Dental Implant Treatment

Where it may be suitable

• Adults missing one or a few teeth whose general health allows surgery and healing
• Enough bone height and width to hold the implant; where there is not, bone grafting or a sinus lift comes into consideration
• Healthy gums, or gum treatment already completed
• People who do not want their neighbouring teeth ground down
• People who cannot manage or do not want a removable partial denture

What is associated with higher risk

The figures below are pooled results of observational studies; they show association, not proven causation.

• Smoking. Compared with non-smokers, people who smoked more than 20 cigarettes a day had about 2.5 times the risk of implant loss per implant¹. Per patient, the risk was about 4 times higher. For early implant loss, a review of 32 studies gave an odds ratio of 2.59 per implant², from the 21 cohorts analysed per implant. This does not mean that the absolute risk is 2.6 times higher. No safe number of cigarettes has been shown.
• A history of periodontitis. Periodontitis is gum disease that has damaged the tissues and bone supporting the teeth. Across 14 prospective studies, implants were lost at about 1.75 times the rate³ seen in people without that history. After fast-progressing disease the rate was about 6 times higher. These are hazard ratios, not absolute risks. Peri-implantitis, inflammation around an implant with loss of the supporting bone, was about 3 times more common; inflammation of the soft tissue alone was not. These were treated patients; implants are not placed while the disease is active.
• Clenching or grinding. The studies looked at people judged likely to clench or grind their teeth (probable bruxism). Across 27 studies, their odds of implant loss were about 2.2 times higher⁴ (an odds ratio). These studies did not test whether a night guard prevents that.
• Diabetes. The findings are mixed. Two of three reviews found no significant difference in implant loss: a nine-study review of type 2 diabetes⁵ and an older review⁶. The third, covering 89 publications, reported a higher odds ratio⁷ for implant loss. All three found more bone loss around implants in people with diabetes. That is why blood-sugar control and regular reviews matter.
• Bone-strengthening medicines (bisphosphonates, denosumab). The risk depends on why, at what dose and for how long the medicine is taken. Whether it is given by drip, by injection or by mouth does not on its own decide it. In people on high-dose antiresorptive treatment for cancer, elective implant surgery is usually avoided. That group includes bisphosphonates given by drip and denosumab given by injection under the skin. The decision is made together with your oncology and oral surgery teams. Do not stop a medicine without asking the doctor who prescribed it. Doses used for osteoporosis, whether tablets, infusions or injections, are assessed separately. With these medicines the main concern is medication-related death of jaw bone (osteonecrosis), an area of jawbone that dies and may not heal. Separately, a 21-study review looked at people taking bisphosphonates as one group, not by the reason they took them. In it, implant loss was about 1.7 times more likely per implant⁸. Jaw osteonecrosis was about 3.5 times more likely per patient. The per-patient analysis of implant loss found no significant difference. These figures are for bisphosphonates and cannot be generalised to denosumab; the certainty of the evidence is very low. Tell us about every medicine you take.
• Radiotherapy to the head and neck. Implants are lost more often in irradiated bone. After extractions and implant surgery there is a risk of wounds that do not heal and of bone death (osteoradionecrosis). We ask about the field and dose of your radiotherapy, and planning is done with your oncology team.

Where another step comes first

• A tooth that can be saved. Whether the tooth can be kept is assessed first. If root canal treatment, gum treatment or a crown could keep it, that comes first. Before you agree to an extraction, ask about the tooth's outlook and the ways of replacing it, an implant among them.
• Active infection, untreated gum disease, uncontrolled medical conditions. These are dealt with first.
• Not enough bone. For one or a few missing teeth, bone grafting or a sinus lift comes into consideration; both lengthen treatment and carry their own risks. Zygomatic implants are not the subject of this page. They are a separate method, considered for people with no teeth in an upper jaw whose bone has been severely lost.
• A jaw that is still growing. In young patients, implants wait until growth is complete.

Suitability is decided by an examination, a 3D scan and your medical history. A plan based on photographs or a panoramic X-ray is not final; it is a preliminary assessment.

There is more than one way to deal with a missing tooth, or one that cannot be saved. The list starts with the option that removes the least tissue.

• Doing nothing. For a single missing back tooth, this is a reasonable option for some people. The trade-off: over time the teeth either side of the gap can drift, and the opposing tooth can over-erupt. The bone in the gap also shrinks. Discuss this option with your dentist too.
• Saving the tooth. If the tooth is still there, ask first whether root canal treatment, gum treatment, a repair or a crown could keep it. Keeping your own tooth is often the least irreversible path.
• A removable partial denture. It is used for people who do not want surgery, or for whom surgery is not suitable. It is not a second-class solution; it is an option with its own indications. You take it out to clean it, and getting used to it takes time.
• A resin-bonded (adhesive) bridge. For suitable single-tooth gaps, a bridge with a wing bonded to the back of the neighbouring tooth can be used. It needs very little or no grinding of that tooth, and no surgery. It does not suit every gap or every bite; it can come loose and may need re-bonding.
• A conventional tooth-supported bridge. The teeth either side of the gap are reduced and a bridge is made over them. If those teeth are healthy, the tissue removed does not grow back. On the other hand, no surgery is needed and the treatment is short.
• An implant crown or bridge. The neighbouring teeth do not need to be reduced. It needs surgery and a healing period. Where several teeth are missing, not every gap needs its own implant; a bridge can be made on a few implants.

Which option suits you depends on where the gap is, the state of the neighbouring teeth, the bone, your bite and your habits. If you have been offered only one option, ask why the others were ruled out.

Implant treatment has two main stages, the surgery and the crown or bridge, with healing in between. The number of visits and the length of each depend on you and your plan; both should be written in the plan. If you would like sedation, the details are on the conscious sedation page. When the restoration is complete, probing measurements around the implant and an X-ray are taken as a baseline record⁹, as the consensus report recommends.

This is the detail patients ask about most, and the answer is not the same for everyone. One of these is chosen for the waiting period:

• The gap is left empty. Some people choose this for back teeth that do not show.
• A removable temporary denture. A small removable piece is made for one or a few teeth. You take it out, and it is adjusted so that it does not press on the healing area.
• A bonded temporary bridge. Where suitable, a thin temporary bridge attached to the neighbouring teeth can be used.
• A temporary tooth on the implant. This is done only in selected patients, if the implant holds firmly enough in the bone at placement (primary stability).

The last option is not for everyone; its risks, and whether it is in your plan, should be discussed separately. A Cochrane review of 26 randomised trials found no convincing difference¹⁰ within one year between loading an implant immediately and waiting. Another review of 39 randomised trials reported slightly lower implant survival¹¹ with immediate loading. The decision depends on how firmly the implant holds during surgery, and on you.

Which of these you will have, and whether it is included in your plan, should be written in your treatment plan. If it is not, ask for it in writing.

There are many different implant systems. Surface treatment, screw design, the range of parts and the availability of the parts that go on top differ from system to system. The 2017 international consensus report on diseases around implants set out how they are defined. In doing so, it noted that there is no generic implant⁹: there are numerous implant designs, with different surfaces. As well as the brand name, ask whether the parts of that system can still be obtained years from now.

When you are given a treatment plan, ask for these in writing:

• Which system is planned, and in which diameter and length?
• Is the part that goes on top (the abutment) from the same system?
• If I change dentist, will another dentist be able to obtain these parts years from now?
• Will I be given an implant card or a similar record?
• If the plan offers an 'upgraded' option, what changes, and why is it needed?

A brand name alone does not decide the result. Published survival rates are not the results of one brand, clinic or dentist either; they are averages pooled from different countries and different patient groups. We give you the systems we use, and the one planned for you, in writing in your treatment plan.

Risks

• Implant loss. A review of 46 studies looked at implants carrying a single crown. Of every 100, about 97 were still in the mouth after five years and about 95 after ten¹². The rest were lost. It is not always possible to place a new implant where one was lost; further surgery or a different restoration may be needed.
• Inflammation around the implant. Peri-implant mucositis is inflammation of the soft tissue around an implant. Peri-implantitis is that inflammation together with loss of the supporting bone; its treatment may need surgery, and if it is not controlled, further bone loss can lead to losing the implant. A 57-study review reported peri-implantitis in about 20 in 100 patients and about 12 in 100 implants¹³. An older 11-study review found mucositis in about 43 in 100 patients¹⁴. The rates vary widely with the definition used.
• Technical and biological problems. The 46-study review estimated these cumulative five-year rates: screw loosening 8.8 percent, soft-tissue problems 7.1 percent and aesthetic complaints 7.1 percent¹². Bone loss of more than 2 millimetres was 5.2 percent, the crown coming loose (loss of retention) 4.1 percent and chipped porcelain 3.5 percent. A loose screw can be tightened and a damaged crown repaired or replaced; soft-tissue problems need assessment and treatment. Regular reviews are needed to find them.
• Surgical risks. Bleeding, swelling, bruising and infection can occur. In the lower jaw, nerves run close to where implants are placed, so the lip, chin or tongue can go numb. This is usually temporary and rarely permanent. The root of a neighbouring tooth can be damaged while the implant site is prepared. In the back of the upper jaw the sinus is close. The sinus membrane can tear, sinusitis can develop, or an opening can form between the mouth and the sinus. A 3D scan and careful planning reduce these risks; they do not remove them.
• An implant placed at the same session as the extraction. A review pooling studies with different follow-up and patient selection found survival of 95.2 percent¹⁵ for implants placed straight into the extraction socket. For implants placed in healed bone it was 98.4 percent (per implant). This is a group average, not a personal probability for you. The review's authors advise caution with the method. The decision depends on the state of the tooth and the bone.
• Limits of appearance. At the front of the mouth, the shape of the gum, the lip line and the colour of the neighbouring teeth decide the result. The gum can recede over time, and the metal edge of the implant can then show. Your expectations are discussed before treatment.

Benefits

• The neighbouring teeth are not ground down; no healthy tooth is reduced for a bridge.
• The implant passes chewing load to the bone. This does not fully prevent the bone loss that follows an extraction. Bone can also be lost around the implant over time or through disease.
• It is fixed: you do not take it out, and there are no denture clasps. A screw can still loosen or the crown come loose, as the figures above show. It does not feel or work exactly like a natural tooth.
• Where several teeth are missing, a bridge on a few implants can do the job with fewer implants.

The first days

• Swelling and bruising increase over the first 48 to 72 hours, then settle. Use cold packs and the medicines prescribed.
• Choose soft, lukewarm food for the first days, and do not chew on the surgical site.
• Do not stop cleaning your mouth. Clean the surgical area the way your dentist shows you, and the rest as usual.
• If you had sedation, do not drive or operate machinery for as long as the sedation team tells you. Whether you need an escort depends on the method. For adults, every form of sedation other than inhalation sedation requires a responsible adult as an escort¹⁶. If an escort cannot be assured where one is required, treatment under sedation is not given.
• Smoking impairs healing. At the very least, do not smoke during the healing period.

Daily care

• Brush twice a day with a soft brush and fluoride toothpaste. Pay particular attention to the line where the implant meets the gum.
• Clean between the teeth every day with interdental brushes, floss or a water flosser. Your dentist shows you which works in your mouth.
• If you clench, a night guard may be advised. It has not been shown to prevent implant loss; its purpose is to protect the restoration from the forces of clenching.
• Reviews. Follow-up for an implant is different from a general dental check-up. The consensus report recommends that an X-ray and probing measurements be taken as a baseline⁹ when the restoration is complete. The European Federation of Periodontology guideline calls for a structured supportive care programme¹⁷ once implants are in use. The NICE guideline on dental recall recommends that the interval between reviews be set for each patient¹⁸. It is based on a risk assessment and discussed with the patient. So there is no ready-made 'once a year' interval that suits everyone; yours may be shorter or different, depending on your risk.

The rates below are not promises. They are pooled estimates, calculated with statistical models from studies with different lengths of follow-up, averaging about five years. What happens in your case depends on your bone, your gum health, your habits and your care.

• The implant itself. In the 46-study review, of every 100 implants, about 97 were still in the mouth after five years and about 95 after ten¹² (per implant).
• The crown on top. In the same review, of every 100 crowns, about 96 were in use after five years and about 89 after ten (per crown). In an older review the figures were about 95 at five years and about 89 at ten¹⁹. The rate for the implant is not the same as the rate for the tooth on top of it.
• No one can promise a lifetime result. The reviews cited on this page give five- and ten-year estimates; the ten-year values are modelled from studies whose follow-up averaged about five years. They were not observed directly over ten. Longer-term reviews exist; those we have checked cover different patient groups and restoration types, so their results are not carried over here. None of them promises a lifetime result.
• Being in place is not the same as being trouble-free. The rates above show only that the implant or the crown is still there. Regular cleaning and reviews are part of maintenance. A loose screw or chipped porcelain needs a repair, and replacing the whole crown counts as losing the restoration. Ask beforehand whether these are included in your plan.

Before you go home after surgery, make sure you have written aftercare instructions and know how to reach the clinic, including out of hours. Contact your dentist after surgery, or at any time once the implant is in use, if you notice any of the following.

• Pain or swelling increases after the third day, or bleeding does not stop
• Numbness of the lip, tongue or chin lasts beyond the expected duration of the anaesthetic
• The implant or crown moves, a screw feels loose, or a piece cracks or breaks
• Bleeding, a bad smell, pus or receding gum around the implant
• Pain on biting, or the bite feels high
• Nasal discharge, a blocked nose or sinus pain on the side of an implant in the back of the upper jaw

Emergencies. Do not wait for the clinic's reply if breathing or swallowing becomes difficult. The same applies to rapidly spreading swelling of the face or neck, a high fever or swelling around the eye. Go to the nearest emergency department or call 112.

This page carries no prices. The main things that shape a plan are:

• How many teeth are missing and where; whether extractions are needed
• Whether bone grafting or a sinus lift is needed
• The number of implants, the system chosen and the abutment that goes on it
• The material of the crown or bridge
• The temporary solution used during the waiting period
• Sedation; the number of visits and the review programme
• The remake terms if there is a complication

Ask for three things in writing. What does your plan include? Which items are left 'to be decided later'? Who pays for further treatment if there is a complication? Two plans for the same procedure often do not describe the same scope. Before treatment we give you, in writing, the route to follow if there is a complication and our remake terms. You can ask us for that document before you decide.