I often hear patients say I can’t have implants. I don’t have enough bone. I am delighted to be able to tell everyone that this is almost universally untrue! It might be that at the time of consultation, that they don’t have enough bone volume. However, in these enlightened days, all experienced Implantologists are able to generate or graft bone.
There are several ways in which we might graft or make new bone. First of all, there is an issue of volume and how much do we need? If it is only a small amount of bone. Maybe to cover up the very top of an implant whilst it is being placed. This can be achieved by keeping the scrapings or cuttings from the preparation of the implant hole. Should it be a really massive defect, it may even be necessary to remove a piece of hip from the patient and then graft it into the mouth. Luckily I hardly ever have to carry out that particular operation now, as we now have more options available. If we really need to use a block of bone, it is usually removed from the lower jaw. Right at the back, very much like removing wisdom tooth.
The most commonly used material is “false bone” straight out of a bottle. The material of choice is bovine derived from which all the organic substrate is very carefully removed. This is presented as a particulate material that is placed into, around, all over the defect. After some time your own bone cells invade and populate forming brand-new bone. At the time of surgery we need to enclose the bone graft material with a collagen membrane. This keeps a particulate material together, and stops any soft tissue growing into the graft area. The graft will then take anything between four and eight months to heal depending on the size of the defect. Other false bone materials are also available, including completely man made.
Having generated sufficient bone, you may then place your implants. Occasionally it may be possible to place the implants and the graft at the same time. It is also possible to use the same technique to build bone, not only in the upper and lower jaws, but also in the nasal sinuses that sit in the upper jaw above the posterior teeth. This is a common area of insufficient bone volume. Molar teeth have often been removed some time ago and have healed, leaving very little bone. In this case, we put our particulate graft into the floor of the sinus, taking care not to damage the internal membrane. This is called a direct lateral window technique sinus lift. It is a very successful technique that I have used for over 20 years with great results. It may sound a little drastic to those with a weak stomach, but generally my patients do well with just a small amount of local anaesthetic and a bit of patience.
The other essential thing to remember, is these days we have a lot of short implants. This allow us to use what bone is left or available, and these are proving to be quite successful. However, if I have an opportunity to use a longer implant. I always will. As it seems to make sense from an engineering point of view.
I hope I’ve shown that there is no reason in the 22nd century for patients not to have implants. If they really want them, there is very little that we can’t achieve these days.