All that a patient should know about dental implants. Procedures and the right price

Analysis, information and opinions regarding dental implants within our area of expertise so that our patients can choose freely. Without obligations. Without hidden extras. What, how and how much in Cirugía Facial Benidorm Clinic (Facial Surgery Benidorm Clinic).

José Manuel Batllés Sebastián
Oral and Maxillofacial Surgery
Director of Cirugía Facial Benidorm Clinic & mytreatmentinspain.uk

 

A brief introduction

Although we think and believe that dental implants are things of our day and age, we know that since remote and even prehistoric times, man has looked for a way to replace lost teeth.
Many have been tested in order to achieve results, from the placing of small carved stones, screws, wires, plates, silver roots, lead, glass, etc. but it wasn’t until the start of the 20th century when they started to feel the scientific bases of modern dental implants through experimental trials with materials such as gold-iridium, titanium and vitalium although with minimal success.

 

The great discovery

It was from the sixties onwards when dental implants revolutionized oral surgery and dentistry, from the moment that Dr. Branemark of Sweden and his collaborators accidentally discovered the biological osseointegration between titanium and bone, revealing the ideal material for the creation of artificial dental roots.
From here on, the implantology race was exponential with the appearance of multiple proposals and designs in titanium.
The first titanium implant in the shape of a screw was presented by Dr. Branemark in 1982 using a clinical base of more than 10 years of experience as a guarantee.

 

In the 90’s

In the decade of the nineties, in many countries around us and also in Spain, implantology diffused as a new surgical discipline and since then the treatment with dental implants has become a very common procedure and the primary one for the substitution of lost pieces. 
In the beginning, the implantology techniques were reserved for very few pioneer professionals: stomatology specialists with surgical experience and oral and maxillofacial surgeons. They were new treatments carried out by very few qualified professionals, with high costs making them expensive and reserved only for those with deep pockets.
Within this development period, the first doctors specializing in implantology, stomatology or surgery, earned a lot of money as it was a time that many teeth were successfully replaced with great satisfaction for the wealthy patients.

 

Dental implantology today

Nowadays, it’s not like this and bit by bit, dental implantology is a routine treatment in any dental clinic. Today there are many general odontologists with postgraduates in implantology who are fitting dental implants with greater or lesser expertise.
Additionally, there exist more than 150 brands of dental implants commercialized in Spain. The industry has also kept an eye on the sector of implantology and the competition has created a moderation of the price of materials without losing the quality of the work. Even the big name brands of implants have had to moderate in order to reduce their products and just like the big pharmaceutical companies, the multinational companies of implants have fused or bought out lesser competitors in order to unite joint strategies within the market.
Because of this, as in any field, it has been the offer and the demand that has moderated greatly the prices of implantology.

 

The big names: Vitaldent, Dentix, IDental, the good and the bad.

The industry techniques and marketing have also contributed to the good and the bad of dental implantology.
The positive part is that the big dental firms that we all know with their superb marketing strategies, such as their television adverts with famous personalities (Does anyone believe that Iker Casillas has implants from Dentix or Jesús Vazquez in Vitaldent?) And the incorporation of finance (this was a great idea) have democratized the treatments.

The negative part is that implantology has been trivialized, it has been sold as something simple and without risks (there are very simple cases and very difficult ones), little or no type of medical rigour. Professionals with a commercial profile have been placed with little or no odontological training, to diagnose health problems and treatment plans (ideal and marvelous ones) without consulting with the executing specialist, which has produced and produces, understandably, many problems for the patient (who feels frustrated and conned) as well as for the health professional (who, on many occasions, cannot carry out the original plan).
In these clinics, very often, the professional implantologists are usually young specialists, recently graduated, who start for little money “lending a hand” and legitimately “disappear “when they find something better or can open their own clinic.
The business men (or better named the business association) do not suffer these shortages. On one hand they will never be short of new professionals ready to “lend a hand” and on the other, the millionaire publicity campaigns keep their niche in the market and remain almost always legally “armored”.

• The new brand Dentix, takes advantage of all of this system to try to offer quality treatments at low prices. Their company method is to fit many implants at lower prices so that they make more money by basing their profits on the volume.They promote fact that they are not a franchise, this way they do not assure the quality of their work and care. The difference is that they are dental clinics that are run by dentists and not just “business men” preoccupied with numbers. Their weakness, in my opinion, is that they are carrying out a very rapid expansion, with a strong inversion which needs to be amortized. If better times do not come with better stability and prosperity, or even if their method is not one hundred percent correct, there could be the problem of a “bubble” once again.
• The new IDental clinics, sell “dentists with a heart” offering discounts of up to 70% for patients with few resources. The truth is that they are like university clinics where treatments are carried out by postgraduate students without experience. What we don’t know is what grade of supervision by teachers or qualified professionals these students have to solve the problems that arise.

 

Ultimately, the sector is divided into good and bad professionals. Whichever the name or brand, if behind it there are well trained and dedicated professionals, the results will be good and the patients will be satisfied.

 

Finally, as a consequence of this corporate boom of the dental sector in the last few years, the rest of the professionals have pulled their socks up and modernized their way of understanding and practicing dentistry: they have gone out on the street to look for patients, they have copied in the best way possible, the big brand names: their marketing, finance and they have ferociously criticized the bad parts: the lack of rigor and trivialization of the treatments.

What is the real price of a dental implant?

After all that we have explained, today in Spain and surrounding areas, the prices per implant are very variable.
We have to differentiate between the price per implant fitted and the price of the prosthesis (the tooth or teeth)
In an ideal, “simple” patient (where there are no additional techniques), we can find prices for standard implants with fitting which can oscillate between 250€ and 1000€ per unit, depending on the clinic that you go to or the professional that fits them.
The cost price of a titanium homologated implant can oscillate between 50€ (or less) and approximately 300€ depending on the make.

The doctors’ fees to fit implants are free and can be fit by any professional or clinic.

 

Is it true that a more expensive implant is better?

NO.

When we started to fit dental implants more than 10 years ago, we offered 3 different makes of implants and therefore 3 different prices: an expensive brand implant  (Nobel Biocare®), a lower priced Spanish implant (Mozo-Grau®) and a special shorter implant  (Endopore®) for cases with little bone.

When we offered the expensive brand together with the cheaper one, no one or almost no one choose the expensive one, everyone or almost everyone, chose the middle one and we found, not only in price, differences between some treatments and others. Time has proven this. We have seen more complications or worse results in implants or prosthesis with “normal” brands when compared with more expensive brands. The reality (I don’t know if this is a good or bad thing) is that practically no patient asks about which make of implant I’m going to fit.
On the other hand, the big brands of implants usually have different models of implants with different prices, in a way that not all implants are the same or of the same quality within the same brand. Additionally, it is not the same buying 1 as 100 the price can vary considerably depending on who buys it. For example, the big names compete so that any director with degrees in implantology of any university can promote their brand and teach it to their students. The director in exchange gets the implant practically free (obviously in the university but also in their private clinic) and their brand will have many future noble clients.

 

Which implants do we currently use in our clinic?

We only use one brand: JD Evolution®. An Italian implant (top 3 in Italy) of a hexagonal internal connection and special mechanical characteristics which we have been working with since 2010 and with which we have had excellent results of osseointegration over short, medium and long term.

We have revised a total of 798 JD Evolution® implants fitted in the last  5 years with a total osseointegration rate within 2 months, of 96,4 %. After 5 years of the first implants fitted, all of the osseointegrated implants are still in the mouths of our patients with good radiological and peri-implantary controls.

Explanations regarding implants and prosthesis of implants. What’s behind the marketing?

The cost of the prosthesis of implants.

One thing is a titanium implant, which is surgically inserted into the bone and is the equivalent of the root and another thing is the prosthesis on an implant, which is the equivalent of a dental crown. Factors which influence the quality and price:

• The prosthesis on an implant can be made of different materials or qualities. The prosthesis is, definitively, what the patient sees and feels and what they eat with, which means for them, becomes the most important part of the treatment.
• The prosthesis can be a unique crown (an implant–a tooth) or can be a structure which replaces various or all of the teeth and which supports 4, 6, 8 or more dental implants. The dental implant has an internal thread. In the implant, the prosthesis can be:
  • Screwed in directly: the crown and the pillar are one piece with a chimney (hole) through which the implant is screwed.
  • Cemented: a pillar is screwed into the implant to which the crown is stuck. This way the pillar and the crown are separate and the crown does not have holes.
• The dental prosthesis on the implants is carried out by the laboratory technicians or dental prosthetics, manually or through  CAD-CAM systems. For their fabrication they use specific pieces for each implant called accessories: pillars, screws, transepithelials, calcinables, interfacial… The fitting, adjustment and biomechanics of the prosthesis are vital, not only for the comfort of the patient but also for the long term survival of the implant.
• The prosthetic accessories many times have higher costs than the actual dental implant however, it is important to use original accessories and to not skimp on money during the fabrication of the prosthesis. Sometimes we see professionals who brag about fitting a determined make of implant and then use unknown brands of accessories to confection the prosthesis which is unacceptable.
• The labor time to confection and adjust prosthesis on an implant is something to take into account. Numerous tests are needed in the clinic until the prosthesis is perfectly adjusted and adequate to the needs and expectations of the patient. This often causes long and meticulous work.

Therefore, depending on the material used and the price of the accessories, the price of the crown on the implant can escalate between 300€ and 800€. If it is higher, in our judgment it is not very justified. If it is less, it possibly has poor quality materials or components.
The cost price of (accessories and laboratory) a well-made crown with mechanized accessories is between 150€ and 350€. Depending on the laboratory and the make of the accessories.

The right price for a good quality crown which is handmade with ceramic metal with original accessories of a normal brand is around 450€. If the crown is made with latest generation milled materials (CAD-CAM) the price can be around 600€.
As we can see, the price of the implant and the prosthesis are similar, we can even argue that in a case without complications, the prosthesis should be more expensive than the implant as the confection of the prosthesis has a higher cost price and longer clinical time.

Therefore, when the marketing of implantology talks to us about “immediate fit and teeth in one hour”;“guided surgery without flap”; “implant + crown 45€”… we should, at the very least, doubt these messages.

 

“Immediate fit and teeth in one hour”

The immediate fit and the “teeth in one hour” in a complete rehabilitation is, in my opinion, an incomplete lie or a half-truth depending on how you look at it. There is no doubt that if this was possible, every single clinic all over the world would be doing it.

• The post-extraction implant and immediate loading in the anterior (aesthetic) sector depends on the type of patient and the individual characteristics of each patient. This technique allows us to better preserve hard and soft tissues without compromising the aesthetics, as during cicatrization a series of changes takes place. The decision to carry out the immediate loading of the implant depends on the surgeon (operator) since, in order to perform the implant, there must be a primary stability which is not achieved in all cases.
• So that the implant osseointegrates (if it does not osseointegrate it is useless) it needs to be free of supports or weight. In other terms: if, on a recently fitted implant a crown is placed so that we can eat, the implant will fail inevitable.
• Because of this, the immediate fit is not possible. However, we can speak about immediate aesthetic or immediate marketing. We can fit the patient with teeth immediately after we fit the implants but these teeth cannot be used to eat with only to smile (which is not minor) and also to be more comfortable. They are provisional teeth, made with provisional material, they are not definitive teeth made with definitive materials.
• In order to fit the final teeth, the ones the patient will have forever and can eat freely with, we should, as in all cases, wait the minimum time of osseointegration of the implants to be able to take the measures and perform the appropriate tests until the confection of the definitive prosthesis.

This is this inevitable way in all patients and in all clinics be it in Barcelona, Houston or in Benidorm.

• When we talk about complete rehabilitations (rehabilitation of all of the teeth of a full dental arch and not one by one), in our opinion, and this is the way we explain it to all of our patients, the immediate fit has more inconveniences than advantages. Far from shortening the treatment of the implants, it has a potential danger of lengthening it. (Advancing with our protocol, in a favorable case which does not require grafts, we can rehabilitate successfully and with a definitive complete prosthesis in 8-10 weeks).Reasons:

1. A complete prosthesis screwed immediately after an implant surgery, makes the hygiene of the patient very difficult, it is important for the correct healing process of the gum and the osseointegration of the implants.
2. It makes the removal of the stitches difficult or impossible of it is necessary (we use sutures which we remove in a week. We do not like to use absorbable sutures as they can stay in the mouth for weeks afterwards before they fall out, which impedes the healing of the tissues as they accumulate lots of bacterial plaque).
3. Additionally, an immediate provisional prosthesis makes it difficult to control the integration of the implants over time, in a way that in order to check that the implants are working, we have to unscrew the prosthesis in every visit (which can take time, discomfort, anesthetic…) What may happen, due to lack of time in the visit or “laziness” on behalf of the patient or professional to unscrew the prosthesis,  is that it is not done within the time scale on most occasions and we do not realize that an implant has not osseointegrated until a long time after the fitting, therefore delaying the treatment plan because when an implant fails, it is necessary to spot it as soon as possible so we can remove it and replace it straight away.

• Ultimately, when a complete prosthesis is fitted and immediately screwed onto 4, 6, 8 or more implants, even if the patient is instructed to eat soft food, this is sometimes difficult for the patient. In the beginning of the immediate post operatory care, everything hurts meaning that the patient is more limited and more conscious, but after 7-12 days, when the gums heal, the patient gains confidence. As all implants work together, it is difficult for the patient to feel if one is not right and this can easily happen.

 

In our experience, the immediate fit practically duplicates the risk that one or more implants will not osseointegrate and therefore the successful final result is considerably delayed.

 

Our method

In Cirugía Facial Benidorm clinic we solve these aspects in a very simple way, fitting 2 to 4 special temporary implants between the definitive implants. These provisional implants are 2mm thick and are easily fitted between the definitive implants. Through a very simple tongue and groove mechanism, the teeth fix themselves to these implants. Once fitted they are completely adjusted with these advantages:

1. The patient can remove the prosthesis easily for better hygiene.
2. The control of the definitive implants is easy.
3. The removal of the sutures is carried out without problems and also, the patient can eat more or less everything as these implants are temporary and do not need to osseointegrate with the bone.

We use them for approximately 2 months, time enough for the definitive implants to osseointegrate and we can fit the definitive prosthesis. The patient can eat without fear and the definitive implants will not suffer. Easy, safe and simple.

With this method we offer our patients immediate aesthetics and function and the maximum comfort at the same time as the maximum safety after an implant surgery.

• When we speak of unitary rehabilitations (one implant-one tooth), although it is proven that the failure indicators rise significantly, we carry out immediate aesthetics (no strain) as we are dealing with visible teeth where the aesthetic requirements always have to be taken into account.
  In this context we offer immediate fit to our patients, advising the conditions (they are more expensive implants) and the risks. In any case, if the patient collaborates, the rate of success is high and this is why we do it.

 

Computer guided surgery without flap

The surgery with fabricated surgical guides CAD-CAM, after a digital planning with a CAT scan of the patient and a computer program, is not a new technique; it has at least ten years of history.
This technique was flourishing when we started to fit dental implants back in 2006. It is a technology which we started to use back then but which we now abandoned. Our experience in the first cases was not good and currently we cannot see the benefits for the patient or for us.
The guided surgery has the great advantage of no flap, this is true, offering post operatory care which in theory, is more comfortable for the patient. However, the guided surgery without flap has a proven margin for error (± 1-2 millimeters, which is very much) which makes it an unsafe technique for cases with little bone or with just enough bone.

If there are cases with sufficient bone where the guided surgery is viable, it means that the conventional surgery, at least in our hands, is infinitively quicker and minimally invasive  ( minimal incisions) meaning that the guided surgery doesn’t actually give us anything, in fact, the total opposite:  it slows down and exhorts the procedure.
Finally, if the guided surgery is with a flap (guide resting directly on the bone and not on the gum) the technique is more precise but creates ample approaches and big detachments in order to fix the guide properly. This creates contradictory greater post operatory care even though the guided bone surgery is very useful many times for complex cases where we should fit very tight fitting implants with concrete angles.

Resuming and always in our opinion, the guided surgery without bone support, in most cases, is only a marketing tool and has served and continues to serve new dentists  who are just starting to fit their first implants, and not much more.

We do have to thank the industry for the development of computer programs which we continue to use to plan our surgeries and as very useful tools of communication with our patients.

 

“Implant + crown: 45€” “Implant: 222€”

This is the latest in commercial marketing. The first part makes reference simply to the finance of the treatment of implants as offered by many clinics:

• Monthly payment of 45 euros during 24 months without interest makes a total of 1080 € implant + crown.
• The implant at 222€ is also very popular. The great offer of Dentix®, brand of dental clinics which have recently appeared, and of great expansion through Spain and LatinAmerica, pretends to make a name for itself in the market of dental implants.Making reference as we said to the philosophy of: more implants for less money so they fit more and make more money. Benefits from volume.It can be a correct strategy if and when you can attend individually, personally and adequately with time for each patient, which is not easy and requires a humane team with consolidated and experienced work method.If it is not done like this, the strategy can convert itself into your worst enemy and into a large headache if you need to attend to a large volume of patients in a short time to redeem a great inversion.

The dental implantology, as a part of medicine, is not an exact science nor a production line, meaning it is not a good business for becoming a millionaire.

Following these protocols and with our brand of implant, in the last year we have had an osseointegration rate of 96, 4% meaning, that of every 100 implants fitted, more than 96 have osseointegrated and are being enjoyed by our patients.
If you prefer you can come and meet us. The first visit is not free and here we explain why First visit and estimate free? This is another marketing strategy which takes professionalism from our work and which is why we don’t like it. What we propose is something fairer for both parties and the price of the first visit is refunded if the patient undergoes the treatment with us. At the end, the first visit is free because practically all patients who come to meet us decide to stay with us.

What makes us different from the rest?

• The first and most important fact is that we are a consolidated team of medical specialist professionals in all that concerns the face-mouth-neck; we do not treat dental cases as something isolated from the rest. We are not a dental clinic. Our Unit of Aesthetic and Dental Implantology is a medical-odontological unit in the Department of Maxillofacial Surgery of a private hospital with more than 25 years of experience: the Hospital Clínica Benidorm.
• The difference with other centers, the Unit is made up of all of the competent specialties: doctors (surgeons and anesthetists), odontologists and dental prosthesis. Our unit has the capacity to solve from the most difficult to the simplest of cases.
• We are the only center in the area directed by a specialist doctor in Oral and Maxillofacial Surgery with double title (medical and odontological), with the safety that this ensures and the tranquility that it brings.
• Visit our installations. We have an operating theater to offer maximum safety and the best working atmosphere. We have a team of anesthetists if preferred or needed.
• You can find our prices and conditions of treatments published on our web page. Without small print. Without  catches.
• We offer made to measure finance plans so that money is not a problem.
• We are the only center with our characteristics which in a few months will have the ISO 2015 certificates.

Because of all of this we receive many patients “rebound” from other clinics. Unsatisfied patients who feel conned. It’s very sad but it’s the way it is. For this reason I have decided, as director of the center who is passionate about the career I love, to write this article, so that any patient requiring  implants, after reading this information can decide who and where.