Implants for Several Missing Teeth

Where implants may be suitable

• Adults with two or more missing teeth, or teeth that cannot be saved, whose general health allows surgery and healing
• Remaining teeth that are healthy, or have been treated, so the plan can be built around them
• Enough bone height and width for the implants, or bone that can be added (see "Assessment" below)
• Gum disease treated and under control, with regular care to keep it that way
• People who want fixed teeth without grinding down healthy neighbouring teeth for a bridge
• People who can clean around implants, and under a bridge, every day

When another option may make more sense

• Teeth that can be saved. If root canal treatment, gum treatment or a crown could keep a tooth, that is assessed first. Before you agree to an extraction, ask about each tooth's outlook.
• Neighbouring teeth that already need crowns. If the teeth at each end of a short gap have large fillings or need crowns anyway, a conventional bridge may be worth discussing.
• Only back teeth (molars) missing. If your front teeth and premolars are in place, you may manage without replacing the molars. This is called a shortened dental arch. A review of adults in this situation found it encouraging for function and satisfaction¹. Whether this suits you depends on your remaining teeth.
• Cleaning you cannot keep up. If the area under a bridge cannot be cleaned, the risk of inflammation around the implants rises². A removable partial denture may then suit better.
• Active gum disease, infection or an uncontrolled medical condition. These are dealt with first.
• A jaw that is still growing. Implants usually wait until growth is complete. If you are asking for someone under 18, ask the dentist whether jaw growth is complete and when implants could be considered.

What is associated with higher risk

The figures below are pooled results of published observational studies, not our own records. 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 implant³. Per patient, the risk was about 4 times higher³. In that review the risk rose with the number of cigarettes, and no level of smoking was shown to be free of extra risk.
• A history of periodontitis (gum disease that has damaged the bone around the teeth). This matters here because, in a review of why adults' teeth are taken out, decay and periodontitis were the most common reasons⁴. That review covered three studies. Across 14 prospective studies, implants were lost at about 1.75 times the rate⁵ seen in people without a history of periodontitis. This is a hazard ratio, which compares rates over time; it is not an absolute risk. These were treated patients; implants are not placed while the disease is active.
• Clenching or grinding. Across 27 studies, people judged likely to clench or grind had about 2.2 times the odds of implant loss, per implant⁶ (an odds ratio). Like the hazard ratio above, it is not an absolute risk. These studies did not test whether a night guard prevents implant loss.
• Diabetes, blood-thinning medicines, bone-strengthening medicines and radiotherapy to the head and neck. Each needs a careful look at your medical history, and sometimes planning with your own doctors. With blood-thinning medicines, Scottish guidance for dentists counts surgery that raises a flap of gum as a higher bleeding risk⁷ than a simple extraction. If you take bone-strengthening medicines (bisphosphonates or denosumab), or have taken them, tell your dentist which one, for how long and why. The dental implant treatment page explains what they mean for the jawbone, and the evidence on the other conditions. Do not stop any medicine without asking the doctor who prescribed it.

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

Where the gaps are shapes the choices. Each gap is planned on its own, so one plan may combine more than one option.

Two or more teeth missing side by side

A gap of several teeth can be filled with an implant for each tooth. Or a bridge can be fixed on implants placed under some of the missing teeth. If there are sound teeth at both ends, a conventional bridge fixed to them is another option. One hospital in England gives its own patients a leaflet on sinus lifts. Among the alternatives, it notes that usually only one or two teeth can be replaced⁸ on a bridge fixed to neighbouring teeth. A removable partial denture is a further option.

Gaps in different places

One gap might suit an implant and another a conventional or resin-bonded bridge. A partial denture can replace teeth in several gaps with one piece, without surgery.

Back teeth missing at the end of the row

If there is no tooth behind the gap, a conventional bridge has nothing to rest on at that end. A bridge on natural teeth held from one side only (a cantilever bridge) is possible in some cases. In a 2007 review, about 80 in 100 of these were still in place after ten years⁹. For bridges supported at both ends the figure was about 89⁹. The review's summary gives no figure for resin-bonded bridges. We could not check whether these figures were counted per bridge or per patient. The review's authors regard the cantilever design as a second choice. So at the end of the row, the choice is often between implants, a partial denture and leaving the gap. Upper back teeth sit below the sinus, and lower back teeth above a nerve; both affect implant planning (see "Assessment" below).

Front teeth

If front teeth are among those missing, the gum and the bone decide how natural the result looks. Not all of that can be controlled. Ask how the result is likely to look in your mouth before you agree to a plan.

For two or more missing teeth there is no rule of one implant per tooth. The plan depends on how many teeth are missing and where, the bone, the sinus and the nerve, your bite and your habits.

• An implant for each missing tooth. Each tooth has its own implant and crown. The crowns are not joined, so you can clean between them with floss or interdental brushes. A problem with one crown can often be dealt with on its own. It needs enough bone and room for every implant, so it can mean more surgery.
• A bridge on implants. Fewer implants carry a bridge that spans the gap. This can avoid placing an implant where the bone is thin or close to the sinus or the nerve. You clean under the bridge every day with bridge floss, interdental brushes or a water flosser. If one implant fails, the whole bridge may have to be remade.
• A bridge joined to a natural tooth and an implant. This is possible in some cases. In the 2007 review, about 78 in 100 of these were still in place after ten years⁹. For bridges on implants alone it was about 87⁹. We could not check whether these figures were counted per bridge or per patient. The review's authors regard this design as a second choice.

What the evidence says

A review of 74 articles, most published between 1995 and 2003, compared these designs in people missing some of their teeth. After more than six years, about 98 in 100 implants under implant bridges and about 96 in 100 single implants¹⁰ were still in place. For implants under bridges joined to natural teeth the figure was about 91¹⁰. None of these differences was statistically significant, which does not show that the designs are equal. The authors found the evidence too thin for firm guidelines. Only two of the 74 articles were randomised trials. So the figures compare different groups of patients and gaps, not the same gap treated both ways. They cannot tell you which design suits yours.

How many implants?

The studies we use give no number of implants for a given gap, and this page gives none. The number is decided from the 3D scan, the bone, the length of the gap and your bite. The hospital leaflet mentioned above notes that fewer implants usually mean more biting and chewing force through the implants⁸. It adds that this can potentially lead to more frequent complications of both the bridges and the implants. More implants, on the other hand, mean more surgery and may need a graft.

Your written plan states the number of implants, where they go and why. If two clinics propose different numbers, ask each of them to explain. You can also ask another dentist for an independent opinion.

If most of the teeth in a jaw are missing or failing, the choices change. The full-mouth implant treatment page compares implant-retained dentures, fixed bridges on four or six implants and several shorter bridges on more implants.

Implants are not the only way to replace several missing teeth. You can ask another dentist for an independent opinion before you decide.

• Leaving some gaps. Not every missing tooth has to be replaced. A review of 83 articles found that having about 20 teeth, front teeth included, was associated with adequate chewing¹¹ for most people. Those teeth formed about 9 to 10 pairs of upper and lower teeth meeting when biting¹¹. People varied a great deal. The trade-off is that the teeth beside and opposite a gap can move. In one study of back teeth that had lost the tooth opposite them, 92 in 100 had moved towards the gap¹². The bone in the gap also shrinks after the extraction (see "Assessment" below).
• A resin-bonded (adhesive) bridge. A false tooth held by a thin wing bonded to the inner surface of a neighbouring tooth. That tooth needs little or no drilling, and no surgery is needed. Depending on your bite, it suits some single-tooth gaps, so it may fill one of several gaps. It can come loose and may need to be bonded again. The reviews we use give no survival figure for it.
• A conventional bridge. The teeth at each end of the gap are reduced and crowned, and the bridge is fixed to them. No surgery is needed and the treatment is short. The tooth tissue removed does not grow back, and the bridge needs sound teeth at both ends. The dental bridges page explains the designs.
• A removable partial denture. A plate carrying the missing teeth, held by clasps on your own teeth. It needs no surgery and little or no grinding, and one denture can fill several gaps. You take it out to clean it. As the gums and jawbone shrink or change over time, it may become loose¹³ and need adjusting. In a review of 46 studies, about 95 in 100 partial dentures with cast clasps were still in use after five years¹⁴. Cast clasps are metal arms that hold the denture on your own teeth. The teeth a denture holds on to had a higher chance of being taken out¹⁴ over time. The review's summary does not say which teeth they were compared with. That is an association, not proof that the denture caused it. Studies of partial dentures did not consistently report better quality of life or satisfaction¹⁵. The dentures page explains the types.
• Implants, with separate crowns or a bridge. The neighbouring teeth are not ground down to support them. They need surgery and a healing period, and usually several appointments.

Bridges on implants and conventional bridges: how do they compare?

The 2007 review below found almost no head-to-head trials. Its figures come from separate groups of studies, mostly published before 2007, and are not our own results.

• In a 2007 review, about 89 in 100 conventional bridges and about 87 in 100 bridges on implants⁹ were still in place after ten years. We could not check whether these figures were counted per bridge or per patient.
• The problems differ. In the same 2007 review, about 39 in 100 patients with bridges on implants had a complication⁹ within five years. For conventional bridges the figure was about 16 in 100. With conventional bridges the problems were mainly decay and loss of vitality (the nerve inside the tooth dying) in the supporting teeth. Crowns and bridges on implants had significantly more technical complications⁹.

So neither is better for everyone. If the teeth at each end of a gap already need crowns, a conventional bridge may make sense. If they are healthy, implants avoid grinding them down. If you have been offered only one option, ask why the others were ruled out.

Before implants are planned, the dentist examines the gaps, your remaining teeth, your gums and your bite, and takes your medical history. X-rays and a 3D scan (cone beam CT) show the bone, and where the nerve canal and the sinus lie. Recommendations on 3D scans in implant dentistry say a scan could be justified for diagnosis and planning before surgery¹⁶. A 3D scan gives a higher radiation dose than a panoramic X-ray. The recommendations ask for the dose to be kept as low as is diagnostically acceptable¹⁶. They also say ordinary dental X-rays remain the main tool for routine checks of implants afterwards.

Bone

Bone shrinks after teeth are taken out, and the amount varies with the type of tooth¹⁷. We have found no good research showing that implants for several missing teeth prevent this shrinkage. Where there is too little bone, bone grafting may be considered; it lengthens treatment and carries its own risks. Adding bone height is not a small extra step. A Cochrane review found complications common, especially with vertical grafting¹⁸, which adds height. It found that, in a shrunken lower jaw, short implants appear to be a better alternative to vertical grafting. Those conclusions rest on few trials, often at high risk of bias.

Upper back teeth and the sinus

In the upper jaw the back teeth sit below the sinus, an air space next to the nose. According to the hospital leaflet mentioned above, many people who have lost their upper back teeth do not have enough bone⁸ for implants. A sinus lift raises the lining of the sinus and adds bone below it, before or at the same time as the implants. A review of 11 studies looked at people with 6 millimetres of bone or less. They had a sinus lift through an opening in the side of the upper jaw. Over at least five years, implants were lost at 0.43 per cent per implant per year (about 4 in every 1,000 implants each year)¹⁹. The same leaflet lists alternatives that may avoid a sinus lift: shorter implants, angled implants, or fewer implants placed further forward. Each has its own trade-offs.

Lower back teeth and the nerve

In the lower jaw a nerve runs through the bone below the back teeth. The 3D scan shows how much bone lies above it. Where there is little, shorter implants or a graft may be considered.

Gums

The gums need to be healthy before surgery, so gum disease is treated first. The teeth you keep matter too. A review looked at people treated for periodontitis who stayed in professional maintenance for at least five years. They lost on average about 0.1 teeth per patient each year (about one tooth for every ten patients)²⁰, and most lost none. Regular gum care is part of looking after the teeth you have, as well as the implants.

Bite and the remaining teeth

When teeth have been missing for a while, the neighbouring teeth can tilt into the gaps. Opposing teeth can move towards them (see "Other options" above). This is planned for before the implants. If you clench or grind, this is taken into account in the design, and a night guard may be advised.

Treatment has two main stages, the surgery and the final crowns or bridge, with healing in between. The number of appointments and the time between them depend on you and your plan; both are 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 each implant and an X-ray are taken as a baseline record²¹. A 2017 international consensus report recommends this. Probing measures the depth of the gum around each implant with a thin probe.

With several teeth missing, what you wear while the implants heal affects eating, speaking and how you look. You and your dentist choose one of these:

• The gaps are left empty. Some people choose this for back teeth that do not show.
• A removable temporary partial denture. A plate carrying the missing teeth. You take it out to clean it, and it is adjusted so that it does not press on the healing areas.
• A bonded temporary bridge. Where a short gap suits it, a temporary bridge attached to the neighbouring teeth.
• Temporary teeth on the implants. This is done only in selected patients, if the implants hold firmly enough in the bone at placement (primary stability). You are told what you can and cannot bite with them.

Temporary teeth on the implants are not for everyone. Ask the dentist to explain their risks for you, and whether they are in your plan. A Cochrane review of 26 randomised trials compared two timings. The implants first carried teeth within a week of placement (immediate loading) or more than two months after it²² (conventional loading). It found no convincing difference²² within one year. Most of its trials were at high or unclear risk of bias. Another review of 39 randomised trials reported slightly lower implant survival²³ with immediate loading. The decision depends on how firmly the implants hold during surgery, and on you.

These trials compare when the teeth are fitted, not how quickly the whole treatment is completed. We have found no good research comparing treatment completed within a few days with treatment spread over months. Which option you will have while the implants heal, and whether it is included in your plan, should be written in your treatment plan.

Implant systems differ in surface, screw design and parts, and the 2017 consensus report noted that there is no generic implant²¹. A bridge on implants is either screwed onto them or fixed with dental cement. A 2012 review found no significant difference in five-year survival²⁴ between cemented and screw-retained bridges on implants. Its authors noted that screw-retained work is easier to remove, so complications can be treated more easily. Cement left under the gum is a possible risk indicator²⁵ for inflammation around implants. Ask which your plan uses, and why.

Ask for these in writing with your treatment plan:

• Which implant system is planned, how many implants, and in which diameter and length?
• Will I have separate crowns or a bridge, and will it be screwed or cemented?
• Are the connecting parts (abutments) 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, showing the batch (lot) number?

A brand name alone does not decide the result. We give you the system planned for you, in writing, in your treatment plan.

Risks

The figures below come from published studies, not from our own records.

• Implant loss. A review of 32 studies looked at bridges on implants. Of every 100 implants under them, about 96 were still in place after five years and about 93 after ten²⁶. It is not always possible to place a new implant where one was lost. Under a bridge, losing one implant can affect the whole bridge.
• Problems with the bridge. In the same review, about a third of patients had some complication within five years²⁶. The most common was fracture of the veneering material, such as chipped porcelain, at 13.5 per cent²⁶. Peri-implantitis and other soft-tissue problems followed at 8.5 per cent²⁶. Loss of the filling over a screw hole was 5.4 per cent, and loose screws 5.3 per cent²⁶. Regular reviews are needed to find these problems.
• Inflammation around the implants. 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 implants²⁷. An older 11-study review found mucositis in about 43 in 100 patients²⁸. The rates vary widely with the definition used.
• Surgical risks. Bleeding, swelling, bruising and infection can occur. In the lower jaw, a nerve runs close to where back implants are placed, so the lip, chin or tongue can go numb. It is usually temporary; rarely, it does not go away. The root of a neighbouring tooth can be damaged while an implant site is prepared. In the back of the upper jaw the sinus is close. The sinus lining 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.
• A graft or a sinus lift. Each adds its own risks and lengthens treatment; they are set out on the bone grafting and sinus lift pages.
• Limits of appearance. At the front of the mouth, the gum, the bone and your smile line decide the result. The gum can recede over time, and the metal edge of an implant can then show.

Benefits

• When implants alone carry the crowns or bridge, the neighbouring teeth are not ground down to hold them.
• The teeth are fixed: you do not take them out, and there are no clasps. A screw can still loosen or porcelain chip, as the figures above show. They do not feel or work exactly like natural teeth.
• A bridge on implants can replace several teeth with fewer implants than missing teeth.

The first days

• Swelling and bruising usually increase over the first two to three days, then settle. Use cold packs and the medicines prescribed.
• Choose soft, lukewarm food for the first days, and do not chew on the surgical sites.
• Do not stop cleaning your mouth. Clean the surgical areas the way we show you, and the rest as usual.
• If you had a sinus lift, follow the written instructions you are given. The hospital leaflet mentioned above advises not blowing your nose for two weeks⁸ after the procedure.
• 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. A UK national standard for sedation in dentistry sets an escort rule. For adults, every form of sedation other than inhalation sedation requires a responsible adult as an escort²⁹. If an escort cannot be assured, it says, treatment under sedation must not be given. Ask us whether the method planned for you needs an escort. Before you leave the clinic after surgery, you and your escort should have written aftercare instructions. You should also know how to reach the clinic, including out of hours.
• Smoking is associated with poorer healing and with implant loss (see "What is associated with higher risk" above). At the very least, do not smoke during the healing period.

Flying after surgery

A 2023 narrative review suggests waiting at least 72 hours³⁰ after implant placement before flying. After a sinus lift it suggests at least two, and ideally six, weeks³⁰. These intervals assume no pain, swelling or bleeding at the treated site³⁰. The authors say the research is limited and comes mostly from military aviation. If you need to fly, ask the dentist who treated you first.

Daily care

• Brush twice a day with a soft brush and fluoride toothpaste. Pay particular attention to the line where the implants meet the gum.
• Clean between the teeth, and under any bridge, every day with interdental brushes, bridge floss or a water flosser. Your dentist shows you which works in your mouth.
• Look after the teeth you still have. Keeping them healthy is part of keeping the plan working.
• If you clench, a night guard may be advised to protect the crowns or bridge. It has not been shown to prevent implant loss, and we have found no study showing how well it protects them.
• Reviews. Follow-up for implants is different from a general dental check-up. The consensus report recommends that an X-ray and probing measurements be taken as a baseline²¹ when the restoration is complete. The European Federation of Periodontology guideline calls for a structured supportive care programme³¹ once implants are in use. A UK guideline on dental recall (NICE) covers check-ups in general, not implants. It asks for the interval between reviews to be set for each patient³², based on a risk assessment and discussed with the patient.

The rates below are not promises, and they come from published studies, not from our own records. They are pooled estimates from studies with different lengths of follow-up. What happens in your case depends on your bone, your gum health, your habits and your care. Different reviews give somewhat different figures, because they include different studies and follow people for different lengths of time.

• The implants under a bridge. In the 32-study review, of every 100 implants, about 96 were still in place after five years and about 93 after ten²⁶.
• The bridge itself. In the same review, about 95 in 100 bridges on implants were in use after five years and about 80 after ten²⁶. Some bridges in the review had a gold-acrylic veneer: a gold framework faced with acrylic plastic. Leaving those out, about 96 in 100 metal-ceramic bridges were in use at five years and about 94 at ten²⁶. The rate for the implants is not the same as the rate for the bridge on top of them.
• Separate implants. For an implant and crown per tooth, the figures are on the dental implant treatment page.
• No one can promise a lifetime result. The reviews we use give five- and ten-year estimates only.
• Being in place is not the same as being trouble-free. Chipped porcelain and loose screws need repairs, and a bridge may have to be remade. Ask beforehand whether these are included in your plan.

If you notice a problem after treatment, contact us through the route written in your plan.

• A loose screw, chipped porcelain, or a crown or bridge that comes loose. These are the usual technical problems (see "Risks and benefits" above). Keep any piece that comes off, and do not glue it back yourself. A screw-retained bridge can be removed by the dentist for repair.
• Inflammation around an implant. Bleeding, swelling or pus around an implant needs assessment soon. The findings are compared with your baseline record.
• An implant that fails. It is not always possible to place a new implant in the same place. Under a bridge, the bridge may have to be remade or replaced by another design. A new implant may need further surgery or a bone graft; sometimes a partial denture is used instead.
• Reviews. Your review interval is written in your plan. Keep to it even when nothing hurts.

Ask for these in writing, and read them before you decide.

• Who will treat you. Before you agree, we name in writing the dentist who will place your implants. If someone else will fit the crowns or bridge, or do a graft or sinus lift, we name them too. Turkey's Patient Rights Regulation lets you ask for the identity, role and title of the dentists and staff who treat you³³. You can also ask for another dentist's opinion.
• The plan. Your written plan states the number of implants and where they go, and whether you will have separate crowns or a bridge, with the reasons. It names the implant system, any graft or sinus lift and the graft material, the temporary teeth and the alternatives considered. According to the hospital leaflet mentioned above, graft material may come from you, from another person or from an animal, or be synthetic⁸. If you have concerns about material of animal origin, raise them before you agree. It also states what the plan covers and does not cover. What we send you after seeing photographs or X-rays is a preliminary view, not a treatment plan. The plan is made after the examination and 3D scan, and we tell you before anything in it changes.
• What you must be told, and the consent form. Turkey's Patient Rights Regulation lists what you must be told before treatment. It includes who will carry it out, where and how, its estimated duration, the other options with their benefits and risks, and the possible complications³³. Private dental clinics must obtain a consent form for every intervention³⁴. The form is signed in two copies, and one copy is for you³³; ask for yours.
• Complications and redoing work. Before treatment we give you, in writing, the route to follow if there is a complication. We also give you the written terms that apply if an implant, crown or bridge has to be redone. They state what is included, for how long and what is not, for the implants and for the crowns or bridge separately. They also state what you need to do for the terms to apply, such as attending reviews, and who pays for further treatment.
• Your records. You can examine your file and get a copy of it³³. At the end of treatment we give you your records in a form another dentist can use. They include the plan, X-rays and scan, each implant's system, diameter and length, the parts used, and the baseline measurements.

You can say no, or ask to stop, at any stage, including after the examination. Once a tooth has been taken out, that step cannot be undone.

After surgery, or at any time later, contact us in these cases.

• Pain or swelling increases after the third day, or bleeding does not stop
• A high temperature, or swelling of the face that keeps growing
• Numbness of the lip, tongue or chin lasts longer than your dentist told you to expect
• An implant, crown or bridge moves, a screw feels loose, or a piece cracks or breaks
• Bleeding, a bad smell, pus or receding gum around an 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

If you cannot reach us quickly, see another dentist; do not wait for our reply.

Emergencies. The signs below need urgent medical help³⁵. Do not wait for a dental appointment; go to a hospital emergency department or call 112.

• It is hard to breathe, speak or swallow
• There is a lot of swelling in your mouth, or it is hard to open your mouth
• Your eye is swollen or painful, or your eyesight changes suddenly
• Your neck is swollen³⁶

This page carries no prices. The main things that shape a plan for several missing teeth are:

• How many teeth are missing and where; whether extractions are needed
• The number of implants, and whether you have separate crowns or a bridge
• Whether bone grafting or a sinus lift is needed
• The implant system and the connecting parts
• The material of the crowns or bridge, and whether it is screwed or cemented
• The temporary teeth used during healing
• Sedation; the number of appointments and the review programme
• The terms for redoing work 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? If you compare two plans, check the number of implants and the design in each. Then compare what each one includes, item by item.