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Replacing teeth and dental rehabilitation
Dental rehabilitation is sometimes needed for improvements in function and/or aesthetics, following the loss of teeth and their supporting structures. This can be achieved by providing a prosthesis (such as a crown, a bridge or dentures) alone or in combination with dental implants.
Crowns and bridges are ‘fixed’ options, meaning they are screwed or cemented into the mouth and cannot be removed by you. Dentures are a ‘removable’ option and can be removed by you to aid cleaning.
The type of rehabilitation will dictate the number and location of implants. The end result and type of prosthesis required needs to be planned first before any implants are placed.
- ‘Crowns’ are fixed options used to replace individual teeth on top of dental implants, or to modify individual natural teeth.
- ‘Bridges’ are fixed options to replace individual or groups of teeth by ‘bridging’ the gap.
- ‘Dentures’ are removable options which can replace some or all of the teeth and larger amounts of the supporting structures (gum area) that may have been lost. This can be important to correct facial profile and provide lip support for facial appearance.
What you individually require is determined by your dentist, in conjunction with you. An alternative for some patients may be to accept the gap left by the loss of teeth. In general, maintaining natural teeth is the best option for function (biting and chewing) and aesthetics (your smile). However, in some cases depending upon the health and position of the remaining teeth, extracting teeth may be recommended by your dentist. The risks and benefits of this should be discussed as part of the consent process but can sometimes allow for better function and aesthetics.
No replacement option for teeth can be assured to be permanent, as they are placed in a harsh biological environment in the mouth and are therefore subject to various stresses, conditions and diseases. They can, however, offer long-term solutions for patients, provided they are cared for and maintained following the recommendations of your dental care team.
Dental implants are a long-term, dental rehabilitation option for when the natural teeth have been, or are going to be, lost. They are sometimes called ‘osseointegrated’ implants, and they consist of a screw or post (usually made from titanium, but they can be ceramic too) that is placed surgically into the jawbone. The jawbone heals closely against the surface of the implant to retain it, i.e., it ‘integrates’ with the bone.
Implants act like replacement tooth roots to which a new crown (the tooth you see above the gum) or bridge (a group of missing crowns/teeth) can be screwed or cemented. They can also be used in fewer numbers to support and hold in removable dentures, often via ‘press-stud’ like attachments or a bar. Because the implants are anchored in the jawbone, they provide greater stability and retention of prosthetics such as crowns, bridges and dentures.
Where single teeth have been lost, implants can replace the tooth and root as an individual unit, preserving and protecting the neighbouring tooth structure.
They are not an instant option and require careful planning, skilled placement, a period of healing, fabrication of the new teeth and long-term maintenance and aftercare. They require a significant commitment from the patient and skilled execution from the clinician.
The assessment and rehabilitation plan needs to be carried out prior to a decision to place implants. Treatment options need to be discussed, including alternatives and the risks and benefits of these. A customised plan can then be tailored to your needs, including the timescale and duration of treatments and financial aspects of care. Assessments include clinical examination and images, such as x-rays, scans and photographs. Models may also be taken. There must be no ongoing dental disease, as a stable, healthy foundation must be present to proceed with implants successfully.
Dental implants are usually placed under local anaesthesia (a numbing injection in the mouth) as it is a minor oral surgery procedure. Sedation may be available for anxious patients. You may require multiple stages of surgery or a single episode dependant on your treatment plan.
After the area is made fully numb, the gum overlying the bone is teased back to expose the jawbone. A small hole, compatible with the implant to be placed, is made in the bone like a tooth socket and the implant is inserted. The gum may be closed over the implant with stitches or, in certain cases, a tooth may be fitted straightaway. This is dependent on the individual case and will be discussed with your dentist. Often a temporary tooth replacement is provided for function and aesthetics during the healing phase.
Sometimes a second procedure is then required if the implant has been closed under the gum at the time of placement. Again, this is done whilst the skin in the mouth is numb. The ‘abutment’ can then be attached to the implant, usually by being screwed into the small screw hole on the inside of the implant now healed into the bone. This forms a small peg which is visible poking through the gum. The crown or bridge can then be cemented or, ideally, screwed into place. Alternatively, a ‘press-stud’ like attachment can be screwed to the implant to ‘clip’ to a removable denture.
Although the procedure is painless after being made numb, it is possible to experience pressure and vibration sensations during placement. Your dentist will consent you in advance of the treatment, outlining the process, risks and benefits. The procedure is comparable to a tooth extraction and initial healing expected within a few days. Over the counter pain relief is satisfactory for controlling discomfort. The bony healing around the implant takes between 6-12 weeks, up to 6 months. Patient’s individual factors may affect this healing process.
Bone grafting is sometimes needed where there is an inadequate amount of your own bone to place the implant into. There are a variety of substances that can be used for this, including your own bone from another site of the mouth/body, a bone substitute derived from animal protein (commonly cow, pig or horse which may not be suitable for specific patients) and synthetic bone substitutes not derived from animal products. Bone substitutes have the advantage of not requiring a second surgical donor site for a patient, resulting in less post-operative discomfort. In part this choice is determined by how much bone is needed, the location it is needed and by patient preference.
Gum surgery/grafting may also be required to improve the quality and resilience of the soft tissues around implants to improve patient comfort or aesthetics. If required, harder-wearing skin or the layer just under the surface skin (like a layer of carpet underlay) is taken from the roof of the mouth usually and surgically placed around the implant site.
Implants can be used to support fixed crowns, fixed bridges and removable dentures. The type of prosthesis that will be required is individual to the patient and is dependent on multiple factors which can be discussed with your dentist.
With all minor surgical procedures, the immediate risks can include bleeding, bruising, swelling, post-operative discomfort and infection. There are also sometimes important local anatomical structures that have been taken into consideration when planning treatment. Any individual risks will be discussed with you as part of the planning and consent process by your dentist.
Although dental implants can be long term tooth replacement options, they are not permanent and not without complications. Complications may occur at a later stage as implants are at the mercy of biological processes including healing, infection and rejection in the oral environment. Implants can suffer from early failure (where they fail to fuse and anchor in the jawbone) and late failure (like natural teeth, they can experience gum disease).
Gum disease around dental implants is termed, 'peri-implant mucositis' (when there is no bone loss associated) or 'peri-implantitis' (when there is bone loss associated). This can be diagnosed by your dental team through examination and the use of appropriate x-rays. Treatment of peri-implant disease can be challenging, but often includes appropriate self-performed cleaning, in addition to cleaning provided by your dental team.
Signs of complications with your implant and/or prosthesis may include:
- Looseness of an implant or prosthesis – this could indicate that either the implant or the prosthesis has a problem
- Pain, bleeding or a bad taste around an implant – these could indicate a form of infection or gum disease around an implant, termed peri-implant mucositis or peri-implantitis (depending if the bone is also affected). Your prosthesis should allow you to clean effectively around it.
- Chipping, fracture or wear of the prosthesis
Should you notice any complications with the implant or prosthesis, contact your dentist.
Implants are suitable for most fully grown adults, with no dental disease and in good general health. They must have the financial means to facilitate placement, restoration and maintenance care, as this is mostly a privately provided option.
Implants are available on the NHS for a select cohort of high-priority patients who are unable to be restored via other means following cancer treatment, trauma or developmental conditions. Even in these situations, patients may be liable for their maintenance and re-treatment costs in the future on a private basis.
Implants are not suitable where:
- There is untreated or active dental disease as this can lead to failure of the implant and/or prosthesis and may make the disease worse. Active gum disease needs to be controlled by treatment or removal of the teeth prior to implant therapy. Although implants can be placed successfully in patients who are susceptible to gum disease, it requires the disease to be stable and an excellent level of oral hygiene to be maintained to reduce the risk of complications (as discussed above). Discussing your oral hygiene and gum health with your dental team prior to implant treatment should form a key part of your preparation and the consent process.
- A young adult has not finished growing. The implant does not grow with the body and could be ‘left behind’ in the jaw leading to poor aesthetics and difficulty restoring again in the future. Caution should be exercised in the provision in younger adults and risk discussed as part of the consent process.
- Patients are active heavy smokers and alcohol consumers.
- People who have some general medical health issues and medications may not be suitable for implants. You must discuss individual circumstances with your dentist.
- The patient is unable to finance the treatment and ongoing maintenance costs.
Implants are a long-term treatment option to aid the replacement of missing teeth but must not be thought of as permanent. With care and maintenance, they may be expected to last 10-20 years prior to retreatment. There may be a need to replace the prosthetic crown, bridge or denture at more regular intervals dependant on the survival in individual patients. Implants require regular monitoring by a clinician, a diligent self-care regimen and professional maintenance.
Self-care is the most important aspect of maintaining your implants. As the placement of dental implants and replacement tooth or teeth can make maintaining oral hygiene more challenging, full, customised instruction will be given by a clinician, tailored to your individual needs. It is essential that bacterial plaque around the gum-line is kept to a minimum to prevent inflammation, disease progression and loss of the implant.
The dentist can aid this process by ensuring the shape of the prosthesis allows for adequate cleaning.
Regular professional surveillance and maintenance will be required. A dental hygienist may need to see you regularly to ensure optimum plaque control is maintained and to support you with self-care techniques and products such as specific brushes, interdental brushes and flosses.
Occasionally fixed prostheses need to be removed to facilitate professional cleaning.
Denture care is very important to keep the skin in the mouth healthy and to prevent plaque-induced disease around the implants. They are often hidden beneath the denture and the material the denture is made from can cause a greater amount of bacterial plaque to collect around the implants. Different care regimens are needed depending on which materials your denture is made from.
Guidance on the appropriate self-performed oral hygiene around implants can be found within the BSP patient information leaflet entitled “Caring for your Implant.”
This can vary dependant on how complicated your individual treatment is.
It is a treatment option which requires a great amount of skill and training to perform safely and optimally. The products used are highly advanced and the technologies used are innovative. This is reflected in the cost.
Individual treatment costs should be provided at the planning stage and payment plans discussed with the practice providing care.
Conventional treatments to replace missing teeth without the use of dental implants may be viable, which include:
- Bridges supported by natural teeth and roots.
- Partial or complete dentures which can be made in a number of materials.
- Accepting the space left by the lost teeth.
There are risks and benefits of all treatment options for individuals which should be discussed with your dentist.
Caution should be exercised when considering travelling abroad for such treatment, as dentistry outside of the UK may not be as well regulated. Although the price tag may seem attractive, the quality of care and products may not be of the same high standard.
Implant brands available in some countries may not be available in the UK, making subsequent maintenance or urgent care more difficult if the correct equipment is not available. This can result in the need for multiple trips abroad if there are issues and this should be discussed with the provider.
If there are issues following provision of such treatment obtained through ‘dental tourism,’ the NHS is not obliged to remedy it and only urgent care to treat pain and infection will be available. It can be costly to re-treat as a private option in the UK.
Excellent advice is available from the General Dental Council below