Why Invisalign Treatment in Des Moines is Leading the Way in 2026
Function
In recent years, the popularity of Invisalign treatment has been skyrocketing across the globe, and its no surprise that Des Moines has emerged as a leading city in embracing this modern dental technology. As we look towards 2026, there are several compelling reasons why Invisalign treatment in Des Moines is not just catching up but actually leading the way in orthodontic solutions.
Firstly, the level of expertise and dedication among Des Moines orthodontists is quite impressive. Many of these professionals have dedicated significant time to specialize in Invisalign treatments, ensuring they are well-equipped to provide top-notch service. ProtocolFollowup However, despite their expertise, sometimes the guidance provided to patients about maintaining the aligners can be a bit unclear. It seems like maintaining clear communication still poses a challenge at times.
Another significant factor is the advanced technological resources available in Des Moines. undefined undefined undefined. The city has seen considerable investments in dental technology, which includes 3D imaging tools that are crucial for the precise customization of Invisalign aligners. OutcomeDurability This technology not only helps in creating a more accurate fit but also in predicting the treatment outcome more effectively.
Followup
Jaw
Occlusion
Resin
Clinic
Precision
Natural
Crownwork
Disease
Extraction
Transformation
Orthodontist
Overbite
Checkup
Retainer
Clinic
Decay Yet, theres a flipside; with rapid technology advancements, sometimes patients feel overwhelmed with the options available and making an informed choice becomes daunting.
The community in Des Moines also plays a vital role. Periodontitis Theres a growing awareness about the aesthetic and health benefits of having properly aligned teeth, and the communitys increasing preference for less visible orthodontic treatments has significantly contributed to the popularity of Invisalign. WhiteninggelFunction Community seminars and workshops, though highly informative, occasionally suffer from poorly organized schedules which can lead to reduced participation.
Moreover, the cost of Invisalign treatment in Des Moines is becoming increasingly competitive. With more clinics offering this treatment, prices have begun to stabilize, making it more accessible to a wider range of people. Nonetheless, for some families, the cost still represents a significant investment, and financing options arent always as flexible as they could be.
Looking ahead to 2026, the trajectory for Invisalign treatment in Des Moines is highly promising. The city is expected to continue leading with innovative practices and an ever-growing base of skilled orthodontists.
Outcome
Skill
Proportion
Treatment
Technology
Alignment
Teeth
Diagnosis
Restorative
Correction
Titanium
Yet, there must be an ongoing effort to improve patient education and financial assistance programs to ensure that more individuals can benefit from this revolutionary dental treatment.
In conclusion, while there are areas that need improvement, the enthusiasm and commitment of the dental professionals and the community at large are what truly make Invisalign treatment in Des Moines stand out!
Underbite
Expertise
Bite
Tray
Preview
Scheduling
Material
Cosmetic
Model
Discomfort
Veneers
As we move closer to 2026, its exciting to imagine how much further ahead Des Moines will be in the realm of orthodontic care.
Dentistry, also known as dental medicine and oral medicine, is the branch of medicine focused on the teeth, gums, and mouth. It consists of the study, diagnosis, prevention, management, and treatment of diseases, disorders, and conditions of the mouth, most commonly focused on dentition (the development and arrangement of teeth) as well as the oral mucosa.[2] Dentistry may also encompass other aspects of the craniofacial complex including the temporomandibular joint. The practitioner is called a dentist.
The history of dentistry is almost as ancient as the history of humanity and civilization, with the earliest evidence dating from 7000 BC to 5500 BC.[3] Dentistry is thought to have been the first specialization in medicine which has gone on to develop its own accredited degree with its own specializations.[4] Dentistry is often also understood to subsume the now largely defunct medical specialty of stomatology (the study of the mouth and its disorders and diseases) for which reason the two terms are used interchangeably in certain regions. However, some specialties such as oral and maxillofacial surgery (facial reconstruction/OMFS) may require both medical and dental degrees to accomplish.
The modern movement of evidence-based dentistry calls for the use of high-quality scientific research and evidence to guide decision-making such as in manual tooth conservation, use of fluoride water treatment and fluoride toothpaste, dealing with oral diseases such as tooth decay and periodontitis, as well as systematic diseases such as osteoporosis, diabetes, celiac disease, cancer, autoimmune diseases, and HIV/AIDS which could also affect the oral cavity. Other practices relevant to evidence-based dentistry include radiology of the mouth to inspect teeth deformity or oral malaises, haematology (study of blood) to avoid bleeding complications during dental surgery, cardiology (due to various severe complications arising from dental surgery with patients with heart disease), etc.
The term dentistry comes from dentist, which comes from French dentiste, which comes from the French and Latin words for tooth.[5] The term for the associated scientific study of teeth is odontology (from Ancient Greek: ὀδούς, romanized: odoús, lit.'tooth') – the study of the structure, development, and abnormalities of the teeth.
Dentistry usually encompasses practices related to the oral cavity.[6] According to the World Health Organization, oral diseases are major public health problems due to their high incidence and prevalence across the globe, with the disadvantaged affected more than other socio-economic groups.[7]
By nature of their general training, dentists, without specialization, can carry out the majority of dental treatments such as restorative (fillings, crowns, bridges), prosthetic (dentures), endodontic (root canal) therapy, periodontal (gum) therapy, and extraction of teeth, as well as performing examinations, radiographs (x-rays), and diagnosis. Dentists can also prescribe medications used in the field such as antibiotics, sedatives, and any other drugs used in patient management. Depending on their licensing boards, general dentists may be required to complete additional training to perform sedation, dental implants, etc.
Irreversible enamel defects caused by an untreated celiac disease. They may be the only clue to its diagnosis, even in absence of gastrointestinal symptoms, but are often confused with fluorosis, tetracycline discoloration, acid reflux or other causes.[8][9][10] The National Institutes of Health include a dental exam in the diagnostic protocol of celiac disease.[8]
Dentists also encourage the prevention of oral diseases through proper hygiene and regular, twice or more yearly, checkups for professional cleaning and evaluation. Oral infections and inflammations may affect overall health, and conditions in the oral cavity may be indicative of systemic diseases, such as osteoporosis, diabetes, celiac disease or cancer.[6][8][11][12] Many studies have also shown that gum disease is associated with an increased risk of diabetes, heart disease, and preterm birth. The concept that oral health can affect systemic health and disease is referred to as "oral-systemic health".
A sagittal cross-section of a molar tooth; 1: crown, 2: root, 3: enamel, 4: dentin and dentin tubules, 5: pulp chamber, 6: blood vessels and nerve, 7: periodontal ligament, 8: apex and periapical region, 9: alveolar boneEarly dental chair in Pioneer West Museum in Shamrock, Texas, U.S.
Studies show that dentists who graduated from different countries,[16] or even from different dental schools in one country,[17] may make different clinical decisions for the same clinical condition. For example, dentists that graduated from Israeli dental schools may recommend the removal of asymptomatic impactedthird molar (wisdom teeth) more often than dentists that graduated from Latin American or Eastern European dental schools.[18]
In the United Kingdom, the first dental schools, the London School of Dental Surgery and the Metropolitan School of Dental Science, both in London, opened in 1859.[19] The British Dentists Act 1878 and the 1879 Dentists Register limited the title of "dentist" and "dental surgeon" to qualified and registered practitioners.[20][21] However, others could legally describe themselves as "dental experts" or "dental consultants".[22] The practice of dentistry in the United Kingdom became fully regulated with the 1921 Dentists Act, which required the registration of anyone practising dentistry.[23] The British Dental Association, formed in 1880 with Sir John Tomes as president, played a major role in prosecuting dentists practising illegally.[20] Dentists in the United Kingdom are now regulated by the General Dental Council.
Dentists in many countries complete between five and eight years of post-secondary education before practising. Though not mandatory, many dentists choose to complete an internship or residency focusing on specific aspects of dental care after they have received their dental degree. In a few countries, to become a qualified dentist one must usually complete at least four years of postgraduate study;[24]Dental degrees awarded around the world include the Doctor of Dental Surgery (DDS) and Doctor of Dental Medicine (DMD) in North America (US and Canada), and the Bachelor of Dental Surgery/Baccalaureus Dentalis Chirurgiae (BDS, BDent, BChD, BDSc) in the UK and current and former British Commonwealth countries.
All dentists in the United States undergo at least three years of undergraduate studies, but nearly all complete a bachelor's degree. This schooling is followed by four years of dental school to qualify as a "Doctor of Dental Surgery" (DDS) or "Doctor of Dental Medicine" (DMD). Specialization in dentistry is available in the fields of Anesthesiology, Dental Public Health, Endodontics, Oral Radiology, Oral and Maxillofacial Surgery, Oral Medicine, Orofacial Pain, Pathology, Orthodontics, Pediatric Dentistry (Pedodontics), Periodontics, and Prosthodontics.[25]
Many countries require licensed dentists to undertake continuing education or continuing professional development (CE/CPD) after graduation. These structured activities help maintain clinical competence, support patient safety, and keep practitioners up to date with current standards of care, with government regulators typically specifying minimum hours or points per cycle and mandating core topics such as infection control, radiography, and medical emergencies.[26]
Some dentists undertake further training after their initial degree in order to specialize. Exactly which subjects are recognized by dental registration bodies varies according to location. Examples include:
Anesthesiology[27] – the specialty of dentistry that deals with the advanced use of general anesthesia, sedation and pain management to facilitate dental procedures.
Cosmetic dentistry – focuses on improving the appearance of the mouth, teeth and smile.
Forensic odontology – the gathering and use of dental evidence in law. This may be performed by any dentist with experience or training in this field. The function of the forensic dentist is primarily documentation and verification of identity.
Geriatric dentistry or geriodontics – the delivery of dental care to older adults involving the diagnosis, prevention, and treatment of problems associated with normal aging and age-related diseases as part of an interdisciplinary team with other health care professionals.
Oral and maxillofacial pathology – the study, diagnosis, and sometimes the treatment of oral and maxillofacial related diseases.
Periodontology (also called periodontics) – the study and treatment of diseases of the periodontium (non-surgical and surgical) as well as placement and maintenance of dental implants
Some prosthodontists super-specialize in maxillofacial prosthetics, which is the discipline originally concerned with the rehabilitation of patients with congenital facial and oral defects such as cleft lip and palate or patients born with an underdeveloped ear (microtia). Today, most maxillofacial prosthodontists return function and esthetics to patients with acquired defects secondary to surgical removal of head and neck tumors, or secondary to trauma from war or motor vehicle accidents.
Sports dentistry – the branch of sports medicine dealing with prevention and treatment of dental injuries and oral diseases associated with sports and exercise.[28] The sports dentist works as an individual consultant or as a member of a sports medicine team.
A wealthy patient falling over because of having a tooth extracted with such vigour by a fashionable dentist, c. 1790. History of Dentistry.Farmer at the dentist, Johann Liss. While distracted his money bag is emptied. c. 1616–17
Tooth decay was low in pre-agricultural societies, but the advent of farming society about 10,000 years ago correlated with an increase in tooth decay (cavities).[29] An infected tooth from Italy partially cleaned with flint tools, between 13,820 and 14,160 years old, represents the oldest known dentistry,[30] although a 2017 study suggests that 130,000 years ago the Neanderthals already used rudimentary dentistry tools.[31][32]
In Italy evidence dated to the Paleolithic, around 13,000 years ago, points to bitumen used to fill a tooth[33] and in Neolithic Slovenia, 6500 years ago, beeswax was used to close a fracture in a tooth.[34] The Indus valley has yielded evidence of dentistry being practised as far back as 7000 BC, during the Stone Age.[35] The Neolithic site of Mehrgarh (now in Pakistan's south western province of Balochistan) indicates that this form of dentistry involved curing tooth related disorders with bow drills operated, perhaps, by skilled bead-crafters.[3] The reconstruction of this ancient form of dentistry showed that the methods used were reliable and effective. The earliest dental filling, made of beeswax, was discovered in Slovenia and dates from 6500 years ago.[36] Dentistry was practised in prehistoric Malta, as evidenced by a skull which had a dental abscess lanced from the root of a tooth dating back to around 2500 BC.[37] The practice of dentistry dates back thousands of years, with evidence of dental procedures such as tooth extraction and fillings found in ancient civilizations like the Egyptians and the Greeks. One notable historical figure is Pierre Fauchard, often referred to as the 'father of modern dentistry,' who wrote the first comprehensive book on the subject in 1728.
An ancient Sumerian text describes a "tooth worm" as the cause of dental caries.[38] Evidence of this belief has also been found in ancient India, Egypt, Japan, and China. The legend of the worm is also found in the Homeric Hymns,[39] and as late as the 14th century AD the surgeon Guy de Chauliac still promoted the belief that worms cause tooth decay.[40]
Recipes for the treatment of toothache, infections and loose teeth are spread throughout the Ebers Papyrus, Kahun Papyri, Brugsch Papyrus, and Hearst papyrus of Ancient Egypt.[41] The Edwin Smith Papyrus, written in the 17th century BC but which may reflect previous manuscripts from as early as 3000 BC, discusses the treatment of dislocated or fractured jaws.[41][42] In the 18th century BC, the Code of Hammurabi referenced dental extraction twice as it related to punishment.[43] Examination of the remains of some ancient Egyptians and Greco-Romans reveals early attempts at dental prosthetics.[44] However, it is possible the prosthetics were prepared after death for aesthetic reasons.[41]
Ancient Greek scholars Hippocrates and Aristotle wrote about dentistry, including the eruption pattern of teeth, treating decayed teeth and gum disease, extracting teeth with forceps, and using wires to stabilize loose teeth and fractured jaws.[45] Use of dental appliances, bridges and dentures was applied by the Etruscans in northern Italy, from as early as 700 BC, of human or other animal teeth fastened together with gold bands.[46][47][48] The Romans had likely borrowed this technique by the 5th century BC.[47][49] The Phoenicians crafted dentures during the 6th–4th century BC, fashioning them from gold wire and incorporating two ivory teeth.[50] In ancient Egypt, Hesy-Ra is the first named "dentist" (greatest of the teeth). The Egyptians bound replacement teeth together with gold wire. Roman medical writer Cornelius Celsus wrote extensively of oral diseases as well as dental treatments such as narcotic-containing emollients and astringents.[51] The earliest dental amalgams were first documented in a Tang dynasty medical text written by the Chinese physician Su Kung in 659, and appeared in Germany in 1528.[52][53]
During the Islamic Golden Age dentistry was discussed in several famous books of medicine such as The Canon in medicine written by Avicenna and Al-Tasreef by Al-Zahrawi who is considered the greatest surgeon of the Middle Ages.[54] Avicenna said that jaw fracture should be reduced according to the occlusal guidance of the teeth; this principle is still valid in modern times. Al-Zahrawi invented over 200 surgical tools that resemble the modern kind.[55]
Historically, dental extractions have been used to treat a variety of illnesses. During the Middle Ages and throughout the 19th century, dentistry was not a profession in itself, and often dental procedures were performed by barbers or general physicians. Barbers usually limited their practice to extracting teeth which alleviated pain and associated chronic tooth infection. Instruments used for dental extractions date back several centuries. In the 14th century, Guy de Chauliac most probably invented the dental pelican[56] (resembling a pelican's beak) which was used to perform dental extractions up until the late 18th century. The pelican was replaced by the dental key[57] which, in turn, was replaced by modern forceps in the 19th century.[58]
The first book focused solely on dentistry was the "Artzney Buchlein" in 1530,[45] and the first dental textbook written in English was called "Operator for the Teeth" by Charles Allen in 1685.[21]
In the United Kingdom, there was no formal qualification for the providers of dental treatment until 1859 and it was only in 1921 that the practice of dentistry was limited to those who were professionally qualified. The Royal Commission on the National Health Service in 1979 reported that there were then more than twice as many registered dentists per 10,000 population in the UK than there were in 1921.[59]
A microscopic device used in dental analysis, c. 1907
It was between 1650 and 1800 that the science of modern dentistry developed. The English physician Thomas Browne in his A Letter to a Friend (c. 1656 pub. 1690) made an early dental observation with characteristic humour:
The Egyptian Mummies that I have seen, have had their Mouths open, and somewhat gaping, which affordeth a good opportunity to view and observe their Teeth, wherein 'tis not easie to find any wanting or decayed: and therefore in Egypt, where one Man practised but one Operation, or the Diseases but of single Parts, it must needs be a barren Profession to confine unto that of drawing of Teeth, and little better than to have been Tooth-drawer unto King Pyrrhus, who had but two in his Head.
The French surgeon Pierre Fauchard became known as the "father of modern dentistry". Despite the limitations of the primitive surgical instruments during the late 17th and early 18th century, Fauchard was a highly skilled surgeon who made remarkable improvisations of dental instruments, often adapting tools from watchmakers, jewelers and even barbers, that he thought could be used in dentistry. He introduced dental fillings as treatment for dental cavities. He asserted that sugar-derived acids like tartaric acid were responsible for dental decay, and also suggested that tumors surrounding the teeth and in the gums could appear in the later stages of tooth decay.[60][61]
Panoramic radiograph of historic dental implants, made 1978
Fauchard was the pioneer of dental prosthesis, and he invented many methods to replace lost teeth. He suggested that substitutes could be made from carved blocks of ivory or bone. He also introduced dental braces, although they were initially made of gold, he discovered that the teeth position could be corrected as the teeth would follow the pattern of the wires. Waxed linen or silk threads were usually employed to fasten the braces. His contributions to the world of dental science consist primarily of his 1728 publication Le chirurgien dentiste or The Surgeon Dentist. The French text included "basic oral anatomy and function, dental construction, and various operative and restorative techniques, and effectively separated dentistry from the wider category of surgery".[60][61]
A modern dentist's workspace
After Fauchard, the study of dentistry rapidly expanded. Two important books, Natural History of Human Teeth (1771) and Practical Treatise on the Diseases of the Teeth (1778), were published by British surgeon John Hunter. In 1763, he entered into a period of collaboration with the London-based dentist James Spence. He began to theorise about the possibility of tooth transplants from one person to another. He realised that the chances of a successful tooth transplant (initially, at least) would be improved if the donor tooth was as fresh as possible and was matched for size with the recipient. These principles are still used in the transplantation of internal organs. Hunter conducted a series of pioneering operations, in which he attempted a tooth transplant. Although the donated teeth never properly bonded with the recipients' gums, one of Hunter's patients stated that he had three which lasted for six years, a remarkable achievement for the period.[62]
Major advances in science were made in the 19th century, and dentistry evolved from a trade to a profession. The profession came under government regulation by the end of the 19th century. In the UK, the Dentist Act was passed in 1878 and the British Dental Association formed in 1879. In the same year, Francis Brodie Imlach was the first ever dentist to be elected President of the Royal College of Surgeons (Edinburgh), raising dentistry onto a par with clinical surgery for the first time.[63]
Long term occupational noise exposure can contribute to permanent hearing loss, which is referred to as noise-induced hearing loss (NIHL) and tinnitus. Noise exposure can cause excessive stimulation of the hearing mechanism, which damages the delicate structures of the inner ear.[64] NIHL can occur when an individual is exposed to sound levels above 90 dBA according to the Occupational Safety and Health Administration (OSHA). Regulations state that the permissible noise exposure levels for individuals is 90 dBA.[65] For the US National Institute for Occupational Safety and Health (NIOSH), exposure limits are set to 85 dBA. Exposures below 85 dBA are not considered to be hazardous. Time limits are placed on how long an individual can stay in an environment above 85 dBA before it causes hearing loss. OSHA places that limitation at 8 hours for 85 dBA. The exposure time becomes shorter as the dBA level increases.
Within the field of dentistry, a variety of cleaning tools are used including piezoelectric and sonic scalers, and ultrasonic scalers and cleaners.[66] While a majority of the tools do not exceed 75 dBA,[67] prolonged exposure over many years can lead to hearing loss or complaints of tinnitus.[68] Few dentists have reported using personal hearing protective devices,[69][70] which could offset any potential hearing loss or tinnitus.
There are various chemical hazards from disinfection and dental materials, that lead to allergens from compounds like mercury, methacrylate, and nickel.[71][72][73]
Chemical disinfectants are necessary in a dental practice to prevent infection and contamination between patients. As a consequence, it introduces many chemical and occupational hazards. The most commonly used active ingredients in disinfection include alcohol, ortho-phthalaldehyde (OPA) solution, hydrogen peroxide, peracetic acid, and glutaraldehyde.[74] In terms of surface-disinfection, workers are especially exposed to agents like aldehydes and quaternary-ammonium compounds via inhalation or physical contact.[75] This may result in allergies, due to lack of adequate ventilation and prolonged exposure. Research shows that around 10.9% of dental professionals may test positive for an allergic reaction to glutaraldehyde, compared to 2% in non-dental control subjects.[76] Additionally, frequent use of disinfectants may result in more respiratory symptoms in dental workers as well as worsened asthma control.[77]
It is essential to implement controls within dental clinics to reduce occupational exposure to these chemical hazards from disinfectants. In terms of engineering, using alternative and less sensitive chemicals as well as maintaining proper ventilation systems within the clinic will help reduce the amount of airborne chemicals. Having a safety data sheet, regular training on chemical safety, appropriate response equipment, and conducting assessments of workplace safety are all recommended administrative controls to minimize exposure.[78] Wearing full personal protective equipment reduces the occurrence of symptoms like burning sensation in eyes, dry cough, skin dermatitis, and respiratory irritation to chemical disinfectants.[79] Therefore, it is vital as a last form of defense that dental professionals wear gloves, gowns, masks, and eye protection when using disinfectant.[80] The application of these engineering techniques, administrative protocols, and personal protection are standard industrial hygiene practices to keep dental professionals safe while keeping the work environment clean.
Pre-capsulated dental amalgam used for restorative procedures, containing approximately 50% elemental mercury.
Elemental mercury makes up approximately 50% of conventional dental amalgam and can release toxic vapor during both placement and removal procedures.[81] Dental amalgam is a restorative material used for filling cavities caused by tooth decay. It is composed of a mixture of metals, approximately 50% of which is elemental mercury (Hg⁰) combined with an alloy powder containing silver, tin, copper, and other trace metals.[81] Mercury serves as a binding agent amalgamates the alloy particles into a durable, moldable mass. Prolonged or repeated exposure to these vapors has been associated with adverse effects on the nervous system and kidneys. Chronic exposure to mercury vapor has been associated with neurological, renal, and immunological effects, as mercury has a high affinity for nervous tissue and the kidneys. Symptoms of overexposure may include tremors, memory impairment, fatigue, and mood changes.[82][83]
Methyl methacrylate is an acrylic resin used in restorative and prosthetic dentistry, especially in dentures, temporary crowns, and retainers. Exposure can occur by inhalation of vapors through grinding or polymerization during dental procedures or by skin contact with uncured materials.[84] Short-term exposure can lead to eye, skin, and respiratory irritation, and long-term exposure can cause occupational asthma or allergic contact dermatitis.[85] One cross-sectional study discovered that dental assistants with high exposure to methacrylate vapors had increased odds of asthma and nasal issues.[86] This study emphasizes the importance of understanding that methacrylate is a respiratory and dermal hazard in dentistry.[87]
Prevention measures to reduce exposure to methacrylate include local exhaust ventilation to capture aerosols, consistent air sampling, covered mixing systems, and proper personal protective equipment such as masks and gloves.[88] The US National Institute for Occupational Safety and Health (NIOSH) recommends keeping methyl methacrylate concentrations below the recommended exposure limit of 100 ppm for an 8-hour time-weighted average.[89] Implementing safety measures to protect dental staff from hazards can be achieved by ventilation improvements and proper personal protective equipment to prevent them from respiratory irritation, asthma, and allergic contact dermatitis.
Nickel exposure in dentistry can primarily occur through the use of nickel-containing alloys like crowns, bridges, brackets, and orthodontic appliances.[90] However, according to recent studies, in people who are not sensitive to nickel, dental alloys release levels that are typically less harmful and regarded as biologically safe.[91]
There is a movement in modern dentistry to place a greater emphasis on high-quality scientific evidence in decision-making. Evidence-based dentistry uses current scientific evidence to guide decisions. It is an approach to oral health that requires the application and examination of relevant scientific data related to the patient's oral and medical health. Along with the dentist's professional skill and expertise, evidence-based dentistry allows dentists to stay up to date on procedures for patients to receive improved treatment. A new paradigm for medical education designed to incorporate current research into education and practice was developed to help practitioners provide the best care for their patients.[92] It was first introduced by Gordon Guyatt and the Evidence-Based Medicine Working Group at McMaster University in Ontario, Canada in the 1990s. It is part of the larger movement toward evidence-based medicine and other evidence-based practices, especially since a major part of dentistry involves dealing with oral and systemic diseases. Other issues relevant to the dental field in terms of evidence-based research and evidence-based practice include population oral health, dental clinical practice, tooth morphology etc.
Like other medical disciplines, dentistry is strongly influenced by the digital transformation of healthcare. Processes are changing fundamentally, affecting the effectiveness and accuracy of patient treatment.[93][94]
Various technologies are being used in dentistry, including computer-aided design and computer-aided manufacturing (CAD/CAM) systems in combination with 3D printing, artificial intelligence (AI), and electronic health records.[95][96] The degree of implementation of such technologies varies significantly across dental practices.[97]
Research shows that larger dental centers are adopting digital solutions more rapidly. Younger dentists, as well as those who regularly participate in digital training programs, show a higher willingness to implement new technologies. However, financial constraints and the lack of comprehensive training opportunities for the digitalization of dentistry currently represent major barriers to implementation.[98]
A dental chair at the University of Michigan School of Dentistry
Dentistry is unique in that it requires dental students to have competence-based clinical skills that can only be acquired through supervised specialized laboratory training and direct patient care.[99] This necessitates the need for a scientific and professional basis of care with a foundation of extensive research-based education.[100] According to some experts, the accreditation of dental schools can enhance the quality and professionalism of dental education.[101][102]
^Whether dentists are referred to as "Doctor" is subject to geographic variation. For example, they are called "Doctor" in the US. In the UK, dentists have traditionally been referred to as "Mister" as they identified themselves with barber surgeons more than physicians (as do surgeons in the UK, see Surgeon#Titles). However more UK dentists now refer to themselves as "Doctor", although this was considered to be potentially misleading by the British public in a single report (see Costley and Fawcett 2010).
^The scope of oral and maxillofacial surgery is variable. In some countries, both a medical and dental degree is required for training, and the scope includes head and neck oncology and craniofacial deformity.
^ abc"Diagnosis of Celiac Disease". National Institute of Health (NIH). Archived from the original on 15 May 2017. Retrieved 6 June 2017.cite web: CS1 maint: bot: original URL status unknown (link)
^Estrella MR, Boynton JR (2010). "General dentistry's role in the care for children with special needs: a review". Gen Dent (Review). 58 (3): 222–29. PMID20478802.
^da Fonseca MA (2010). "Dental and oral care for chronically ill children and adolescents". Gen Dent (Review). 58 (3): 204–09, quiz 210–11. PMID20478800.
^Owen, Lorrie K., ed. (1999). Dictionary of Ohio Historic Places. Vol. 2. St. Clair Shores: Somerset. pp. 1217–1218.
^Mary, Otto (2017). Teeth: the story of beauty, inequality, and the struggle for oral health in America. New York: The New Press. p. 70. ISBN978-1-62097-144-4. OCLC958458166.
^"History". Pennsylvania School of Dental Medicine. Retrieved 13 January 2016.
^Yehuda, Zadik; Liran, Levin (January 2008). "Clinical decision making in restorative dentistry, endodontics, and antibiotic prescription". J Dent Educ. 72 (1): 81–86. doi:10.1002/j.0022-0337.2008.72.1.tb04456.x. PMID18172239.
^Yehuda, Zadik; Liran, Levin (April 2006). "Decision making of Hebrew University and Tel Aviv University Dental Schools graduates in every day dentistry—is there a difference?". J Isr Dent Assoc. 23 (2): 19–23. PMID16886872.
^Yehuda, Zadik; Liran, Levin (April 2007). "Decision making of Israeli, East European, and South American dental school graduates in third molar surgery: is there a difference?". J Oral Maxillofac Surg. 65 (4): 658–62. doi:10.1016/j.joms.2006.09.002. PMID17368360.
^Coppa, A.; et al. (2006). "Early Neolithic tradition of dentistry". Nature. 440 (7085). Springer Science and Business Media LLC: 755–756. doi:10.1038/440755a. ISSN0028-0836. PMID16598247.
^Bjørklund G (1989). "The history of dental amalgam (in Norwegian)". Tidsskr Nor Laegeforen. 109 (34–36): 3582–85. PMID2694433.
^Czarnetzki, A.; Ehrhardt, S. (1990). "Re-dating the Chinese amalgam-filling of teeth in Europe". International Journal of Anthropology. 5 (4): 325–332.
^Meri, Josef (2005). Medieval Islamic Civilization: An Encyclopedia (Routledge Encyclopedias of the Middle Ages). Psychology Press. ISBN978-0-415-96690-0.
^Friedman, Saul S. (2006). A history of the Middle East. Jefferson, N.C.: Mcfarland. p. 152. ISBN0-7864-5134-3.
^Gregory Ribitzky. "Pelican". Archived from the original on 25 January 2020. Retrieved 23 June 2018.
^Gregory Ribitzky. "Toothkey". Archived from the original on 23 June 2018. Retrieved 23 June 2018.
^Gregory Ribitzky. "Forceps". Archived from the original on 23 June 2018. Retrieved 23 June 2018.
^Stevens, M (1999). "Is someone listening to the din of occupational noise exposure in dentistry". RDH (19): 34–85.
^Merrel, HB (1992). "Noise pollution and hearing loss in the dental office". Dental Assisting Journal. 61 (3): 6–9.
^Wilson, J.D. (2002). "Effects of occupational ultrasonic noise exposure on hearing of dental hygienists: A pilot study". Journal of Dental Hygiene. 76 (4): 262–69. PMID12592917.
^Cohen, B. I.; Pagnillo, M. K.; Musikant, B. L.; Deutsch, A. S. (December 1998). "Formaldehyde evaluation from endodontic materials". Oral Health. 88 (12): 37–39. ISSN0030-4204. PMID10323136.
^Formicola, Allan J.; Bailit, Howard L.; Beazoglou, Tryfon J.; Tedesco, Lisa A. (February 2008). "The interrelationship of accreditation and dental education: history and current environment". Journal of Dental Education. 72 (2 Suppl): 53–60. doi:10.1002/j.0022-0337.2008.72.2_suppl.tb04480.x. ISSN0022-0337. PMID18250379.
Implantology (from Latin in meaning 'into' and planta 'cutting,'[1] and -logy from the Greek λόγος lógos 'word,' 'study,') is the term for the placement of dental implants by a dentist, specialist dentist in oral surgery, or oral and maxillofacial surgeons. With a license to practice, every dentist obtains permission to practice the full range of dentistry and thus also to place dental implants. The 'focus area in implantology' established in 2001 by the European Association of Dental Implantologists (BDIZ EDI) before the Federal Constitutional Court[2] is not an additional designation according to the training regulations and is not granted under public law.
A dental implant (also known as an endosseous implant or fixture) is a prosthesis that interfaces with the bone of the jaw or skull to support a dental prosthesis such as a crown, bridge, denture, or facial prosthesis or to act as an orthodontic anchor. The basis for modern dental implants is a biological process called osseointegration, in which materials such as titanium or zirconia form an intimate bond to the bone.[3] The implant fixture is first placed so that it is likely to osseointegrate, then a dental prosthetic is added. A variable amount of healing time is required for osseointegration before either the dental prosthetic (a tooth, bridge, or denture) is attached to the implant or an abutment is placed which will hold a dental prosthetic or crown.
Success or failure of implants depends primarily on the thickness and health of the bone and gingival tissues that surround the implant,[4] but also on the health of the person receiving the treatment and drugs which affect the chances of osseointegration.[5][6][7][8][9][10][11][12] The amount of stress that will be put on the implant and fixture during normal function is also evaluated. Planning the position and number of implants is key to the long-term health of the prosthetic since biomechanical forces created during chewing can be significant. The position of implants is determined by the position and angle of adjacent teeth, by lab simulations or by using computed tomography with CAD/CAM simulations[13][14][15][16] and surgical guides called stents. The prerequisites for long-term success of osseointegrated dental implants are healthy bone and gingiva. Since both can atrophy after tooth extraction, pre-prosthetic procedures such as sinus lifts or gingival grafts are sometimes required to recreate ideal bone and gingiva.
The final prosthetic can be either fixed, where a person cannot remove the denture or teeth from their mouth, or removable, where they can remove the prosthetic. In each case an abutment is attached to the implant fixture. Where the prosthetic is fixed, the crown, bridge or denture is fixed to the abutment either with lag screws or with dental cement. Where the prosthetic is removable, a corresponding adapter is placed in the prosthetic so that the two pieces can be secured together.
The risks and complications related to implant therapy divide into those that occur during surgery (such as excessive bleeding or nerve injury, inadequate primary stability), those that occur in the first six months (such as infection and failure to osseointegrate) and those that occur long-term (such as peri-implantitis and mechanical failures). In the presence of healthy tissues, a well-integrated implant with appropriate biomechanical loads can have 5-year plus survival rates from 93 to 98 percent[17][18][19] and 10-to-15-year lifespans for the prosthetic teeth.[20] Long-term studies show a 16- to 20-year success (implants surviving without complications or revisions) between 52% and 76%, with complications occurring up to 48% of the time.[21][22]
Individual teeth were replaced with implants where it is difficult to distinguish the real teeth from the prosthetic teeth.
Movement in a lower denture can be decreased by implants with ball and socket retention.
A bridge of teeth can be supported by two or more implants.
The primary use of dental implants is to support dental prosthetics (i.e. false teeth). Modern dental implants work through a biologic process where bone fuses tightly to the surface of specific materials such as titanium and some ceramics. The integration of implant and bone can support physical loads for decades without failure.[23]: 103–107
The US has seen an increasing use of dental implants, with usage increasing from 0.7% of patients missing at least one tooth (1999–2000), to 5.7% (2015–2016), and was projected to potentially reach 26% in 2026.[24] Implants are used to replace missing individual teeth (single tooth restorations), multiple teeth, or to restore edentulous (toothless) dental arches (implant retained fixed bridge, implant-supported overdenture).[25] While use of dental implants in the US has increased, other treatments to tooth loss exist.
Dental implants are also used in orthodontics to provide anchorage (orthodontic mini implants). Orthodontic treatment[26] might be required prior to placing a dental implant. An evolving field is the use of implants to retain obturators (removable prostheses used to fill a communication between the oral and maxillary or nasal cavities).[25]Facial prosthetics, used to correct facial deformities (e.g. from cancer treatment or injuries), can use connections to implants placed in the facial bones.[27] Depending on the situation the implant may be used to retain either a fixed or removable prosthetic that replaces part of the face.[28][29]
Single tooth restorations are individual freestanding units not connected to other teeth or implants, used to replace missing individual teeth.[25] For individual tooth replacement, an implant abutment is first secured to the implant with an abutment screw. A crown (the dental prosthesis) is then connected to the abutment with dental cement, a small screw, or fused with the abutment as one piece during fabrication.[30]: 211–232 Dental implants, in the same way, can also be used to retain a multiple tooth dental prosthesis either in the form of a fixed bridge or removable dentures.
There is limited evidence that implant-supported single crowns perform better than tooth-supported fixed partial dentures (FPDs) on a long-term basis. However, taking into account the favorable cost-benefit ratio and the high implant survival rate, dental implant therapy is the first-line strategy for single-tooth replacement. Implants preserve the integrity of the teeth adjacent to the edentulous area, and it has been shown that dental implant therapy is less costly and more efficient over time than tooth-supported FPDs for the replacement of one missing tooth. The major disadvantage of dental implant surgery is the need for a surgical procedure.[31]
Implant retained fixed bridge or implant supported bridge
An implant supported bridge (or fixed denture) is a group of teeth secured to dental implants so the prosthetic cannot be removed by the user. They are similar to conventional bridges, except that the prosthesis is supported and retained by one or more implants instead of natural teeth. Bridges typically connect to more than one implant and may also connect to teeth as anchor points. Typically the number of teeth will outnumber the anchor points with the teeth that are directly over the implants referred to as abutments and those between abutments referred to as pontics. Implant supported bridges attach to implant abutments in the same way as a single tooth implant replacement. A fixed bridge may replace as few as two teeth (also known as a fixed partial denture) and may extend to replace an entire arch of teeth (also known as a fixed full denture). In both cases, the prosthesis is said to be fixed because it cannot be removed by the denture wearer.[30]
A removable implant-supported denture (also an implant-supported overdenture[32]: 31 ) is a removable prosthesis which replaces teeth, using implants to improve support, retention and stability. They are most commonly complete dentures (as opposed to partial), used to restore edentulous dental arches.[25] The dental prosthesis can be disconnected from the implant abutments with finger pressure by the wearer. To enable this, the abutment is shaped as a small connector (a button, ball, bar or magnet) which can be connected to analogous adapters in the underside of the dental prosthesis.
Dental implants are used in orthodontic patients to replace missing teeth or as a temporary anchorage device (TAD) to facilitate orthodontic movement by providing an additional anchorage point.[31][33] For teeth to move, a force must be applied to them in the direction of the desired movement. The force stimulates cells in the periodontal ligament to cause bone remodeling, removing bone in the direction of travel of the tooth and adding it to the space created. In order to generate a force on a tooth, an anchor point (something that will not move) is needed. Since implants do not have a periodontal ligament, and bone remodelling will not be stimulated when tension is applied, they are ideal anchor points in orthodontics. Typically, implants designed for orthodontic movement are small and do not fully osseointegrate, allowing easy removal following treatment.[34] They are indicated when needing to shorten treatment time, or as an alternative to extra-oral anchorage. Mini-implants are frequently placed between the roots of teeth, but may also be sited in the roof of the mouth. They are then connected to a fixed brace to help move the teeth.
The introduction of small-diameter implants has provided dentists the means of providing edentulous and partially edentulous patients with immediate functioning transitional prostheses while definitive restorations are being fabricated. Many clinical studies have been done on the success of long-term usage of these implants. Based on the findings of many studies, mini dental implants exhibit excellent survival rates in the short to medium term (3–5 years). They appear to be a reasonable alternative treatment modality to retain mandibular complete overdentures from the available evidence.[35][36]
A standard 13 mm root form dental implant with pen beside it for size comparison
A zygomatic implant is longer than standard implants and used in people without adequate bone in the maxilla. It secures to the cheek bone.
A small diameter implant is a single piece implant (no abutment) that requires less bone.
Ultrashort Plateau Root Form (PRF) or "finned" dental implants used in regions that would otherwise require a sinus lift or bone graft.
An orthodontic implant is placed beside teeth to act as an anchor point to which braces can be secured.
A one-piece all-ceramic implant
A typical conventional implant consists of a titanium screw (resembling a tooth root) with a roughened or smooth surface. The majority of dental implants are made of commercially pure titanium, which is available in four grades depending upon the amount of carbon, nitrogen, oxygen and iron contained.[37] Cold work hardened CP4 (maximum impurity limits of N .05 percent, C .10 percent, H .015 percent, Fe .50 percent, and O .40 percent) is the most commonly used titanium for implants. Grade 5 titanium, Titanium 6AL-4V (signifying the titanium alloy containing 6 percent aluminium and 4 percent vanadium alloy) is slightly harder than CP4 and used in the industry mostly for abutment screws and abutments.[38]: 284–285 Most modern dental implants also have a textured surface (through etching, anodic oxidation or various-media blasting) to increase the surface area and osseointegration potential of the implant.[39]: 55 If C.P. titanium or a titanium alloy has more than 85% titanium content, it will form a titanium-biocompatibletitanium oxide surface layer or veneer that encloses the other metals, preventing them from contacting the bone.[40]
Ceramic (zirconia-based) implants exist in one-piece (combining the screw and the abutment) or two-piece systems – the abutment being either cemented or screwed – and might lower the risk for peri‐implant diseases, but long-term data on success rates is missing.[41]
To help the surgeon position the implants a guide is made (usually out of acrylic) to show the desired position and angulation of the implants.
Sometimes the final position and restoration of the teeth will be simulated on plaster models to help determine the number and position of implants needed.
CT scans can be loaded to CAD/CAM software to create a simulation of the desired treatment. Virtual implants are then placed and a stent created on a 3D printer from the data.
Planning for dental implants focuses on the general health condition of the patient, the local health condition of the mucous membranes and the jaws and the shape, size, and position of the bones of the jaws, adjacent and opposing teeth. There are few health conditions that absolutely preclude placing implants[example needed] and there are certain conditions that can increase the risk of failure. Those with poor oral hygiene, heavy smokers and diabetics are all at greater risk for a variant of gum disease that affects implants called peri-implantitis, increasing the chance of long-term failures. Long-term steroid use, osteoporosis and other diseases that affect the bones can increase the risk of early failure of implants.[30]: 199 It has been suggested that radiotherapy can negatively affect the survival of implants.[11][42] Nevertheless, a systemic study published in 2016 concluded that dental implants installed in the irradiated area of an oral cavity may have a high survival rate, provided that the patient maintains oral hygiene measures and regular follow-ups to prevent complications.[43]
The long-term success of implants is determined in part by the forces they have to support. As implants have no periodontal ligament, there is no sensation of pressure when biting so the forces created are higher. To offset this, the location of implants must distribute forces evenly across the prosthetics they support.[44]: 15–39 Concentrated forces can result in fracture of the bridgework, implant components, or loss of bone adjacent the implant.[45] The ultimate location of implants is based on both biologic (bone type, vital structures, health) and mechanical factors. Implants placed in thicker, stronger bone like that found in the front part of the bottom jaw have lower failure rates than implants placed in lower density bone, such as the back part of the upper jaw. People who grind their teeth also increase the force on implants and increase the likelihood of failures.[30]: 201–208 [46][47][48][49]
The design of implants has to account for a lifetime of real-world use in a person's mouth. Regulators and the dental implant industry have created a series of tests to determine the long-term mechanical reliability of implants in a person's mouth where the implant is struck repeatedly with increasing forces (similar in magnitude to biting) until it fails.[50] When a more exacting plan is needed beyond clinical judgment, the dentist will make an acrylic guide (called a stent) prior to surgery which guides optimal positioning of the implant. Increasingly, dentists opt to get a CT scan of the jaws and any existing dentures, then plan the surgery on CAD/CAM software. The stent can then be made using stereolithography following computerized planning of a case from the CT scan. The use of CT scanning in complex cases also helps the surgeon identify and avoid vital structures such as the inferior alveolar nerve and the sinus.[51][52]: 1199
The use of bone-building drugs, like bisphosphonates and anti-RANKL drugs, requires special consideration with implants because they have been associated with a disorder called medication-associated osteonecrosis of the jaw (MRONJ). The drugs change bone turnover, which is thought to put people at risk for death of bone when having minor oral surgery. At routine doses (for example, those used to treat routine osteoporosis) the effects of the drugs linger for months or years but the risk appears to be very low. Because of this duality, uncertainty exists in the dental community about how to best manage the risk of BRONJ when placing implants. A 2009 position paper by the American Association of Oral and Maxillofacial Surgeons discussed that the risk of BRONJ from low dose oral therapy (or slow-release injectable) as between 0.01 and 0.06 percent for any procedure done on the jaws (implant, extraction, etc.). The risk is higher with intravenous therapy, procedures on the lower jaw, people with other medical issues, those on steroids, those on more potent bisphosphonates and people who have taken the drug for more than three years. The position paper recommends against placing implants in people who are taking high-dose or high-frequency intravenous therapy for cancer care. Otherwise, implants can generally be placed[53] and the use of bisphosphonates does not appear to affect implant survival.[54] Additional precaution can be taken by administering pentoxifylline and tocopherol both pre-operatively and post-operatively.[55] Moreover, patients taking bisphosphonates present a higher risk of implant failure in comparison to patients not taking this class of drugs.[7][8]
Most implant systems have five basic steps for placement of each implant:[30]: 214–221
Soft tissue reflection: An incision is made over the crest of bone, splitting the thicker attached gingiva roughly in half so that the final implant will have a thick band of tissue around it. The edges of tissue, each referred to as a flap, are pushed back to expose the bone. Flapless surgery is an alternate technique, where a small punch of tissue (the diameter of the implant) is removed for implant placement rather than raising flaps.
Drilling at high speed: After reflecting the soft tissue, and using a surgical guide or stent as necessary, pilot holes are placed with precision drills at highly regulated speed to prevent burning or pressure necrosis of the bone.
Drilling at low speed: The pilot hole is expanded by using progressively wider drills (typically between three and seven successive drilling steps, depending on implant width and length). Care is taken not to damage the osteoblast or bone cells by overheating. A cooling saline or water spray keeps the temperature low.
Placement of the implant: The implant screw is placed and can be self-tapping;[52]: 100–102 otherwise, the prepared site is tapped with an implant analog. It is then screwed into place with a torque controlled wrench[56] at a precise torque so as not to overload the surrounding bone (overloaded bone can die, a condition called osteonecrosis, which may lead to failure of the implant to fully integrate or bond with the jawbone).
Tissue adaptation: The gingiva is adapted around the entire implant to provide a thick band of healthy tissue around the healing abutment. In contrast, an implant can be "buried", where the top of the implant is sealed with a cover screw and the tissue is closed to completely cover it. A second procedure would then be required to uncover the implant at a later date.
There are different approaches to placement dental implants after tooth extraction.[57] The approaches are:
Immediate post-extraction implant placement.
Delayed immediate post-extraction implant placement (two weeks to three months after extraction).
Late implantation (three months or more after tooth extraction).
An increasingly common strategy to preserve bone and reduce treatment times includes the placement of a dental implant into a recent extraction site. On the one hand, it shortens treatment time and can improve aesthetics because the soft tissue envelope is preserved. On the other hand, implants may have a slightly higher rate of initial failure. Conclusions on this topic are difficult to draw, however, because few studies have compared immediate and delayed implants in a scientifically rigorous manner.[57]
After an implant is placed the internal components are covered with either a healing abutment, or a cover screw. A healing abutment passes through the mucosa, and the surrounding mucosa is adapted around it. A cover screw is flush with the surface of the dental implant, and is designed to be completely covered by mucosa. After an integration period, a second surgery is required to reflect the mucosa and place a healing abutment.[58]: 190–1
In the early stages of implant development (1970−1990) implant systems used a two-stage approach, believing that it improved the odds of initial implant survival. Subsequent research suggests that no difference in implant survival existed between one-stage and two-stage surgeries, and the choice of whether or not to "bury" the implant in the first stage of surgery became a concern of soft tissue (gingiva) management.[59] When tissue is inadequate, deficient or mutilated by the loss of teeth, adjacent bone or gingiva, implants are placed and allowed to osseointegrate, then the gingival flat is surgically placed around the healing abutments. The downside of a two-stage technique is the need for additional surgery and compromise of circulation to the tissue due to repeated surgeries.[60]: 9–12 The choice of one or two stages now centers around how best to reconstruct the soft tissues around lost teeth.
Additional procedures to augment deficient bone in implant site
If bone width is inadequate it can be regrown using either artificial or cadaveric bone pieces to act as a scaffold for natural bone to grow around.
When a greater amount of bone is needed, it can be taken from another site (commonly the back of the bottom jaw) and transplanted to the implant site.
The maxillary sinus can limit the amount of bone height in the back of the upper jaw. With a "sinus lift", bone can be grafted under the sinus membrane increasing the height of bone.
For an implant to osseointegrate, it needs to be surrounded by a healthy quantity of bone. In order for it to survive long-term, it needs to have a thick healthy soft tissue (gingiva) envelope around it. It is common for either the bone or soft tissue to be so deficient that the surgeon needs to reconstruct it either before or during implant placement.[52]: 1084 All techniques of augmenting the alveolar bone in preparation for implant placement are invasive and associated with a degree of morbidity.[61]
Bone grafting is necessary when there is a lack of bone. It also helps to stabilize the implant by increasing survival rates of the implant and decreasing marginal bone level loss.[62] While there are always new implant types, such as short implants, and techniques to allow compromise, a general treatment goal is to have a minimum of 10 mm (0.39 in) in bone height, and 6 mm (0.24 in) in width. Alternatively, bone defects are graded from A to D (A=10+ mm of bone, B=7–9 mm, C=4–6 mm and D=0–3 mm) where an implant's likelihood of osseointegrating is related to the grade of bone.[63]: 250
To achieve an adequate width and height of bone, various bone grafting techniques have been developed. The most frequently used is called guided bone graft augmentation where a defect is filled with either natural (harvested or autograft) bone or allograft (donor bone or synthetic bone substitute), covered with a semi-permeable membrane and allowed to heal. During the healing phase, natural bone replaces the graft, forming a new bony base for the implant.[58]: 223
Vertical alveolar augmentation (increase in the height of a site)
Other, more invasive procedures, also exist for larger bone defects including mobilization of the inferior alveolar nerve to allow placement of a fixture, onlay bone grafting using the iliac crest or another large source of bone and microvascular bone graft where the blood supply to the bone is transplanted with the source bone and reconnected to the local blood supply.[44]: 5–6 The final decision about which bone grafting technique that is best is based on an assessment of the degree of vertical and horizontal bone loss that exists, each of which is classified into mild (2–3 mm loss), moderate (4–6 mm loss) or severe (greater than 6 mm loss).[64]: 17 Orthodontic extrusion or orthodontic implant site development can be used in selected cases for vertical/horizontal alveolar augmentation.[65]
When mucosa is missing, a free gingival graft of soft tissue can be transplanted to the area.
When the metal of an implant becomes visible a connective tissue graft can be used to improve the mucosal height.
The gingiva surrounding a tooth has a 2–3 mm band of bright pink, very strong attached mucosa, then a darker, larger area of unattached mucosa that folds into the cheeks. When replacing a tooth with an implant, a band of strong, attached gingiva is needed to keep the implant healthy in the long-term. This is especially important with implants because the blood supply is more precarious in the gingiva surrounding an implant, and is theoretically more susceptible to injury because of a longer attachment to the implant than on a tooth (a longer biologic width).[66]: 629–633
When an adequate band of attached tissue is absent, it can be recreated with a soft tissue graft. There are four methods that can be used to transplant soft tissue. A roll of tissue adjacent to an implant (referred to as a palatal roll) can be moved towards the lip (buccal), gingiva from the palate can be transplanted, deeper connective tissue from the palate can be transplanted or, when a larger piece of tissue is needed, a finger of tissue based on a blood vessel in the palate (called a vascularized interpositional periosteal-connective tissue (VIP-CT) flap) can be repositioned to the area.[60]: 113–188 Xenogeneic collagen matrices are used for gingival augmentation after dental implantation.[67][68]
Additionally, for an implant to look esthetic, a band of full, plump gingiva is needed to fill in the space on either side of implant. The most common soft tissue complication is called a black triangle, where the papilla (the small triangular piece of tissue between two teeth) shrinks back and leaves a triangular void between the implant and the adjacent teeth. Dentists can only expect 2–4 mm of papilla height over the underlying bone. A black triangle can be expected if the distance between where the teeth touch and bone is any greater.[52]: 81–84
Alveolar bone resorption is a common side effect of tooth removal (extraction) due to severe tooth decay, trauma, or infection that limits dental implant placement. Surgical bone augmentation is associated with limitations such as high cost, bone graft rejection or failure, pain, infection, and the addition of 6–12 months to the treatment time till the graft matures. Compared with invasive bone augmentation surgery, orthodontic tooth movement has the capacity to regenerate the deficient alveolar ridge and create adequate bone volume for implant placement. This is particularly useful when restoring one or two missing teeth with implants; however, the orthodontic implant site-switching technique[69][70] can only be used when there is an edentulous area adjacent to healthy teeth that can be moved orthodontically into the edentulous site and generate healthy bone volume for implant placement.[71]
Orthodontic tooth movement can generate new bone.[72] This is because of the fibres of the periodontal ligament (PDL) surrounding the teeth and attached to the alveolar bone, the stretched fibres in the PDL stimulate the osteoblasts depositing new alveolar bone. For instance, the orthodontic forced eruption of hopeless teeth can augment the bone vertically and eliminate or reduce the amount of bone graft required prior to implant placement.[73] Similarly, where there is a bone-deficient edentulous (toothless) site, it is possible to move the healthy adjacent teeth into this area, closing the edentulous space and simultaneously creating an implant site with enough bone adjacent to where implant placement was originally planned.[74][75][76]
The steps taken to secure dental crowns on the implant fixture including placement of the abutment and crown
The prosthetic phase begins once the implant is well integrated (or has a reasonable assurance that it will integrate) and an abutment is in place to bring it through the mucosa. Even in the event of early loading (less than three months), many practitioners will place temporary teeth until osseointegration is confirmed. The prosthetic phase of restoring an implant requires an equal amount of technical expertise as the surgical because of the biomechanical considerations, especially when multiple teeth are to be restored. The dentist will work to restore the vertical dimension of occlusion, the esthetics of the smile, and the structural integrity of the teeth to evenly distribute the forces of the implants.[30]: 241–251
There are various options for when to attach teeth to dental implants,[77] classified into:
Immediate loading procedure.
Early loading (one week to twelve weeks).
Delayed loading (over three months)
For an implant to become permanently stable, the body must grow bone to the surface of the implant (osseointegration). Based on this biologic process, it was thought that loading an implant during the osseointegration period would result in movement that would prevent osseointegration, and thus increase implant failure rates. As a result, three to six months of integrating time (depending on various factors) was allowed before placing the teeth on implants (restoring them).[30] However, later research suggests that the initial stability of the implant in bone is a more important determinant of success of implant integration, rather than a certain period of healing time. As a result, the time allowed to heal is typically based on the density of bone the implant is placed in and the number of implants splinted together, rather than a uniform amount of time. When implants can withstand high torque (35 Ncm) and are splinted to other implants, there are no meaningful differences in long-term implant survival or bone loss between implants loaded immediately, at three months, or at six months.[77] The corollary is that single implants, even in solid bone, require a period of no-load to minimize the risk of initial failure.[78]
An abutment is selected depending on the application. In many single crown and fixed partial denture scenarios (bridgework), custom abutments are used. An impression of the top of the implant is made with the adjacent teeth and gingiva. A dental lab then simultaneously fabricates an abutment and crown. The abutment is seated on the implant, a screw passes through the abutment to secure it to an internal thread on the implant (lag-screw). There are variations on this, such as when the abutment and implant body are one piece or when a stock (prefabricated) abutment is used. Custom abutments can be made by hand, as a cast metal piece or custom milled from metal or zirconia, all of which have similar success rates.[52]: 1233
The platform between the implant and the abutment can be flat (buttress) or conical fit. In conical fit abutments, the collar of the abutment sits inside the implant which allows a stronger junction between implant and abutment and a better seal against bacteria into the implant body. To improve the gingival seal around the abutment collar, a narrowed collar on the abutment is used, referred to as platform switching. The combination of conical fits and platform switching gives marginally better long term periodontal conditions compared to flat-top abutments.[79][80]
Regardless of the abutment material or technique, an impression of the abutment is then taken and a crown secured to the abutment with dental cement. Another variation on abutment/crown model is when the crown and abutment are one piece and the lag-screw traverses both to secure the one-piece structure to the internal thread on the implant. There does not appear to be any benefit, in terms of success, for cement versus screw-retained prosthetics, although the latter is believed to be easier to maintain (and change when the prosthetic fractures) and the former offers high esthetic performance.[52]: 1233
Four lower implants to retain a complete denture with novaloc abutments
Underside of a denture; housing fits like a ball and socket to hold the denture
Xray of four Straumann implants and abutments
When a removable denture is worn, retainers to hold the denture in place can be either custom made or "off-the-shelf" (stock) abutments. When custom retainers are used, four or more implant fixtures are placed and an impression of the implants is taken and a dental lab creates a custom metal bar with attachments to hold the denture in place. Significant retention can be created with multiple attachments and the use of semi-precision attachments (such as a small diameter pin that pushes through the denture and into the bar) which allows for little or no movement in the denture, but it remains removable.[32]: 33–34 However, the same four implants angled in such a way to distribute occlusal forces may be able to safely hold a fixed denture in place with comparable costs and number of procedures giving the denture wearer a fixed solution.[81]
Alternatively, stock abutments are used to retain dentures using a male-adapter attached to the implant and a female adapter in the denture. Two common types of adapters are the ball-and-socket style retainer and the button-style adapter. These types of stock abutments allow movement of the denture, but enough retention to improve the quality of life for denture wearers, compared to conventional dentures.[82] Regardless of the type of adapter, the female portion of the adapter that is housed in the denture will require periodic replacement, however the number and adapter type does not seem to affect patient satisfaction with the prosthetic for various removable alternatives.[83]
After placement, implants need to be cleaned (similar to natural teeth) with a periodontal scaler to remove any plaque. Because of the more precarious blood supply to the gingiva, care should be taken with dental floss. Implants will lose bone at a rate similar to natural teeth in the mouth (e.g. if someone has periodontal disease, an implant can be affected by a similar disorder) but will otherwise last. The porcelain on crowns should be expected to discolour, fracture or require repair approximately every ten years, although there is significant variation in the service life of dental crowns based on the position in the mouth, the forces being applied from opposing teeth and the restoration material. Where implants are used to retain a complete denture, depending on the type of attachment, connections need to be changed or refreshed every one to two years.[44]: 76 An oral irrigator may also be useful for cleaning around implants.[84]
The same kinds of techniques used for cleaning teeth are recommended for maintaining hygiene around implants, and can be manually or professionally administered.[85] Examples of this would be using soft toothbrushes or nylon-coated interproximal brushes.[85] The one implication during professional treatment is that metal instruments may cause damage to the metallic surface of the implant or abutment, which can lead to bacterial colonisation.[85] To avoid this, there are specially designed instruments made with hard plastic or rubber. Additionally rinsing (twice daily) with antimicrobial mouthwashes has been shown to be beneficial.[85] There is no evidence that one type of antimicrobial is better than the other.[85]
Peri-implantitis is a condition that may occur with implants due to bacteria, plaque, or design and it is on the rise.[85][86][87] This disease begins as a reversible condition called peri-implant mucositis but can progress to peri-implantitis if left untreated, which can lead to implant failure.[86][85] People are encouraged to discuss oral hygiene and maintenance of implants with their dentists.[85][86][87] There are different interventions if peri-implantitis occurs, such as mechanical debridement, antimicrobial irrigation, and antibiotics. There can also be surgery such as open-flap debridement to remove bacteria, assess/smooth implant surface, or decontaminate implant surface.[86] There is not enough evidence to know which intervention is best in the case of peri-implantitis.[86]
Placement of dental implants is a surgical procedure and carries the normal risks of surgery including infection, excessive bleeding and necrosis of the flap of tissue around the implant. Nearby anatomic structures, such as the inferior alveolar nerve, the maxillary sinus and blood vessels, can also be injured when the osteotomy is created or the implant placed.[88][89] Even when the lining of the maxillary sinus is perforated by an implant, long term sinusitis is rare.[90][91] An inability to place the implant in bone to provide stability of the implant (referred to as primary stability of the implant) increases the risk of failure to osseointegration.[44]: 68
Implant complications
Bone loss (peri-implantitis) on implants over 7 years in a heavy smoker
Recession of the gingiva leads to exposure of the metal abutment under a dental crown.
Black triangles caused by bone loss between implants and natural teeth
Fracture of an implant and abutment screw is a catastrophic failure and the fixture cannot be salvaged.
Fracture of an abutment (all-zirconia) requires replacement of the abutment and crown.
Fracture of abutment screws (arrow) in 3 implants required removal of the remainder of the screw and replacement.
Dental cement under the gingiva causes peri-implantitis and implant failure.
Primary implant stability refers to the stability of a dental implant immediately after implantation. The stability of the titanium screw implant in the patient's bone tissue post surgery may be non-invasively assessed using resonance frequency analysis. Sufficient initial stability may allow immediate loading with prosthetic reconstruction, though early loading poses a higher risk of implant failure than conventional loading.[92]
The relevance of primary implant stability decreases gradually with regrowth of bone tissue around the implant in the first weeks after surgery, leading to secondary stability. Secondary stability is different from the initial stabilization, because it results from the ongoing process of bone regrowth into the implant (osseointegration). When this healing process is complete, the initial mechanical stability becomes biological stability. Primary stability is critical to implantation success until bone regrowth maximizes mechanical and biological support of the implant. Regrowth usually occurs during the 3–4 weeks after implantation. Insufficient primary stability, or high initial implant mobility, can lead to failure.
An implant is tested between 8 and 24 weeks to determine if it is integrated. There is significant variation in the criteria used to determine implant success, the most commonly cited criteria at the implant level are the absence of pain, mobility, infection, gingival bleeding, radiographic lucency or peri-implant bone loss greater than 1.5 mm.[94] Dental implant success is related to operator skill,[95] quality and quantity of the bone available at the site,[4] and the patient's oral hygiene, but the most important factor is primary implant stability.[96] While there is significant variation in the rate that implants fail to integrate (due to individual risk factors), the approximate values are 1 to 6 percent[44]: 68 [77] Integration failure is rare, particularly if a dentist's or oral surgeon's instructions are followed closely by the patient. Immediate loading implants may have a higher rate of failure, potentially due to being loaded immediately after trauma or extraction, but the difference with proper care and maintenance is well within statistical variance for this type of procedure. More often, osseointegration failure occurs when a patient is either too unhealthy to receive the implant or engages in behavior that contraindicates proper dental hygiene including smoking[97][98][99] or drug use.
The long-term complications that result from restoring teeth with implants relate directly to the risk factors of the patient and the technology. There are the risks associated with appearance including a high smile line, poor gingival quality and missing papillae, difficulty in matching the form of natural teeth that may have unequal points of contact or uncommon shapes, bone that is missing, atrophied or otherwise shaped in an unsuitable manner, unrealistic expectations of the patient or poor oral hygiene. The risks can be related to biomechanical factors, where the geometry of the implants does not support the teeth in the same way the natural teeth did such as when there are cantilevered extensions, fewer implants than roots or teeth that are longer than the implants that support them (a poor crown-to-root ratio). Similarly, grinding of the teeth, lack of bone or low diameter implants increase the biomechanical risk.[100]: 27–51 Finally there are technological risks, where the implants themselves can fail due to fracture or a loss of retention to the teeth they are intended to support.[100]: 27–51
Beyond the possibility of mechanical failure[101] which may be due to poor prosthetic fitment, wear and tear, or user-induced actions such as bruxism, dental implants are also subject to peri-implant mucositis and peri-implantitis, where gum tissue and bone mass around the implant are resorbed, and the implant gradually becomes loose, and has to be removed.[102][103] In addition, although titanium is generally well tolerated by the body, there have been cases where the build-up of titanium particles released by the implant may cause systemic inflammatory response.[104] Because there is no dental enamel on an implant, it does not fail due to cavities like natural teeth. While large-scale, long-term studies are scarce, several systematic reviews estimate the long-term (five to ten years) survival of dental implants at 93–98 percent depending on their clinical use.[17][18][19] During initial development of implant retained teeth, all crowns were attached to the teeth with screws, but more recent advancements have allowed placement of crowns on the abutments with dental cement (akin to placing a crown on a tooth). This has created the potential for cement, that escapes from under the crown during cementation to get caught in the gingiva and create a peri-implantitis (see picture below). While the complication can occur, there does not appear to be any additional peri-implantitis in cement-retained crowns compared to screw-retained crowns overall.[105]
In compound implants (two stage implants), between the actual implant and the superstructure (abutment) are gaps and cavities into which bacteria can penetrate from the oral cavity. Later these bacteria will return into the adjacent tissue and can cause periimplantitis. Criteria for the success of the implant supported dental prosthetic varies from study to study, but can be broadly classified into failures due to the implant, soft tissues or prosthetic components or a lack of satisfaction on the part of the patient. The most commonly cited criteria for success are function of at least five years in the absence of pain, mobility, radiographic lucency and peri-implant bone loss of greater than 1.5 mm on the implant, the lack of suppuration or bleeding in the soft tissues and occurrence of technical complications/prosthetic maintenance, adequate function, and esthetics in the prosthetic. In addition, the patient should ideally be free of pain, paraesthesia, able to chew and taste and be pleased with the esthetics.[94]
The rates of complications vary by implant use and prosthetic type and are listed below:
15-year: 66.6 percent (44.3 to 86.4 percent with a confidence interval at 95 percent)[20]
10-year incidence of framework fracture: 6 percent (2.6 to 9.3 percent with a confidence interval at 95 percent)[20]
10-year incidence of esthetic deficiency: 6.1 percent (2.4 to 9.7 percent with a confidence interval at 95 percent)[20]
prosthetic screw loosening: 5 percent over five years[19] to 15 percent over ten years[20]
The most common complication being fracture or wear of the tooth structure, especially beyond ten years[19][20] with fixed dental prostheses made of metal-ceramic having significantly higher ten-year survival compared those made of gold-acrylic.[19]
Greenfield's basket: one of the earliest examples of a successful endosseous implant was Greenfield's 1913 implant systemWhile studying bone cells in a rabbit tibia using a titanium chamber, Branemark was unable to remove it from bone. His realization that bone would adhere to titanium led to the concept of osseointegration and the development of modern dental implants. The original x-ray film of the chamber embedded in the rabbit tibia is shown (made available by Branemark).Panoramic radiograph of historic dental implants, taken 1978Sapphire blade type implants used in the past
There is archeological evidence that humans have attempted to replace missing teeth with root form implants for thousands of years. Remains from ancient China (dating 4000 years ago) have carved bamboo pegs, tapped into the bone, to replace lost teeth, and 2000-year-old remains from ancient Egypt have similarly shaped pegs made of precious metals. Some Egyptian mummies were found to have transplanted human teeth, and in other instances, teeth made of ivory.[23]: 26 [109][110] Etruscans produced the first pontics using single gold bands as early as 630 BC and perhaps earlier.[111][112]Wilson Popenoe and his wife in 1931, at a site in Honduras dating back to 600 AD, found the lower mandible of a young Mayan woman, with three missing incisors replaced by pieces of sea shells, shaped to resemble teeth.[113] Bone growth around two of the implants, and the formation of calculus, indicates that they were functional as well as esthetic. The fragment is currently part of the Osteological Collection of the Peabody Museum of Archaeology and Ethnology at Harvard University.[23][109]
In modern times, a tooth replica implant was reported as early as 1969, but the polymethacrylate tooth analogue was encapsulated by soft tissue rather than osseointegrated.[114]
The early part of the 20th century saw a number of implants made of a variety of materials. One of the earliest successful implants was the Greenfield implant system of 1913 (also known as the Greenfield crib or basket).[115] Greenfield's implant, an iridioplatinum implant attached to a gold crown, showed evidence of osseointegration and lasted for a number of years.[115] The first use of titanium as an implantable material was by Bothe, Beaton and Davenport in 1940, who observed how close the bone grew to titanium screws, and the difficulty they had in extracting them.[116] Bothe et al. were the first researchers to describe what would later be called osseointegration (a name that would be marketed later on by Per-Ingvar Brånemark). In 1951, Gottlieb Leventhal implanted titanium rods in rabbits.[117] Leventhal's positive results led him to believe that titanium represented the ideal metal for surgery.[117]
In the 1950s research was being conducted at Cambridge University in England on blood flow in living organisms. These workers devised a method of constructing a chamber of titanium which was then embedded into the soft tissue of the ears of rabbits. In 1952 the Swedish orthopaedic surgeon, Per-Ingvar Brånemark, was interested in studying bone healing and regeneration. During his research time at Lund University he adopted the Cambridge designed "rabbit ear chamber" for use in the rabbit femur. Following the study, he attempted to retrieve these expensive chambers from the rabbits and found that he was unable to remove them. Brånemark observed that bone had grown into such close proximity with the titanium that it effectively adhered to the metal. Brånemark carried out further studies into this phenomenon, using both animal and human subjects, which all confirmed this unique property of titanium.[118]Leonard Linkow, in the 1950s, was one of the first to insert titanium and other metal implants into the bones of the jaw. Artificial teeth were then attached to these pieces of metal.[119] In 1965 Brånemark placed his first titanium dental implant into a human volunteer. He began working in the mouth as it was more accessible for continued observations and there was a high rate of missing teeth in the general population offered more subjects for widespread study. He termed the clinically observed adherence of bone with titanium as "osseointegration".[66]: 626 Since then implants have evolved into three basic types:
Root form implants; the most common type of implant indicated for all uses. Within the root form type of implant, there are roughly 18 variants, all made of titanium but with different shapes and surface textures. There is limited evidence showing that implants with relatively smooth surfaces are less prone to peri-implantitis than implants with rougher surfaces and no evidence showing that any particular type of dental implant has superior long-term success.[120]
Zygoma implant; a long implant that can anchor to the cheek bone by passing through the maxillary sinus to retain a complete upper denture when bone is absent. While zygomatic implants offer a novel approach to severe bone loss in the upper jaw, it has not been shown to offer any advantage over bone grafting functionally although it may offer a less invasive option, depending on the size of the reconstruction required.[121][122] There is a small risk of postoperative complications, such as sinusitis, soft tissue infection, paresthesia, and oroantral fistulas.[123][124]
Small-diameter implants are implants of low diameter with one-piece construction (implant and abutment) that are sometimes used for denture retention[36] or orthodontic anchorage.[33]
Modern clinical records geriatric dentistry have documented long-term osseointergration in centenarians. A documented case from 2012-2013 involved a maxillary dental implant (27 tooth) placed in a 92-year-old patient (Rev. Fr. John Mathews Elanjileth) by Prof. Dr. Jijo Paul at Mazhuvenchery Speciality Dental Clinic (Aluva, Kochi, Kerala). The implant remained clinically functional for over 10 years until the patient's death at age 105, serving as a benchmark for dental implant success rates in extreme age.[125][126][127]
^ abPapaspyridakos P, Mokti M, Chen CJ, Benic GI, Gallucci GO, Chronopoulos V (October 2014). "Implant and prosthodontic survival rates with implant fixed complete dental prostheses in the edentulous mandible after at least 5 years: a systematic review". Clinical Implant Dentistry and Related Research. 16 (5): 705–17. doi:10.1111/cid.12036. PMID23311617.
^ abBerglundh T, Persson L, Klinge B (2002). "A systematic review of the incidence of biological and technical complications in implant dentistry reported in prospective longitudinal studies of at least 5 years". Journal of Clinical Periodontology. 29 (Suppl 3): 197–212, discussion 232–3. doi:10.1034/j.1600-051X.29.s3.12.x. PMID12787220.
^ abcdefghPjetursson BE, Thoma D, Jung R, Zwahlen M, Zembic A (October 2012). "A systematic review of the survival and complication rates of implant-supported fixed dental prostheses (FDPs) after a mean observation period of at least 5 years". Clinical Oral Implants Research. 23 (Suppl 6): 22–38. doi:10.1111/j.1600-0501.2012.02546.x. PMID23062125.
^ abcdefghBozini T, Petridis H, Garefis K, Garefis P (2011). "A meta-analysis of prosthodontic complication rates of implant-supported fixed dental prostheses in edentulous patients after an observation period of at least 5 years". The International Journal of Oral & Maxillofacial Implants. 26 (2): 304–18. PMID21483883.
^Simonis P, Dufour T, Tenenbaum H (July 2010). "Long-term implant survival and success: a 10-16-year follow-up of non-submerged dental implants". Clinical Oral Implants Research. 21 (7): 772–7. doi:10.1111/j.1600-0501.2010.01912.x. PMID20636731.
^Chappuis V, Buser R, Brägger U, Bornstein MM, Salvi GE, Buser D (December 2013). "Long-term outcomes of dental implants with a titanium plasma-sprayed surface: a 20-year prospective case series study in partially edentulous patients". Clinical Implant Dentistry and Related Research. 15 (6): 780–90. doi:10.1111/cid.12056. PMID23506385.
^ abcMisch CE (2007). Contemporary Implant Dentistry. St. Louis, Missouri: Mosby Elsevier.
^ abcdPalmer, R. (2008). A clinical guide to implants in dentistry. Palmer, Paul J., Howe, Leslie C., British Dental Association. (2nd ed.). London: British Dental Association. ISBN978-0-904588-92-7. OCLC422757942.
^Sinn DP, Bedrossian E, Vest AK (May 2011). "Craniofacial implant surgery". Oral and Maxillofacial Surgery Clinics of North America. 23 (2): 321–35, vi–vii. doi:10.1016/j.coms.2011.01.005. PMID21492804.
^Arcuri MR (April 1995). "Titanium implants in maxillofacial reconstruction". Otolaryngologic Clinics of North America. 28 (2): 351–63. doi:10.1016/S0030-6665(20)30549-1. PMID7596615.
^ abMalet J (2018). Implant dentistry at a glance. Mora, Francis, Bouchard, Philippe (Second ed.). Hoboken, NJ: John Wiley & Sons. ISBN978-1-119-29263-0. OCLC1021055256.
^ abJokstad A, ed. (2009). Osseointegration and Dental Implants (in English). John Wiley & Sons. ISBN978-0-8138-0474-3.
^ abChen Y, Kyung HM, Zhao WT, Yu WJ (March 2009). "Critical factors for the success of orthodontic mini-implants: a systematic review". American Journal of Orthodontics and Dentofacial Orthopedics. 135 (3): 284–91. doi:10.1016/j.ajodo.2007.08.017. PMID19268825.
^Lee SL (2007). Applications of orthodontic mini implants. Hanover Park, Illinois: Quintessence Publishing Co, Inc. pp. 1–11. ISBN978-0-86715-465-8.
^Brandt R, Hollis S, Ahuja S, Adatrow P, Balanoff W (2012). "Short-term objective and subjective evaluation of small-diameter implants used to support and retain mandibular prosthesis". The Journal of the Tennessee Dental Association. 92 (1): 34–38, quiz 38–39. ISSN0040-3385. PMID22870551.
^Arturo N. Natali (ed.) (2003). "Dental Biomechanics". Taylor & Francis, London / New York, 273 pp., ISBN978-0-415-30666-9, pp. 69–87.
^Ferracane JL (2001). Materials in Dentistry: Principles and Applications (in English). Lippincott Williams & Wilkins. ISBN978-0-7817-2733-4.
^Reza M (2007). Nanomaterials and Nanosystems for Biomedical Applications [Mozafari] (in English). SpringerLink: Springer e-Books. ISBN978-1-4020-6289-6.
^Smith Nobrega A, Santiago JF, de Faria Almeida DA, Dos Santos DM, Pellizzer EP, Goiato MC (December 2016). "Irradiated patients and survival rate of dental implants: A systematic review and meta-analysis". The Journal of Prosthetic Dentistry. 116 (6): 858–866. doi:10.1016/j.prosdent.2016.04.025. hdl:11449/162230. PMID27460315.
^ abcdefgBranemark PI, Worthington P, eds. (1992). Advanced osseointegration surgery: applications in the maxillofacial region (in english). Carol Stream, Illinois: Quintessence Books. ISBN978-0-86715-242-5.
^Pallaci P (1995). Optimal implant positioning and soft tissue management for the Branemark system (in english). Germany: Quintessence Books. pp. 21–33. ISBN978-0-86715-308-8.
^ abcdefLindhe J, Lang NP, Karring T, eds. (2008). Clinical Periodontology and Implant Dentistry 5th edition (in English). Oxford, UK: Blackwell Munksgaard. ISBN978-1-4051-6099-5.
^Ruggiero SL, Dodson TB, Assael LA, Landesberg R, Marx RE, Mehrotra B (May 2009). "American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws--2009 update". Journal of Oral and Maxillofacial Surgery. 67 (5 Suppl): 2–12. doi:10.1016/j.joms.2009.01.009. PMID19371809.
^Kumar MN, Honne T (December 2012). "Survival of dental implants in bisphosphonate users versus non-users: a systematic review". The European Journal of Prosthodontics and Restorative Dentistry. 20 (4): 159–62. PMID23495556.
^McCracken MS, Mitchell L, Hegde R, Mavalli MD (January 2010). "Variability of mechanical torque-limiting devices in clinical service at a US dental school". Journal of Prosthodontics. 19 (1): 20–4. doi:10.1111/j.1532-849X.2009.00524.x. PMID19765196.
^ abPeterson LJ, Miloro M (2004). Peterson's Principles of Oral and Maxillofacial Surgery, 2nd Edition. PMPH-USA.
^Esposito M, Grusovin MG, Chew YS, Coulthard P, Worthington HV (2009). "One-stage versus two-stage implant placement. A Cochrane systematic review of randomised controlled clinical trials". European Journal of Oral Implantology. 2 (2): 91–9. PMID20467608.
^ abSclar A (2003). Soft tissue and esthetic considerations in implant dentistry (in english). Carol Stream, Illinois: Quintessence Books. ISBN978-0-86715-354-5.
^Herford A, Dean J (2011). "Complications in Bone Grafting". Oral and Maxillofacial Surgery Clinics of North America. 23 (3): 2433–442. doi:10.1016/j.coms.2011.04.004. PMID21622007.
^ abBuser D, Schenk RK (1994). Guided bone regeneration in implant dentistry (in english). Hong Kong: Quintessence Books. ISBN978-0-86715-249-4.
^Laskin D (2007). Decision making in oral and maxillofacial surgery. Chicago: Quintessence Pub. Co. ISBN978-0-86715-463-4.
^Borzabadi-Farahani A, Zadeh HH (2016). "Orthodontic Therapy in Implant Dentistry: Orthodontic Implant Site Development". In Tolstunov L (ed.). Vertical Alveolar Ridge Augmentation in Implant Dentistry: A Surgical Manual. John Wiley & Sons. pp. 30–37. doi:10.1002/9781119082835.ch04. ISBN978-1-119-08283-5.
^ abNewman M, Takei H, Klokkevold P, eds. (2012). Carranza's Clinical Periodontology (in English). St. Louis, Missouri: Elsevier Saunders. ISBN978-1-4377-0416-7.
^Borzabadi-Farahani A, Zadeh HH (2016). "Orthodontic Therapy in Implant Dentistry: Orthodontic Implant Site Development". In Tolstunov L (ed.). Vertical Alveolar Ridge Augmentation in Implant dentistry:A Surgical Manual. John Wiley & Sons, Inc. pp. 30–37. doi:10.1002/9781119082835.ch04. ISBN978-1-119-08283-5.
^Salama H, Salama M (1993). "The role of orthodontic extrusive remodeling in the enhancement of soft and hard tissue profiles prior to implant placement: A systematic approach to the management of extraction site defects". Int. J. Periodontics Restor. Dent. 13 (4): 312–333. PMID8300319.
^Borzabadi-Farahani A, Zadeh HH (2016). "Orthodontic Therapy in Implant Dentistry: Orthodontic Implant Site Development". In Tolstunov L (ed.). Vertical Alveolar Ridge Augmentation in Implant Dentistry:A Surgical Manual. John Wiley & Sons, Inc. pp. 30–37. doi:10.1002/9781119082835.ch04. ISBN978-1-119-08283-5.
^Atieh MA, Atieh AH, Payne AG, Duncan WJ (2009). "Immediate loading with single implant crowns: a systematic review and meta-analysis". The International Journal of Prosthodontics. 22 (4): 378–87. PMID19639076.
^Atieh MA, Ibrahim HM, Atieh AH (October 2010). "Platform switching for marginal bone preservation around dental implants: a systematic review and meta-analysis". Journal of Periodontology. 81 (10): 1350–66. doi:10.1902/jop.2010.100232. PMID20575657. S2CID6507288.
^Patzelt SB, Bahat O, Reynolds MA, Strub JR (December 2014). "The all-on-four treatment concept: a systematic review". Clinical Implant Dentistry and Related Research. 16 (6): 836–55. doi:10.1111/cid.12068. PMID23560986.
^Assunção WG, Barão VA, Delben JA, Gomes EA, Tabata LF (June 2010). "A comparison of patient satisfaction between treatment with conventional complete dentures and overdentures in the elderly: a literature review". Gerodontology. 27 (2): 154–62. doi:10.1111/j.1741-2358.2009.00299.x. PMID19467020.
^Greenstein G, Cavallaro J, Romanos G, Tarnow D (August 2008). "Clinical recommendations for avoiding and managing surgical complications associated with implant dentistry: a review". Journal of Periodontology. 79 (8): 1317–29. doi:10.1902/jop.2008.070067. PMID18672980.
^Javed F, Romanos GE (August 2010). "The role of primary stability for successful immediate loading of dental implants. A literature review". Journal of Dentistry. 38 (8): 612–20. doi:10.1016/j.jdent.2010.05.013. PMID20546821.
^Esposito M, Ardebili Y, Worthington HV (22 July 2014). "Interventions for replacing missing teeth: different types of dental implants". Cochrane Database of Systematic Reviews (7) CD003815. doi:10.1002/14651858.CD003815.pub4. PMID25048469.
Branemark PI, Worthington P (1992). Advanced osseointegration surgery: applications in the maxillofacial region (in english). Carol Stream, Illinois: Quintessence Books. ISBN978-0-86715-242-5.
Laskin D (2007). Decision making in oral and maxillofacial surgery. Chicago: Quintessence Pub. Co. ISBN978-0-86715-463-4.
Lee SL (2007). Applications of orthodontic mini implants. Hanover Park, Illinois: Quintessence Publishing Co, Inc. pp. 1–11. ISBN978-0-86715-465-8.
Sclar A (2003). Soft tissue and esthetic considerations in implant dentistry (in english). Carol Stream, Illinois: Quintessence Books. ISBN978-0-86715-354-5.
Buser D, Schenk RK (1994). Guided bone regeneration in implant dentistry (in english). Hong Kong: Quintessence Books. ISBN978-0-86715-249-4.
Pallaci P (1995). Optimal implant positioning and soft tissue management for the Branemark system (in english). Germany: Quintessence Books. ISBN978-0-86715-308-8.
Renouard F (1999). Risk Factors in Implant Dentistry: Simplified Clinical Analysis for Predictable Treatment. Paris, France: Quintessence International. ISBN978-0-86715-355-2.
Lindhe J, Lang NP, Karring T, eds. (2008). Clinical Periodontology and Implant Dentistry 5th edition (in English). Oxford, UK: Blackwell Munksgaard. ISBN978-1-4051-6099-5.
Newman M, Takei H, Klokkevold P, eds. (2012). Carranza's Clinical Periodontology (in English). St. Louis, Missouri: Elsevier Saunders. ISBN978-1-4377-0416-7.