INFORMATION REGARDING IMPLANT AND BONE GRAFTING CARE
This information pamphlet is written to provide you with information about the surgical procedures involved in placing grafts and dental implants. The overall global success of implant and bone grafting care is excellent. However, it is important to remember that implants and grafts are considered “implanted medical devices” and, as such, require a life-long commitment to monitor and maintain. Though they are generally successful procedures, there is no guarantee they will last your lifetime.
Implant and bone grafting treatment is a cooperative team effort between the patient, surgeon, restorative dentist, and the laboratory. Prior to surgery, you will require examination and appropriate treatment planning by both the restorative dentist and Dr. Eidinger. Your dentist assesses, from a restorative standpoint, the need for placing implants, and/or any current difficulties you may be having with an existing restoration, bridge or denture. Dr. Eidinger will initially assess your medical health and your ability to undergo the surgical procedures. She will also evaluate the anatomy of your mouth, and determine, together with your dentist, if grafting is necessary, and the ideal number and location for the placement of your implant(s). Dental imaging radiographs, such as a panoramic, periapical, or three-dimensional cone beam CT scans, may be required to help make this determination. The indications, contraindications, advantages, disadvantages, pros and cons, and possible alternate treatment approaches to your care will be reviewed. After surgery, Dr. Eidinger will need to examine you on a regular basis, until healing is complete.
If you are medically fit, you will be able to have your surgery in the office. You may wish to have your surgery under local anesthesia, with an oral sedative in combination with local anesthesia, or under an intravenous sedation. These options will be discussed with you during your consultation appointment.
Surgical Placement of Implants - One or Two Stages
The technique for placement of implants, which may be completed in one or two stages, is described, as follows: an incision is made through the tissue overlying the bone in the upper and/or lower jaw, and the proper number of implant fixtures are inserted into bone. If the implant fixture is to remain covered or buried during the healing period, and/or when bone grafting is required, a titanium healing cap is placed on each implant, and the gum tissue is sutured closed. This the first phase or surgical procedure and is referred to as Stage 1. The implants are not visible in the mouth at the completion of Stage 1. This necessitates returning for a second surgical procedure (Stage 2), from four to nine months after Stage 1, to uncover or expose the implants that are healing under the gum. At Stage 2 surgery, a small incision is made at the previous surgical site, and the titanium healing cap is exposed. The healing cap is removed, and is replaced by a taller healing abutment, which will now be visible in the mouth. Radiographs are taken to verify proper insertion of the healing abutment. Sutures may be placed, and a follow-up appointment may be required one week after this appointment. The final restorative phase of treatment with your dentist may then begin as early as two to four weeks after the completion of Stage 2 surgery.
If the implant surgery can be completed in a single surgical appointment, Stages 1 and 2 will be completed together. In that case, the healing abutment is placed on the implant immediately after implant insertion. This eliminates the need for a second surgical procedure. In the majority of most cases, Stages 1 and 2 may be completed together, and so only one surgical appointment is necessary. The healing abutment is meant to be easily removed by the restorative dentist at the time of your crown fabrication, as it is inserted with finger pressure only. As such, on occasion, the healing abutment may loosen and fall out during the implant healing period. If this happens, the healing abutment will require re-insertion.
Implant surgery may last one or more hours, depending on the number of implants placed and the complexity of surgery. A gauze pad is placed over the surgery site, and you will be asked to maintain mild pressure for several hours to minimize swelling and bleeding. Printed instructions for your home care will be provided. You may have been given a prescription for pre-operative antibiotic and an oral rinse. After surgery, you will be given further guidance about the continuation of these prescriptions. A prescription for pain medication may be given to minimize postoperative discomfort.
The body fuses or integrates the implant fixture by forming new bone within and around it. This process is called "osseointegration." This usually requires about four to six months to occur in the lower jaw, and about six to nine months to occur in the upper jaw. If you require a graft in preparation for future implant placement, or in combination with implant placement, a longer healing period may be required.
Recovery from Implant and Bone Grafting Surgery
After Stage 1 surgery, it is normal to have discomfort, swelling and bruising near the surgical site, especially following placement of implants in the lower jaw. Please read the information brochure you will be given following surgery. This will help explain how you should manage diet and activity, and will review many other very important matters.
With the exception of local tissue irritation as previously described, recovery when Stage 1 and 2 surgeries are done together or after Stage 2 is swift and easy. In the unlikely event that there is irritation of the tissue at the site of the abutment, further treatment may be required. Occasionally, it may be necessary to exchange an abutment for one of a different size before the dentist begins the fabrication of the bridge, denture or crown. Stage 2 surgery is a short procedure which can done under local anesthesia.
Time Off: It is very difficult to accurately estimate how much time may be required for recovery following surgery, due to the tremendous variability in patient response to surgery. However, it may take from two to seven days for you to feel comfortable enough to resume normal activities.
Wearing your Temporary Denture: Because implant surgery changes the height of your gum tissues, you must not insert your existing denture until you have had an opportunity to see your dentist. Your dentist will insert your denture, and trim/adjust it as needed. It is critical that the denture not exert any force on the implants or overlying healing abutments, as they heal. This can cause the implants to loosen and fall out. Plan to set aside time to visit your dentist for this reason, in the days immediately following your surgery. In order to improve retention of your denture, the use of denture adhesives is recommended. Do not insert your denture or have your denture adjusted until the effects of the local anesthesia have completely gone away.
Oral Hygiene: Try to maintain meticulous oral hygiene after your implant surgery. Any debris clinging to the tissues or implant hardware will cause irritation, and may lead to loss of the implant. The site of surgery must be cleaned by rinsing your mouth with warm salt water. A special mouth wash, as prescribed by Dr. Eidinger, may also be used in advance of, and following surgery. The use of a "water-pik" is strongly discouraged.
Hardware Exposure: If the surface of the healing cap covering the implants becomes visible through the gum after Stage I surgery, this is usually not a concern. The patient should inform Dr. Eidinger if there are any concerns arising between the first and second stage of surgery.
Recovery from Intravenous Anesthesia: You will be drowsy for several hours following anesthesia. Therefore, you are required to have a responsible adult stay with you until the effects of the anesthetic medications have subsided. You should not drive, operate machinery, or carry out business activities for twenty-four hours after a sedative anesthetic. You must not drink alcohol if you are taking prescription medication. Please inform Dr. Eidinger of the names of all the medications you are currently taking, or have taken, in the past year.
Surgical Complications
Even with the most carefully planned and executed surgery, and despite a 95 - 97% global success rate for implant care, there are risks to implant surgery, and complications may occur. They include, but are not limited to the following:
Peri-mucositis/implantitis: Peri-mucositis and implantitis are common pathological conditions characterized by inflammation affecting the soft and hard tissues surrounding an implant. Peri-mucositis involves inflammation affecting the soft tissues (the gums) surrounding the implant. Peri-implantitis involves inflammation involving both the soft tissues and bone surrounding the implant. Unfortunately, it is very challenging to treat and may lead to implant loss. A new and current consensus now evident in the global literature suggests that up to 45% of patients present with some degree of peri-mucositis and up to 25% with some degree of implantitis. For this reason, the dental profession, and the patient population that they treat, is now rethinking the expectation that implants represent a permanent, life-long replacement following loss of natural teeth. As implanted medical devises, not native to the body, they may fail.
Infection/Failure/Fracture: An implant that fails to "osseointegrate" either during the initial healing period, or after the insertion of the prosthesis, will require removal. Infection is one of the causes of implant failure. As noted in the paragraph above, the tissue surrounding or overlying the healing implant may become irritated or swollen. Implant loss may be also be related to smoking, inadequate oral hygiene, poor ongoing maintenance, poorly controlled diabetes, clenching and grinding habits, failure to take the prescribed antibiotic medications, premature loading by an ill-fitting temporary prosthesis, idiopathic, or premature replacement and loading of a new denture or bridge. Patients being treated with bisphosphonate drugs for the treatment of osteoporosis or metastatic cancer may experience a rare complication referred to medication-related osteonecrosis of the jaw, or MRONJ. Finally, recent research has suggested that patients who have experienced previous implant failure may be more prone to subsequent implant failures. This is referred to as “cluster failure.”
Adjacent Structures: Implants placed near the top jaw bone, near the nasal cavity or the maxillary sinus (under the cheek bone) may create small openings into these spaces. The body normally heals these openings. However, there may be increased discomfort and in some instances, additional treatment may be required at a later date. Rarely, it may be necessary to remove the implant fixture.
Altered Sensation: Implants may be placed close to the main nerve trunk in the lower jaw. This nerve, called the inferior alveolar nerve, is identified on x-ray images prior to surgery. In response to manipulation during surgery, the nerve may cease to function, which is almost always temporary. A temporary numbness, altered sensation, or paresthesia may last, if it occurs, several weeks or months, and may last up to two years. Rarely, altered sensation, or paraesthesia, may be permanent. If nerve function is altered, it can result in any of the following perceptions; a diminished or heightened sensation, tingling, pins and needles, burning pain, or most commonly, a numb feeling, with a distribution to the surface tissue overlying the implants, inside the lip, the surface of the lip, or the skin on the front of the lip or chin and tongue. If the upper jaw is extremely thin, a similar altered sensation may occur along the side of the nose, upper lip or upper gum tissue. There is no effect on muscle movement or appearance because these nerves are sensory, or feeling nerves, not motor, or movement nerves. The occurrence and duration of altered sensation is unpredictable. Patients may experience slow, steady improvement in their numbness or altered sensation for up to two years following their surgery.
Bone Fracture: On very rare occasions, especially when the bone of the upper and lower jaw is very thin or brittle, a fracture of the bone may occur during placement of an implant. This usually necessitates removal of the implant, and additional treatment to stabilize the fractured bones.
Bone Augmentation Drugs (Bisphosphonates) and Implants: Research indicates that patients who have taken or are currently taking bone stabilizing drugs either orally or by infusion for the treatment of osteoporosis or metastatic cancer, MAY have a longer healing time, may be at increased risk for implant failure or may development of a rare complication referred to medication-related osteonecrosis of the jaw (MRONJ). This is more likely to develop the longer you have been taking these medications. This will be discussed in detail with you at your consultation appointment and input from your other healthcare provider managing you may be indicated. On occasion, a temporary drug holiday may be suggested.
Parafunctional Clenching/Grinding Habits: Implant patients who have dental clenching and grinding habits must wear a protective occlusal or night guard. Implant integration may be prevented or lost by these parafunctional habits. Please speak to your dentist regarding fabrication of such an appliance.
Post-operative Chronic Sinusitis: Rarely, sinus lift/bone grafting procedures may cause perforation of the sinus membrane, a chronic post-surgical sinus infection, a permanent opening between the sinus and mouth, or loss of the graft that may require treatment with antibiotics and/or additional corrective surgery.
Change in Gum Color: While a tooth root is very light in color, the surface of the implant is metal and dark gray. For this reason, some patients may see the tissues overlying the implant appear darker. If this is visible when a patient smiles, further soft tissue grafting may be required to eliminate this esthetic issue.
Treatment Principles, Results and Outcomes
The titanium implant must become directly fused to bone (osseointegration) during the initial four to six month healing period. This healing provides a solid foundation onto which the final prosthesis (crown and/or bridge) can be anchored. Clinical and laboratory- based research has shown that titanium is harmless to human tissues and does not cause any currently known harmful rejection or “foreign body” reaction. In fact, it is the very bio-compatibility of the titanium surface that leads to its successful fusion to bone.
The long-term success of this treatment is dependent on many factors. These include patient understanding of the procedure, an appreciation of the expected end results, the need for meticulous oral hygiene, and regular post-surgical evaluation by the surgeon and the dentist. Individual healing factors in the jawbone and gum tissue also influence long-term success. Large differences exist not only between individuals, but within the same patient, in the volume and strength of the bone, and even between the upper and lower jawbone. This means that implant success may vary in different areas of the mouth: the thin soft bone of the upper jaw, may lead to failure of osseointegration. If osseointegration is not achieved for an implant, it will need to be removed. Once bone healing has occurred, a new implant can be inserted. Experience has clearly demonstrated that implants remain osseointegrated in the overwhelming majority of patients. The current overall global success rate is stated to be 95-97%. Should you wish to interrupt the treatment at some stage, an ordinary denture or "standard" fixed bridge can be used as in the past. Implant research has indicated a strong association between smoking and implant loss. The risk of implant loss is three times greater in smokers, as compared to non-smokers. Patients are strongly encouraged to make use of all available resources to permanently discontinue smoking, in advance of their implant surgery.
The Design of Your Implant Supported Prosthesis
The amount of available bone tissue is a major determining factor in the final design of the prosthesis. One implant may be inserted to replace a single missing tooth, or many implants may be inserted to replace multiple missing teeth. A prosthesis may be permanently fixed into position (by either a screw or cement) or may be removable. Inadequate bone height, width or volume, may prevent the placement of a sufficient number of implants to support a fixed bridge prosthesis. In these instances, it may be necessary to place a smaller number of implants. These implants can provide support for a complete removable denture (or bar "overdenture"). Through a team effort and with careful treatment planning, you, Dr. Eidinger and the restorative dentist will discuss the options available to you with respect to the prosthetic design that is most appropriate for you.
Bone Grafting and Membranes
For most patients, treatment with implants can be completed using the remaining jawbone. The volume of bone in the jaw can usually be estimated by thorough pre-operative clinical and radiographic (x-ray) examinations. In most cases, even if there is a small volume of remaining jaw bone, the patient can be treated by inserting implants directly into the remaining bone. If, however, the jaw has "shrunk" too much, there may be a need for building up the future implant site using grafting procedures. Simply stated, this requires that a material be placed at the implant site to increase the size and volume of bone, into which the implant may be inserted. If bone is used, it may be taken or harvested from a site within the patient's jaws. Donor human bone and synthetic bone analogues are also available. All of these materials are successful. If this is applicable, you will be given further detailed information regarding bone grafting options available to you, at the consultation appointment. Though bone grafting procedures are usually successful, these procedures and outcomes are not guaranteed: grafts may fail to heal as intended, preventing successful implant placement. Often, it is necessary to cover over a freshly grafted surgical site with a “membrane” that separates the grafted bone from the overlying gum tissue. This technique is called “guided tissue regeneration” or GTR. The requirement for membranes will be reviewed with you in greater detail during the consultation appointment, as dictated by your specific treatment needs.
Adapting to an Implant-Supported Prosthesis
Most patients require a period of time to get used to their new teeth or prosthesis, supported by implants. The first six to nine months of function is very important, as occasional, albeit infrequent, loosening of previously osseointegrated implants or the overlying prosthesis may occur. There may be the occasional need to surgically treat the gum tissue adjacent to the implants. The need for this may not become apparent until after the bridge or denture is inserted. Some patients will occasionally notice sensitivity to cold or changes in temperature around one or more abutments. This is usually a short-lived problem. You are encouraged to inform Dr. Eidinger or the dentist, about any matter that is of concern to you. It is very important that you see your dentist regularly for ongoing preventive hygiene, to maintain an optimum oral environment for your new implants.
Financial Obligations and Costs for Treatment
The fees outlined in the estimate are for all anticipated components of your surgical care, and for all routine postoperative care. Arrangements for payment of your account must be made prior to surgery. The fee for the initial consultation appointment and radiographic examination is not included in the outline of the surgical fees. All fees for procedures carried out for you in the office will be itemized in a detailed written estimate prior to surgery and will include the corresponding insurance codes. The cost for each implant and abutment will be charged directly to you and is in addition to the professional fees charged for their insertion.
Professional fees and laboratory costs associated with the restoration of your implants are matters that must be discussed directly with your restorative dentist. Estimates for care provided for you at other offices will not be provided.
In the unlikely event that abutments or implants must be removed, there will be appropriate fees charged for the anesthesia and surgery. The overall fee will be less than that for the initial surgery. Any financial obligation in respect to surgery and anesthesia for re-implantation of previously removed implants or abutments may be discussed prior to your agreeing to proceed.
Post-operative Appointment Schedule Following Implant/Bone Grafting Surgery
In order to monitor healing following implant surgery, several appointments are recommended. Below is a typical number of visits required during this phase of care.
1st appointment: Surgery day Approximately 1 - 2 hours
2nd appointment: 1 week post surgery Approximately 5 - 10 minutes
3rd appointment: 3 months post surgery Approximately 5 -10 minutes
4th appointment: 6 months post surgery Approximately 10 - 20 minutes
- a final set of radiographs will be taken during last appointment. These images will be sent to your restorative dentist for their use and records.
Costs for all of the above listed appointments are included in the original treatment estimate. There will be no additional charges incurred if additional follow-up appointments are necessary, during this time period.