Sedation Dentist serving High Point, Greensboro, Winston-Salem and the Triad area.

Implant Dentistry

Dental implants come in many different forms. There are subperiosteal implants, ramus frames, blades, and root form implants.”The subperiosteal implant is mostly used for areas where the bone is not of sufficient height to accommodate root form implants, and is mostly used in’shrunken lower jaws. The ramus frame and blade implants are mostly used in the lower back jaw when the patient is not an ideal candidate for advanced bone grafting techniques or the doctor is proficient with this procedure and offers it as an option. The most common type of implants used most of the time are root form implants that mimic’the root of the tooth. The reasons given in this chapter are addressed primarily to the root form implant.

The implant consists of a titanium alloy that is biocompatible’to bone and encourages the bone to form around it, holding it in place. The healing process is referred to as osteointegration.

Once the implant becomes osteointegrated, it helps to preserve alveolar bone. Approximately 60 percent of the bone in your jaws grew in response to the erupting teeth.”When a tooth is extracted, you go through a process of losing bone in that area that can last a lifetime. An implant helps to preserve this bone structure by slowing down the’shrinkage.”It also helps to prevent malocclusion. When you lose a back tooth, you set up’shifting in the other teeth. Teeth adjacent tend to move into the space, and the teeth opposing’drift up or’down into the newly formed space. Some’spaces become “food traps and contribute to bad breath and periodontal disease.

Implants can slow facial atrophy- shrinkage which occurs in facial muscles when they are not properly exercised.”Roughly 150 newtons of force are applied on normally functioning back teeth, while only 50 newtons are applied on the front teeth. This force keeps the facial muscles’toned and maintains our “looks. If missing teeth are replaced with implants, this force is restored and good facial muscle tone is preserved. Additionally, the ability to chew properly vastly improves the digestion process.

Teeth are more efficient at chewing than dentures, sometimes’two or three times more. Th ere is an increased risk of aspiration of food if you have false teeth. Aspiration of food is one of the causes of death in the elderly that hardly gets mentioned, except in CPR courses.”In order to keep false teeth more stable, many denture users will place denture adhesive inside their denture to help keep them in place. In America, about $148 million is spent on denture adhesives every year.

Complete lower dentures usually move about ten to twelve millimeters during chewing and contribute to the need’to chew softer foods that may be less nutritious. Many’denture wearers develop anti-social tendencies because of’their limited ability to chew a wide variety of foods. Many are unwilling or are uncomfortable when they go out for a meal.

Dental implants will stabilize dentures, crowns, and bridges and allow for more efficient and confident chewing.

Many general dentists in the Unites States of America do not surgically place implants, although many of them advertise one of their services to be “dental implants.” What’they mean is they will plan and restore your implant after a specialist surgically placed the implant. The disadvantageI found when I did it this way twenty years ago is that if the patient had a problem with the implant, they did not have a’direct recourse with one dentist. A concern for the patient is when the restoring doctor and the specialist disagrees on who should take responsibility for defective materials or accidental damage to the implant. I have found that most good dental teams are willing to help the patient restore’their dentition by redoing the work at a reduced fee.

Note: It is the patient’s responsibility to keep the information on the size and make of the implant in the event the patient relocates or their dentist(s) retire, leave the practice or change locations.

In the long run, implants are the most cost effective, and efficient option. Some patients choose bridgework to restore’dentition because they lack the bone needed for an implant or because they think this is a less costly option.”However, when a dentist prepares one tooth for a crown,’the chances of needing a root canal is about 3-5% in a five year period. When at least two teeth are prepared for a’three-unit bridge it increases the odds of needing a root canal over the next five years from 3 percent to about 15 percent. The additional cost and the possibility of needing’to redo your bridge aft er root canal treatment could end up costing you more than you thought you were saving over the cost of doing an implant. Cost is measured in money, but more costly is the inconvenience and time away from your other activities.

Did Grandma die early because she did not have implants

In 1999 my grandmother passed away at the age of’seventy-nine on the way to work. She was a firm believer’that “If you are not sick, you should have a job.” She also had a great sense of adventure and oft en accompanied me on my mission dental trips or visiting another state or country. Although we had arranged for her to live with my mom and dad, she insisted on “turning her own key in her own door.”

Grandma, like a lot of those born in the 1920s, got her’denture by the time she was forty years old, and like a lot of people, she did not like her bottom denture because it had no suction. I was not insistent on her having implants because she wanted to save her money to support her independence. In retrospect, this might not have been’the best long-term decision, because not having implants meant she could not crush her food properly in order’to receive the best nutrition. Studies show that dentures are about 30 percent efficient at crushing food, implant supported’dentures around 70 percent, and natural teeth around 90 percent.

Grandma complained about loss of appetite, stomach pains, and irregular bowel movements. She had medication’that needed to be taken with meals to prevent further’stomach irritation. On that fateful morning, her lack of appetite meant she did not eat in order to take her medication, and her increased blood pressure led to a stroke from which she did not regain consciousness.

I miss my grandmother and wish I could have done more for her. I have committed myself “and my practice to the promotion of the benefits of having dental implants, becauseI think it can make a difference in people’s lives. No amount of money saved was able to keep Grandma with us for additional years, but money properly invested in making sure she could eat more than soups and “mush might have given me additional years with her.

If you are missing some teeth and your dentist suggests implants, you should consider it a good option. Listen an open mind. My Grandma would have wanted me to give you the option of implants, and I hope you agree.

Evaluating the Bone

As soon as a tooth is extracted, blood forms a clot in the’socket and new bone cells migrate into the socket area, accompanied by immune cells and cells that form supporting’tissues. Remodeling leads to the formation of new hard and soft tissue.

At initial healing the largest amount of bone loss occurs at the extraction site, and then bone-loss’slows but continues gradually over the years.”The jawbone is composed of alveolar and base bone.”Alveolar bone forms in response to the erupting teeth and’starts to go away when the tooth is lost. Base bone provides’the foundation on which the alveolar bone develops.

When we look at the series of pictures of an edentulous jawbone (a jawbone without teeth) over time, we notice’that bone loss progresses after loss of a tooth and can be accelerated when pressure is placed on the tissue by wearing a denture. In order to slow bone loss after extracting teeth, it is recommended that implants be placed, preferably after’the extraction sockets are grafted.

To slow bone loss and the shrunken jaws associated with aging, people wearing any type of denture should be evaluated for implants. National standard of care recommends’that if you wear a complete lower denture, you should have at least two implants for lateral stabilization and more if possible for bone preservation.

People are living longer, and they will need to preserve’their oral structures longer. The loss of even one strategic’tooth could make for a long and miserable “golden years. After all, what are the golden years like without the ability’to chew, digest, and receive proper nutrition

The same principle of implanting new teeth for accident victims or people born with congenitally missing teeth applies. Congenitally missing teeth is a condition where’the patient has fewer than a full complement of teeth. With new advancements in implants, it is getting easier to find an implant to replace the missing teeth.


Any implant with a diameter less than three millimeters is considered a mini-implant. An implant needs to be surrounded on all sides by bone if it is to have the best chance of surviving over a long time. Historically, many implants were small because patients had lost bone as a result of extractions and/or wearing fixed or removable dentures.

As the ability to grow (graft ) new bone has increased, the need for smaller implants may decrease. Initially, smaller implants were considered temporary implants to stabilize’temporary teeth until the larger implants had a chance to integrate with the bone. The mini-implants were then removed and new dentures attached to the larger implants.

Today the technology for mini-implants is so good, we are finding that you can place the implant and on the’same day attach the patient denture crown or bridge and have a high’degree of success. Several years ago, I started to use the best of both worlds. I would place mini-implants at the same’time I placed normal implants and attach the denture to’the minis while letting the larger implants integrate. In a lot of the cases we completed, we found that the aggressive’threads of the minis that allowed you to use them right away, along with the new technology and surfaces, made it difficult to remove the minis, so we incorporated them into the final prostheses (dentures).

If a patient had a well-fitting lower denture that moved’during chewing and did not want to wait four to six months until their implants integrated, they could have an initial evaluation and the necessary diagnostic X-rays and/or CT scan so they could be “sized based on the remaining jawbone for implants. On the day of the surgery,’they could be pretty confident that they would leave with an implanted denture with some degree of stability.

Th e Sterngold Company, a longtime manufacturer of attachments for dentures and crowns, came up with their’version of using mini-implants with conventional implants adapted to work with their ERA (Extra-coronal ResilientAttachment) system that allows the prosthesis a small range of movement and enhances their longevity. A rigid attachment puts a lot more force on the implants than a resilient attachment and being able to replace the resilient part of the attachment is an advantage of the ERA system.

This system has since been bought by the Zimmer dental company. Implant Direct also manufactures a’similar’system that already has the attachment for’the popularLocator attachment.

If you could see a series of models of the lower jawbone just before and aft er teeth were lost, you would see a consistent pattern. Initially, the jawbone is at its maximum height and width, and supports the patient’s facial features very well.

When a tooth is extracted, the alveolar bone that grew in response to the erupting tooth starts to shrink also. When’the first’denture is made, it is usually the best, because most of the alveolar bone is there for support; however, as bone loss continues, the denture sinks further into the soft tissue and the height of the lower face contracts, giving’the patient an aged appearance. The next denture should be made larger, to compensate for the shrinking bone. But when the dentist does this, the patient usually complains, because they had slowly over time adapted to the first denture.

At that point, the dentist usually cuts back the new’denture so it could feel like the fi rst denture, except it does not feel as secure, because some of the bone was lost. This bone loss continues until the nerve of the jawbone is close’to the surface and causes the denture wearer discomfort.

At that point, the patient usually suffers with one denture after another, looking for a dentist who could give them’the feel of their first denture.”The way to slow this bone loss and aged look is to place’socket grafts and/or implants as soon aft er extraction as is possible, because alveolar bone stays around implants as if it was the root of a tooth. In effect, implants only help’to retain dentures but help to maintain as well.

What Are Combination Cases

Our office prides itself in our ability to take care of multiple problems in a reasonable period of time, with or without’sedation. Over the last few years, we had several cases that involved sinus surgery. With our current technologies, we are able to assess’the amount of bone that exists in the upper jaw before we encounter the membrane of the sinus.”The sinus membrane is very forgiving and can repair itself in six weeks. If there is enough bone, seven millimeters or more, we can use blunt instruments to lift up the membrane like a blanket and insert bone graft ing before placing’the implant. If the amount of bone left is seven millimeters or less, I may elect a two-stage technique.

In the two-stage technique, bone is grafted below the sinus by displacing the membrane upward through a small hole made in the side of the bone. The membrane is then protected by a collagen liner and bone graft is packed, leading’to a new bone growth of ten to twenty millimeters. Six months later, implants of varying lengths are placed and allowed to integrate as the graft ed bone continues to mature.

After integration of the implants, implant-supported’teeth are placed. The patient does not go without teeth, because they wear a transitional prosthesis (temporary’dentures or bridges) while they wait on the body to heal.”In our office, we use several systems of implants, depending on the results we are trying to achieve. Sometimes we have’to do extractions, bone graft s, root canals, fillings, or gum’treatments; place implants; or place transitional appliances all during the same visit. If the case warrants it, we can use mini-implants to hold initial appliances securely until the long-term implants heal. A lot of prior planning goes into providing these treatments for combination cases.

Some patients who live a long distance from the office or even in another state can have a CT scan made and the results e-mailed’to us, so we can do the virtual surgery and have all the supplies needed to perform the procedures before they arrive at our office.


Chapter 8: Cosmetic Dentistry