Full-Mouth Implant Treatment

The list starts with the option that needs the least surgery.

• Keeping the remaining teeth. If teeth in the jaw can be saved, keeping them is also a route. Gum treatment, root canal treatment and a partial denture can gain years. Extracting all the teeth cannot be undone, so the first question is always "do they really all need to come out?"
• A removable full denture. There is no surgery. It rests on the gums and, in the upper jaw, on the palate. Getting used to it takes time, chewing force is limited and the jaw bone continues to shrink. On the other hand, it can be made now and is easy to replace.
• An implant-retained removable denture. It clips onto implants: often two in the lower jaw, usually at least four in the upper. You take it out to clean it. Grip improves clearly. In the lower jaw it can often be done with fewer implants. The number of implants and the extent of surgery depend on the jaw and the denture design. Because you can take it out, cleaning is easier than with a fixed bridge for most patients.
• A fixed bridge on four or six implants. You cannot take this bridge out; your dentist can. Where the anatomy allows, the back implants are placed at an angle. The details are on the All-on-4 and All-on-6 pages.
• Several short bridges on more implants. If there is enough bone, more implants can be placed and two or three fixed bridges made for the jaw. Some problems can then be dealt with in one section only, although others can still need treatment across the jaw. On the other hand, more implants mean more surgery and often a graft.

Not all five routes are possible for every patient. If you have been offered only one, ask why the others were ruled out.

If you answer these questions for yourself before the examination, it becomes easier to judge the plan you are offered.

1. Is taking a denture out of your mouth acceptable to you? If it is, an implant-retained removable denture can mean fewer implants and less surgery, especially in the lower jaw. It is also easier to clean for most patients. If it is not, a fixed bridge is discussed.
2. What is the state of the bone? This is decided on a 3D scan. If there is bone at the front, a fixed bridge on angled implants may be possible. If the bone has shrunk severely, a graft, a sinus lift or zygomatic implants come into consideration.
3. Will you be able to do the cleaning? The area under a fixed bridge can be difficult to clean. Manual dexterity, eyesight and regular reviews decide a lot here.
4. What is in the opposing jaw? Natural teeth, a denture or a bridge in the other jaw changes the design and the load.
5. Do you clench or grind your teeth? If you do, the bridge material and a night guard become part of the plan.
6. Are there teeth that could be saved? If so, ask for the reason for each extraction in writing, such as a root fracture, decay that cannot be repaired or advanced bone loss.

Being told "let's take them all out and make it fixed" is not a reason on its own. In the same way, "it won't work for you" should come with its reasoning.

When an implant solution is considered

• No teeth left in a jaw, or the remaining teeth cannot be saved (advanced decay, root fractures, advanced gum disease)
• People who cannot use a removable full denture, have problems with its grip or have a strong gag reflex
• General health that allows surgery and healing
• People who can keep up daily cleaning and regular reviews

What is associated with higher risk

The figures below are pooled results of observational studies. They show an association, not proven cause and effect.

• Smoking. In people smoking more than 20 cigarettes a day, implant loss was about 2.5 times as likely per implant as in non-smokers¹. Per patient it was about 4 times as likely. For early loss, a pooled analysis of 32 studies gave an odds ratio of 2.59 per implant². This does not mean that the absolute risk is 2.6 times higher. No safe number of cigarettes has been shown.
• A history of gum disease. Across 14 prospective studies, the rate of implant loss was about 1.75 times higher³; after fast-progressing disease it was about 6 times higher. These are hazard ratios, not absolute risks. These were treated patients; implants are not placed while the disease is active.
• Clenching or grinding. The 27 studies in one review compared people judged likely to clench or grind their teeth with people who do not. The odds of implant loss were about 2.2 times higher⁴ in the first group (an odds ratio). These studies did not test whether a night guard prevents loss.
• Diabetes. The findings are mixed. Two of three reviews found no significant difference in implant loss: a nine-study review of type 2 diabetes⁵ and an older review⁶. The third, covering 89 publications, reported a higher odds ratio⁷ for implant loss. All three found more bone loss around implants in people with diabetes.
• Bone-strengthening medicines (bisphosphonates, denosumab). The risk depends on why, at what dose and for how long the medicine is taken. Whether it is given by drip, by injection or by mouth does not on its own decide it. In people on high-dose antiresorptive treatment for cancer, elective implant surgery is usually avoided. That group includes bisphosphonates given by drip and denosumab given by injection under the skin. The decision is made together with your oncology team; do not stop a medicine without asking your doctor. Doses used for osteoporosis are assessed separately. In a 21-study review, implant loss in people taking bisphosphonates was about 1.7 times more likely per implant⁸. Jaw osteonecrosis was about 3.5 times more likely per patient. The per-patient analysis of implant loss found no significant difference. These figures are for bisphosphonates and cannot be generalised to denosumab; the certainty of the evidence is very low.
• Radiotherapy to the head and neck. Implants are lost more often in irradiated bone. There is a risk of wounds that do not heal and of bone death (osteoradionecrosis). Planning is done together with your oncology team.

When a fixed bridge may not suit

• People who cannot keep up daily cleaning. If the area under the bridge cannot be cleaned, the risk of inflammation around the implants rises. For these patients a removable solution may be safer.
• Expectations about lip support. Where the bone has shrunk severely, a fixed bridge may not support the lip and cheek as well as a removable denture. This is discussed before a decision is made.
• Active infection, untreated gum disease, uncontrolled medical conditions. These are dealt with first.
• A jaw that is still growing. In young patients, implants wait until growth is complete.

Suitability is decided by an examination, a 3D scan and your medical history. A plan based on photographs or a panoramic X-ray is not final; it is a preliminary assessment.

Bone is the most common obstacle in a jaw with no teeth. The options differ in the extent of surgery, their risks and their duration. A graft or a sinus lift lengthens treatment. In suitable patients, angled or zygomatic implants can shorten it compared with grafting; zygomatic implants carry their own risks, set out below.

• Angled implants. The back implants are placed at a slant to keep clear of the sinus and the nerve canal. The consensus report of the International Team for Implantology (ITI) states that, where conditions are suitable, implants can be deliberately placed at an angle⁹. In many patients this can reduce the need for a graft.
• Bone grafting and sinus lift. A review pooled 11 prospective studies with at least five years of follow-up. Its patients had 6 mm of bone height or less, and their sinus floor was raised through a side window (the lateral approach). Implant loss was 0.43 per cent per implant per year¹⁰. This result cannot be applied to methods that work through the top of the ridge. Vertical bone augmentation, on the other hand, is not a small extra step. In a Cochrane review, complications were more frequent than with short implants: an odds ratio of 4.97 per patient¹¹. The 95 per cent confidence interval was 1.10 to 22.40. This does not mean that the absolute risk is five times higher. The difference in implant loss was not significant. The details are on the bone grafting page.
• Short implants. The same Cochrane review states that in a shrunken lower jaw, short implants appear to be a better option¹¹ than vertical bone grafting. This rests on few studies, most at high risk of bias; whether short implants suit a full-arch design is assessed separately.
• Zygomatic implants. When the upper jaw bone is not enough for standard implants, implants anchored in the cheekbone can be used. A Cochrane review describes the procedure as technically demanding¹² and notes that it may be associated with serious complications. One small trial compared them with implants placed after bone grafting. Zygomatic implants led to fewer implant losses but more complications¹²; the two results belong together. It is not a routine option; it is explained at the consultation.

Imaging alone does not decide which route suits you. Your dentist assesses the examination, the 3D scan, your medical history and a denture plan prepared in advance together, and discusses the options with you. If a graft or a sinus lift is done, treatment takes longer.

The sequence below is shared by the fixed bridge and the implant-retained denture; the details vary with the route chosen. Times vary from patient to patient, and your plan is given in writing. We have found no good research comparing treatment compressed into a short period with treatment staged over months. If a plan leaves little time between stages, ask how healing will be confirmed. If you would like sedation, the details are on the conscious sedation page. When the denture or bridge is complete, measurements around the implants and an X-ray are taken as a baseline¹³, as the consensus report recommends.

Risks

• Steps that cannot be undone. An extracted tooth does not come back. Extracting all the teeth while some could have been saved cannot be put right later. That is why getting a second opinion is reasonable.
• Implant loss. In a 55-study review, about 2 to 3 in 100 implants¹⁴ were lost at five years and beyond. With a fixed bridge, losing one implant can affect the whole bridge; with short bridges, the problem often stays limited to one section. That difference has not been measured; it is clinical reasoning.
• Inflammation around implants. Peri-implant mucositis is inflammation of the soft tissue around an implant. Peri-implantitis is that inflammation with loss of the supporting bone. An umbrella review of reviews on full-arch bridges reports peri-implantitis at 4 to 18 per cent¹⁵ (as stated in the review abstracts). Whether the rate counts patients or implants could not be verified in the full text. In implant patients in general, a 57-study review found it in about 20 in 100 patients¹⁶. The rate depends on the definition used and the time in function.
• Bone loss. Studies report an average bone loss of about 1 mm around the implants at five years¹⁴; "no bone loss" is not true.
• Technical problems with the bridge. Reviews report screw loosening at 5 to 15 per cent and framework fracture under 5 per cent¹⁵. Chipping of veneered zirconia is reported at 15 to 35 per cent. These rates are as given in the review abstracts, which cover 5 to 15 years of follow-up. Whether each rate counts patients, bridges or implants could not be verified in the full text. Monolithic zirconia and screw-retained designs have fewer technical problems.
• Surgical risks. Bleeding, swelling, bruising and infection. In the lower jaw, the nerve canal is close: the lip and chin may feel numb for a while and, rarely, permanently. In the upper jaw, the sinus membrane may tear, and sinusitis or an opening between the mouth and the sinus may follow.
• Immediate loading. Provisional teeth on the same day can work well in selected patients. A review of 39 randomised trials found slightly lower implant survival¹⁷ with immediate loading; the Cochrane review¹⁸ found no convincing difference within one year. Placing an implant straight into the socket of an extracted tooth is a separate question. There, survival was lower, 95.2 versus 98.4 per cent¹⁹.
• Speech, lip support and adaptation. Speech and chewing change in the first weeks. A fixed bridge may not support the lip as well as a removable denture.

Benefits

• Implant solutions can improve grip and chewing comfort. Sensation and use are not the same as natural teeth; the result varies by person and design.
• Shrinkage around the implants slows, but some bone loss is still expected. It cannot be said that bone loss stops altogether.
• With a fixed bridge the palate stays uncovered; for many patients this matters for taste and speech.
• Where the anatomy allows, angled back implants can reduce the need for a graft and shorten treatment.
• An implant-retained removable denture can give a clear gain in grip with fewer implants, especially in the lower jaw. Because you can take it out, cleaning is easier for most patients.

The first days

• Swelling and bruising increase over the first 48 to 72 hours, then settle. Use cold packs and the medicines prescribed.
• Eat soft, lukewarm food in the first weeks. While the provisional denture or bridge is in place, do not chew hard or sticky food; this protects healing.
• If you had sedation, do not drive or operate machinery for as long as the sedation team tells you. Whether you need an escort depends on the method. For adults, every form of sedation other than inhaled sedation requires a responsible adult as an escort²⁰. If an escort cannot be arranged, treatment under sedation is not given.
• If you had a sinus lift, do not blow your nose or drink through a straw, and if you sneeze, keep your mouth open. These rules reduce pressure changes on the sinus membrane. Follow the written instructions you are given.
• Smoking impairs healing. At the very least, do not smoke during the healing period.

Daily care

• With a fixed bridge: clean under the bridge every day with bridge floss, interdental brushes or a water flosser. Your dentist shows you which works in your mouth.
• With a removable denture: take the denture out and clean it with the cleaner your dentist recommends. Clean the implant heads and the clip parts separately. Ask whether to leave it out at night. The clip parts are renewed over time.
• Brush twice a day with a soft brush, paying particular attention to the line where the gum meets the bridge or denture. Use fluoride toothpaste on a fixed bridge and on any natural teeth; a removable denture is cleaned as above.
• If you clench, a night guard may be advised. It has not been shown to prevent implant loss; its purpose is to protect the bridge or denture from the forces of clenching.
• Reviews. The consensus report recommends that an X-ray and probing measurements be taken as a baseline¹³ when the bridge or denture is complete. The European Federation of Periodontology guideline calls for a structured supportive care programme²¹. The UK NICE guideline on dental recall recommends that the interval between reviews be set for each patient²². It is based on a risk assessment and discussed with the patient.

The rates below are not promises. They are pooled estimates, calculated with statistical models from studies with different follow-up periods. What happens in your case depends on your bone, your habits and your care.

• Implants under a fixed bridge. In the 55-study review, about 97 to 98 in 100 implants¹⁴ were still in place at five years and beyond (per implant).
• The bridge itself. In an umbrella review of seven systematic reviews, about 90 to 97 in 100 bridges¹⁵ were still in use over 5 to 15 years. A 2012 review looked at full-arch bridges on four to six implants. In the upper jaw, about 97 in 100 were in use at five years and 95 at ten²³. In the lower jaw the figures were 98 at five years and 96 at ten.
• Several short bridges on more implants: indirect data only. We have no pooled direct data for this route. The nearest data are for single crowns. In a 46-study review, about 97 in 100 implants carrying a single crown were in place at five years, and about 95 at ten²⁴. Of the crowns on them, about 96 in 100 were in use at five years and about 89 at ten. These figures cannot be carried over directly to short bridges or full-arch designs.
• Maintenance. Being in use does not mean no repair was needed. Regular cleaning and reviews are part of care. A loose screw or chipped porcelain needs extra repair, and remaking the bridge counts as losing it. Ask beforehand whether these are included in your plan.
• No one can promise a lifetime result. Follow-up in the reviews cited here goes up to fifteen years. Longer studies of implants in general exist, but they cannot predict how long this particular bridge will last. An offer that promises a result for life is not based on evidence.

After surgery, or at any time while you use your bridge or denture, contact your dentist if you notice any of the following.

• Pain or swelling that increases after the third day, or bleeding that does not stop
• Numbness of the lip, tongue or chin that lasts beyond the expected duration of the anaesthetic
• The bridge or denture moves, a screw feels loose, or a piece cracks or breaks
• Bleeding, a bad smell, pus or receding gum around the bridge or denture
• Pain on biting, or a bite that feels high
• Nasal discharge, a blocked nose or sinus pain (upper jaw)
• A sore spot under a removable denture, or a sore that does not heal

Emergencies. Difficulty breathing or swallowing, rapidly spreading swelling of the face or neck, a high fever or swelling around the eye are serious signs. If you have any of them, do not wait for the clinic's reply. Go to the nearest emergency department or call 112.

This page does not quote fees. The main factors in a plan are these:

• The route chosen: removable denture, implant-retained denture, fixed bridge or several short bridges on more implants
• The number of extractions, and any bone reshaping
• The number of implants, the system chosen and the connecting parts
• Whether a graft or a sinus lift is needed
• The provisional denture or bridge used during healing
• The material of the final bridge: monolithic zirconia, veneered zirconia or acrylic on titanium
• Sedation, the number of appointments and the review programme
• The remake terms in case of complications

Ask in writing what your plan includes and which items are left for later. The plan should also state who pays for further treatment if there is a complication. Two plans often do not describe the same scope: the number of implants, the material and the number of teeth can differ. Before treatment we give you, in writing, the route to follow if there is a complication and our remake terms. You can ask us for that document before you decide.