Do you know the placement of dental implants?

Dr. José Candia Bouso is a maxillofacial surgeon with more than 20 years of experience. He has worked for 10 years in highly specialized centers of the Social Security, although he is currently focused exclusively on private practice combined with the welfare activity and teaching. He has been awarded the Prize of the Royal Academy of Medicine and Surgery of Galicia.

What are dental implants?

Dental implants are screws that replace the root of the tooth that has been lost. Then, on these implants, on these screws, we place prostheses that will finally replace the definitive crown of the teeth. We place the implants, these are these screws that are placed on the bone structure and then, once we have placed them, we are going to place the crowns on them, the pieces that go on them. If we have different types of dental implants, we have implants that can be short, implants that can be wide, implants that can be very long, that are going to be placed at different levels. For example, when a patient loses the root of a dental piece and we simply replace that root, we are going to find the difference if they are pieces that we find in the incisors, in the front part of the mouth, or in molars. When we are working on incisors or on premolars, we are going to replace them with standard implants. Standard implants that are 4 millimeters.

When we are going to place an implant to replace a molar, which is a wide tooth, we have to use very wide implants. We should be working normally with 6.5 or 7 mm wide implants, which are extremely wide, but give much more comfort to the patient and less chance of fracture. When the patient has lost all his teeth, for example in the upper jaw, has little bone volume, then we have to resort to long implants. Long implants are implants that are placed at the level of the upper jaw, normally, and they are implants that we are talking about, not long implants of 11 or 13 mm, we are talking about 30, 40, 45, even 50 mm. And they are placed in the upper jaw and it is to try to reach the cheekbone area, that is to say, we will try to insert the implant at this level, so that, when we have lost the bone of the upper jaw, we can resort to the upper floor, upper floor, to insert the implants there and, in this way, be able to rehabilitate the upper arch when the patient has no bone to be able to place them.

In these cases we avoid what we were doing in the past, or until a few years ago, we were doing the rehabilitation with iliac crest graft, tibia graft, which were surgical techniques applied in Maxillofacial Surgery for other techniques and which are now being replaced by the application of zygomatic implants which, although they do not achieve the same esthetic result, they do achieve speed and comfort for the patient. Once we have placed the implants, we are going to organize them according to the type of prosthesis, which is the objective of the implant. The objective of the implant is to replace the pieces that the patient had previously, then, depending on the patient’s needs, depending on his objectives, depending on his budget, depending on an ideal treatment plan for each patient, we are going to place different types of prostheses. If the patient is an older patient, who is used to having a removable prosthesis, we normally place two or preferably three implants. For that we are going to go to prostheses that we call prostheses on locates.

We currently place two implants, since several years ago, we are placing three implants, that gives much more stability to the prosthesis, we place a removable prosthesis that is placed and it clicks in this way. This gives great stability to the patient but, above all, to patients who already have a habit of having a removable prosthesis. When the patient does not have a removable prosthesis habit, we have an intermediate option, to place a bar, a micro-milled bar, on which the prosthesis with its structure is placed. And finally, the ideal situation is to replace the prosthesis, placing the entire prosthesis of the upper jaw, or of the mandible, in porcelain metal, which is the ideal situation for the rehabilitation of a dental arch. Well, when a patient comes to the consultation, as in the case of the patient we are going to see next, it is a patient who comes with implants placed in another clinic, which had failed, he had no bone volume, the implants had produced a fall of two of them and two others were about to fall.

We see the patient and we start the study. We study the photos, we have the molds, we mount them in an articulator, it is important to know the relationship of the maxilla and mandible, we do the photographic study and we also do the scanner study. In the scanner we see the volume of bone we have, we see that this is a patient who has two implants, they are about to fall out, the ones on the other side have fallen out and there is no bone at any level. We do the assessment, we do the planning and we talk to the anesthesiologist to be able to do it in consultation and place four zygomatic implants. The patient had four zygomatic implants placed and, subsequently, a prosthesis was placed over the implants. Specifically, we placed four zygomatic implants and one standard implant. We combined them and we placed a fixed prosthesis that gives stability and will give the patient security. We take impressions, we prepare some models, we mount the models in the articulator, in order to prepare the provisional prosthesis. Once we have the provisional prosthesis ready, to start with the definitive one, we prepare a metal test. Once the metal try-in goes well, we begin to place ceramic layers for the definitive one.

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How is a dental implant placed?

Well, the placement of a dental implant, generally, if they are a small number of implants, 1 or 3 implants, we place them under local anesthesia in the office. Previously we make a study, we have to make a CAT scan, we have to make some models. We will mount the models in an articulator, we generally fit these models to know the conditions in which the patient is and, finally, we program the patient. If we are going to do it locally, we do it here in the office; in other cases we have to do it under sedation. We require the collaboration of an anesthesiologist, for those patients who are anxious, who are afraid of pain, or for surgeries that require great delicacy, so that the patient does not move and we do not need the patient’s collaboration in those cases. We make a hole at the level of the alveolar process, that is to say, in the patient’s bone.

We make a tiny hole and we insert the implant over it, as it is placed. This is basically the technique. If it is possible, we have a bone stability that we have previously evaluated, what we do is to apply an immediate screw-retained prosthesis on the implant, or on the group of implants, as we can find in prostheses of this type. We have placed the implants in the patient and once we have finished, we take the measurements and we place a provisional prosthesis, screwed that is going to be for a period of 3 or 4 months, it is made of acrylic, and finally we transform it, we change it for a definitive prosthesis.

What are the advantages and disadvantages of the different types of implants?

The main advantages that implants give us is the security that they provide to the patient from the point of view of their esthetics, their comfort, that they can live a life similar to normal life. Otherwise, many patients have limitations when they are using removable prostheses, which are not stable, which do not give security, which have to change the type of food and, in this way, we can have a great security at the time of our chewing and make a normal social life. The disadvantages that we can find with dental implants are in those cases in which, either for commercial reasons, or for reasons of speed, a proper planning of rehabilitation with implants was not done, or was not performed by a person, or the surgery was performed by a person with experience, which can lead to complications such as inflammation, infections, even injuries to the dental nerve, which are sometimes seen, with loss of sensitivity of an area of the lip or half of the face.

How long do dental implants last?

In principle, implants are placed with the aim of lasting as long as possible. In fact, in the implant guarantees, when we plan the implants, we explain to the patient the previous advice. Advice on the care to be taken, maintenance, follow-up and we offer a 5-year guarantee. So the implants are expected to have a long term duration. Right now we have patients, a high percentage of patients, 70% of the patients we are following, have a 20-year duration. They are the first implants that we have placed, 20 or 22 years, and they are still coming for their check-ups, periodic check-ups, and they are not deteriorating, what is happening? It is true that it is considered that 2% in the best hands, 2% of the implants, are considered to be lost. In fact, the house, the commercial houses, put those implants automatically, since it is considered that this percentage is considered to be lost.

If the patient does not take care of them, does not do maintenance, if they were not placed in an ideal way, then the percentage of loss can be much higher.