Last Friday, Ed Pearson, a 45-year-old computer programmer from Charlestown, climbed into the dentist’s chair for what has become almost routine for him: dental implant surgery.
At roughly $2,000 per implant, not counting the crown that goes on top, Pearson wasn’t thrilled – who would be? But he was upbeat. The two implants he’s had before caused little pain, except to the wallet, and look good – “like having real teeth again.”Besides, he says, “You have to have a mechanism to eat.”
Dental implants have improved markedly since half a century ago, when dentists sliced open the gum, carved a groove in the jaw, inserted a crude screw, “loaded” it with false teeth – and hoped the whole thing wouldn’t wiggle.
The big breakthrough came in the early 1980s, when Swedish researchers announced they could boost the success rate by avoiding high speed drills – which burned the bone so severely it did not regrow around the implant – and began using slower drills instead. Switching to pure titanium instead of steel or other metals also helped, because it allowed the bone to grow more tightly around the implant.
Since then, implants have become a badge of dental derring-do, at least among the well-to-do.
A 1993 estimate showed Americans were getting 300,000 implants a year, according to the American Academy of Implant Dentistry. That figure is now believed to be more than 450,000, though millions more get permanent bridges or removable dentures.
But implants – which run $50,000 to $60,000 for a full set of teeth for the totally edentulous, or toothless – are not always the best solution.
For one thing, many insurers still consider them experimental and won’t pay. For another, there are other options, like removable dentures that cost from a few hundred to a few thousand dollars, and fixed bridges that can cost roughly $10,000 for each jaw. Both options are often covered by insurers, at least partially, and thanks to advances in restorative dentistry, may in some cases be better choices.
Still, there’s no doubt that “implants have really revolutionized dentistry,” says Hans-Peter Weber, head of the department of restoration dentistry at the Harvard School of Dental Medicine.
They are especially good for people who are born missing a tooth or two, he says, for those who have no teeth and hate their dentures, and for some people who have had jaw cancer.
Others, like Dr. Arthur Falvey of Newton, agree that implants “are great things when used in the right place.”
But the more prosthodontists, periodontists, oral surgeons and general dentists work with implants, the more they are fine tuning their sense of who should, and shouldn’t, get them.
Implants are primarily used to replace missing teeth – either those you never had or those you lost.
In the standard procedure, an implantologist opens the gum, drills away a precise spot of jawbone, taps or screws an anchor in place, then stitches the gum closed over the implant. If a number of adjacent teeth are missing, several implants can be inserted during one procedure, though it’s not necesssary to replace each tooth with an implant.
After this surgery, which takes from one to several hours and can be done in the office under local anesthesia, the patient must wait three to four months for the bone to heal in the lower jaw and five to six months in the upper jaw, says Dr. Paul A. Schnitman, former chairman of implant dentistry at Harvard and now in private practice in Wellesley Hills. Because of this lengthy healing process, implants take roughly four times longer to complete than bridges or dentures.
After the healing comes a second surgery, in which the dentist slices open the gum again to insert a post into the implant. After the patient heals – in 2 to 4 weeks – a restoration specialist (not necessarily the same person who performed the surgery) makes a false tooth or crown that goes on top of the post. Many people wear temporary dentures during the months of healing and crafting of the crown, which can also take a month or more.
Some dentists now use a one-step procedure, in which the anchor is inserted so that it sticks up vertically through the gumline, says Dr. Michael DiPace, a Brookline periodontist who favors this approach. The implant is covered with a temporary cap, then after the patient has healed, a post is screwed into the implant and a crown made, without further surgery.
The downside of this is that the implant may not work as well as when it is buried below the gum, says Schnitman, who is also president of the American Board of Oral Implantology.
But there’s something else to chew on if you’re considering an implant: the dicey issue of bone grafting.
If the jawbone into which the implant would go is too shallow or too narrow, as is often the case, you may need bone grafts before the implant, says Dr. Gary Rogoff, a maxillofacial surgeon at the Tufts University School of Dental Medicine.
Because it takes six to nine months for grafts to heal, it may be nearly a year before you can start the implant process.
Sometimes, bone is harvested from the chin and packed into the jawbone in the dental office. But if you don’t have enough to spare in your chin or other areas in your mouth, bone may be taken from your hip – in a hospital operating room.
Cadaver grafts are a safe alternative, though some patients worry about the very remote chance of catching a transmissible disease. And other materials may work, too.
If, knowing all this, you want to go ahead with an implant, there’s still something else to consider. Implants can fail – necessitating bridges or dentures or another attempt at implantation, and much of this depends on where in the mouth they are placed.
In the lower jaw in the chin area, implants have a documented success rate of more than 95 percent at 5 years, and this appears to hold at 10 years, too. In the upper jaw under the nose, it’s 90 percent. But the odds drop to 85 percent for the lower back jaw and to 70 to 75 percent for the upper back jaw.
“People should be very cautious about implants in the upper back part of the jaw,” says Schnitman. “This is a real iffy place” because the bones abut the sinuses and are often weak.
The type of implant may matter, too. Anchors with a roughened surface often work better in soft bone because they provide more surface for the bone to grow into.
(The American Dental Association reviews data on implant devices and gives its approval only to those whose failure rate is less than 85 percent. The US Food and Drug Administration classifies most implants as Class III devices for which there is insufficient data to evaluate safety and efficacy, although a panel met last week to begin reconsidering this.)
And there are other risks, too, notably that the implantologist may inadvertently nick a nerve in your jaw while inserting the implant – which would leave you with a numb lip.
In general, implants don’t make sense if you have untreated periodontal disease, uncontrolled diabetes (which can retard healing) or a weakened immune system (because of the increased risk of infection). People with other medical conditions that affect blood or bone may also be ruled out, though many people with osteoporosis can get implants. Heavy smokers and drinkers are also at higher-than-normal risk of implant failure.
And if you’re fussy about esthetics, you should know that an implant may be visible where it joins the artificial tooth, especially if you have a “high smile” or receeding gumline.
All that said, implants can be a good solution if you’re in good health and have, say, knocked out a tooth or two playing sports, says Dr. John Da Silva, a prosthodontist at the Harvard Dental Center, part of the Harvard School of Dental Medicine.
In this situation, an implant makes sense because the alternative is a permanent bridge, which, at least in the past, has involved filing down to stumps the adjacent teeth to support the bridge – damaging two healthy teeth to restore one.
Recently, though, dentists have begun using newer materials to prepare adjacent teeth for a bridge with minimal damage, says Dr. Jamie Wong, a Brookline dentist.
In the future, bone growth factors may make all this less daunting, if, as researchers hope, new drugs can truly spur growth of the jawbone and speed the healing process.
But for the moment, it’s wise to consider all the options and shop around before deciding on an implant.
Says Schnitman, the Wellesley Hills implantologist: “Sometimes you don’t need all these exotic procedures, so patients should be cautious.”