of gum so that it cannot be seen - this is the first stage. At the second stage some weeks or months later, the implant is uncovered and components added bringing it above the gum ready to begin placing a new tooth. Same-day implants This technique is most often used to treat the lower jaw and requires considerable planning before the actual day of surgery. Several implants are installed and a few hours later a complete arch of temporary or permanent teeth can be fixed in place. If temporary teeth are used these will normally be replaced with a permanent bridge after a suitable healing interval. Not all patients are suitable for this style of treatment. Immediate implant For this technique a tooth is removed and an implant placed immediately into the extraction site. Depending upon the local bone and soft tissue conditions, the implant surgery may be a one or two stage procedure. Not all patients are suitable for this approach. Immediate implant and early loading This is distinctly different from an immediate implant placement. It is effectively a one-stage technique where the implant is placed into a new, healing or healed extraction site and is fitted with a new tooth at the same appointment. This first tooth will normally be kept out of direct contact with opposing teeth for a healing period of more than 3 months, after which it is finally restored. This technique tends to be more common in regions of the mouth where optimum aesthetics are important. Again, not all patients are suitable for this approach.

Diagnosis and treatment planning after which it may be necessary to carry out repairs or treatment to any remaining teeth. Implant placement is usually followed by a period of healing lasting from 6 weeks to 6 months. Often the implants are completely hidden beneath the gum, however one-stage procedures where the implant is visible from the time of placement are also commonplace. Stitches are normally removed 7 to 10 days after the implant placement. Several visits may be needed over the next few weeks to adjust temporary teeth or dentures and to monitor healing. Once the implants have healed uneventfully for the required time, they are uncovered if necessary and made ready to connect the teeth. Sometimes the time allowed for implants to integrate may be increased or decreased to suit the local bone conditions and the overall quality of healing. In some cases the first teeth fitted to your implants are not the final ones, but replicas of the intended design. This stage can be used to assess the implants, control early loading and in areas where aesthetics are more critical, also gives the gums time to mature around each implant before final teeth are fitted. Final teeth are commonly fitted between 3 and 9 months after the implants were first placed. The way that the teeth fit together is carefully adjusted so that they do not interfere with each other. Regular examination and hygiene appointments are then all that is required to maintain the health of the mouth, teeth and implants