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    Dentures and implants
    Zev Kaufman, DDS posted:
    Technically speaking, a denture is any prosthetic use to replace a partial, or a complete dentition. It can be fixed (permanent), such as a bridge between two teeth to replaced a missing tooth, or a removable denture to replace one or more teeth.

    This discussion will focus on the REMOVABLE, partial and complete dentures and the used of implants.

    There are two parameters by which dentures are evaluated:

    Resistance form--the ability of the denture to absorb and transfer the masticatory (chewing and biting) forces to the underlying bone and tissue. This transfer of forces should allow a person to function comfortably, without pain or sores. It is generally governed by the quality of the denture making process from impression, to laboratory fabrication, to fitting and upkeep.

    Retention form--the ability of the denture to stay in place while in function. This parameter is mostly determined by the remaining oral structures used to secure the denture in place. The construction of the denture is very important, however, if there are teeth present to hold the denture in place, it will stay put far better than a complete (full) denture which rests on limited bone (low ridge).

    This is where implants (mini, or conventional) come into play.

    In the early 1980's a predictable way to place "root form" implants was introduced to dentistry, and we never looked back.
    Dental implants, as we know them today, are titanium screws/anchors, which are placed into the human jaw bone. These implants can be used to anchor a variety of prosthetic devices in place. At first, they were use to anchor a complete lower fixed bridge. Four to six implants were placed into the lower jaw, and a metal structure covered with pink acrylic (plastic) and denture teeth was screwed in place into the implants. As the confidence in the implants grew, the use of implants to replace single, free standing, not connected, teeth, became common. Today, the restoration of choice, when a tooth, or multiple teeth are missing, is the implant supported and retained prosthesis.

    The standard of care has evolved, as well. Whereas in the past, the implant retained prosthesis was the "alternative" treatment, today, it is the treatment of choice, mostly due to the fact that the implant retained prosthetic does not involve the used of adjacent teeth for anchorage. When it comes to complete (full) lower dentures, using two implants with "snap" attachments to the denture is considered the standard of care. All the studies of biological factors and psychological factors point to the fact that the implant retained removable denture is an excellent restoration, allowing people to function in a higher capacity and preserving the remaining oral structures.

    The most common misconception I have encountered in removable denture is "once the implants are 'in', the denture will be comfortable."

    The most important factor to the success of implant retained denture therapy is the proper fit of the denture--the Resistance Form. Only when a denture is evaluated and is deemed satisfactory in function, should implant therapy begin. This holds true especially in situations where one does not have dentures at all. The placement and position of the implants are determined by the position of the teeth and the shape of the well-fitting denture. Placing implants prior to the fabrication and evaluation of a denture can result in problems and improperly placed implants.

    Proper implants treatment should START with the final prosthetic (denture).
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    Zev Kaufman, DDS responded:
    The first step in the "implant process" is having a great removable denture (partial, or complete) by your general/family/cosmetic dentist. The new denture should be worn for at least two weeks without any problems or sore spots, even if retention is a problem. Most dentists get good, basic, denture skills in dental school, and can deliver good results to most people, in most cases.

    If the situation is challenging, the expert to see is called the Prosthodontist. Prosthodontists receive three more years of training after dental school in order to handle the more difficult situations. They are also the experts in planning the implant treatment. (Some Prosthodontists are also trained in implant surgery and can place the implants for you as well). Nevertheless, most cases can be easily handled by your family/cosmetic/general dentist.

    Once the denture is comfortably worn for a while, your dentist will generally refer you to a Periodontist or an Oral Surgeon for an evaluation for implant surgery. If you have good bone support and enough to hold implants predictably, your dentist should duplicate your denture and prepare a surgical guide which will be give to your surgeon. The surgeon will use the guide in proper positioning of the implants.

    If there is not enough bone, the denture should be duplicated and markers should be put into it. Your dentist or the surgeon should prepare this and there is usually a charge for the radiographic (X-ray)/surgical guide. A CT scan is then taken with the guide in place, which will allow your dentists to evaluate the availability of the bone in relation to the position of the teeth and that will allow them to plan the proper location of the implants and/or the bone graft necessary.

    Once a proper diagnosis is made, based on proper physical and X-ray information, placement of implants can commence.
    Zev Kaufman, DDS replied to Zev Kaufman, DDS's response:
    The simplest and most cost effective way to "get into" implant dentistry is having two implants placed in the lower jaw, typically where the canine teeth used to be. Once the implants are placed, they are allowed to integrate (the bone bonds to them) for 2-6 months. In the mean time, the patient is asked not to eat hard foods and a temporary denture might be used and relined (fitted) with soft material so that the implants are not traumatized. Once they are integrated, they are uncovered (the tissue is opened and a healing abutment is connected) After two weeks of healing, the healing abutments are replaced with attachments which will connect the implants into the denture.

    Lately, the placement of four "mini" implants in the front and connecting them into the denture right away has been introduced. This is designed to work in places where bone is very limited and costs are a problem. The surgical step of the mini implants is designed to be fast, and thus the costs should be lower.

    The main problem with the mini implants is that the system is not "upgradable". When conventional implants are used and the patient decides to upgrade to a fixed restoration, with more implants, the attachments can be changed with abutments and fixed restorations. This cannot be done with the mini implant system.

    The other issue is with the "immediate load" process of the mini implants. Since the implants are loaded right away, the risk of implant failure is increased. Once an mini implant fails, it can be readily replaced,

    In short, if you are charged a much lower rate for the mini implants vs. the conventional implants, it is worth it. If you are charged the same amount as the conventional ones, consider going with the conventional, traditional implants.
    Zev Kaufman, DDS replied to Zev Kaufman, DDS's response:
    Once an implant system is selected, your dentist, or prosthodontist will decide if he/she will place the implants, or you should be referred to a periodontist or oral surgeon.

    Many general dentist will chose to place the mini imlants for you in their office. The system is simler to use and is designed for it.

    The traditional implant are more surgically involve and require more training. Most times, they are placed by the periodontist or an oral surgeon. If the Prosthodontist is trained in surgery as well, some will place the implants themselves. As long as the communication is good between the working team an excellent result can be expected.
    An_245387 replied to Zev Kaufman, DDS's response:
    Dr Kaufman,

    Your are great in explaining things in depth. I understood this topic very well now. what kind of ball park numbers that we are talking when people go for implants/tooth. I would appreciate if you could through numbers on that.
    Zev Kaufman, DDS replied to An_245387's response:
    Dear An_24537:
    I am sorry for the delay. However, it is hard for me to give you concrete numbers, since the fee for a specific procedure is typically dictated by the doctor's level of expertise, level of practice and geographical region. The cost of the parts themselves, laboratory work, and staff also play an important role in establishing the fee for a procedure.
    What I always recommend is to first evaluate YOUR trust level with YOUR dentist. If you trust your dentist and require only minor work, such as one implant to replace a non-conspicuous tooth, ask your dentist for the fee and for a referral to a periodontist, oral surgeon, or a prosthodontist to have the implant placed. Then have your dentist restore it.
    If you require extensive work, or work that esthetically could be challenging such as an implant in the front of the mouth, I always advise to go to a Prosthodontist for a consultation first.
    The Prosthodontist is the expert in cosmetic, restorative, and implant treatment, and will usually be priced at the top.
    This will give you an understanding what the best that can be done and how much it would cost to have it done by a specialist.
    From that, you can compare and make your own decision as to what factors are important to you. There are many excellent general/family/cosmetic (all the same thing) dentists out there, but if you see the specialist first and see his/her photos of the work, you will be able to be in a position to better evaluate your general dentist and see if you can get reasonable work for reasonable fee.
    I am sorry that I cannot give you a more specific answer.
    Best of luck,
    Dr. Zev Kaufman
    plazadental replied to Zev Kaufman, DDS's response:
    Very helpful post Dr.Zev. This gives complete information on dentures and helps a layman to understand why its needed and the other related details too. I am sure a lot of queries of people related to this is answered by simply reading your post.

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