Dr. Peter Balle examines Rocco Lagana, who's receiving a dental implant to replace a front tooth he lost in a hockey accident years ago. Back then, a bridge would have been the dental fix for Lagana's missing tooth. Photos by Craig L. Moran. Dental implants also offer a means of replacing multiple lost teeth. Individual implants can be placed where the missing teeth used to be, or implants can be used as anchors for full or partial dentures.

In his mid-20s, after he lost a front tooth while playing hockey, Rocco Lagana was fitted with a retainer to wear until a more permanent dental fix could be made.

"I think it was meant to last two days," Lagana said. "I ended up keeping it over 20 years."

The retainer wasn't comfortable to wear, it was difficult to eat with, and it posed a nearly constant threat of leaving his mouth when he didn't want it to. But, Lagana figured, it was a better option -- and certainly, he suspected, a less painful one -- than a bridge, the best alternative available to him at the time.

Lagana is now in his 50s, and it turned out that waiting wasn't such a bad idea. Today, Lagana is having his missing tooth replaced with something that wasn't readily available 30 years ago: a dental implant.

Once mysterious, once rare, dental implants have moved into the mainstream during the past decade.

Think of an implant as an artificial tooth root. To place one, a dentist makes a small incision in the top of the gum on which the missing tooth used to sit and drills a hole into the bone underneath. Into that hole, he inserts a titanium-alloy implant and then closes the incision.

During the next few months the bone around the implant grows to incorporate it in a process called osseointegration. After that happens, the dentist will attach to the implant a post that rises from the gum surface and to which will be attached an artificial tooth.

The result: A fake tooth that looks and functions almost exactly like the natural tooth it is replacing.

Implants aren't new -- research was being done on them in the '60s -- but their use has increased as the materials used to make them and the techniques used to place them have improved.

According to Dr. Robert Lockhart, clinical associate professor and co-chairman of clinical sciences at the University of Nevada, Las Vegas School of Dental Medicine, the number of implants placed in the United States "has been doubling every year. Three years ago it was in the range of 400,000. The year after that it was 750,000 or 800,000. Now, it's a couple (of) million."

For many patients, an implant serves as an alternative to the bridges and dentures that long have been used to deal with missing teeth.

In a bridge, the teeth next to a missing tooth are used as anchors to hold a connected artificial tooth in-between them. The problem, Lockhart said, is that bridges require the irreversible "cutting down of adjoining teeth."

Implants don't. Now, Lockhart said, a single implant can be put in place without disturbing nearby healthy teeth.

Implants also can be a more secure alternative to dentures. Replacing the individual lost teeth with implants is one option. Another, said Las Vegas dentist Dr. Peter Balle, is positioning implants around the mouth on which a denture can be anchored.

Implants, Balle said, can anchor a denture more securely, particularly on the lower jaw where a good fit is difficult.

Dentures, he added, are "certainly nothing like what nature gave us. The closest thing we've come up with, as far as dentists, is implants."

The procedure used to place implants is no more painful than any other dental procedure. Balle said patients typically require local sedation and often can manage whatever soreness they have afterward with over-the-counter medications.

Lagana admitted that fear of pain was a major reason he delayed having his missing tooth replaced. But, he said, the implant procedure -- he's a patient of Balle's -- caused "not one bit of pain."

"The only thing that caught me off-guard was the drilling of the bone (in his upper jaw) and the vibration of your head. When the sedative wore off, I didn't feel anything."

Implants aren't for everybody. For example, Lockhart said implants typically aren't used to replace missing teeth in children whose bones are growing.

Dr. Michael Fisher of the Southwest Institute of Implant Dentistry said his youngest patient was 16. "She was born missing some teeth, which never developed in the jaw," he said.

At the other end of the spectrum, Fisher continued, "we treated a patient in her 80s, who's now in her 90s, who just got tired of all of those years wearing dentures. It covers a huge range of ages."

Some patients -- Fisher estimated the number at about one-third of the patients he sees -- don't have sufficient bone on which to seat an implant. Those patients would first receive a bone graft in a process similar to that used to place an implant.

That, Balle said, can add another three to four months to the timeline, which typically ranges from three to six months from start to finish. During that time, the patient will wear a temporary appliance in the mouth.

Also, taking some medications -- for example, Fosamax, taken for osteoporosis -- can preclude some patients from receiving an implant, Lockhart said.

Dentists also wouldn't use an implant on patients in poor health, such as those with severe heart disease or with poorly controlled diabetes, Fisher said.

The cost of implants can pose a hurdle to many patients. Balle estimated that the cost of a single-tooth implant can range from $2,000 to $5,000, and noted that many dental insurers don't cover them.

But that may be changing. Lockhart said he talked last year with an administrator of a major Southern California dental plan, "and he was telling me they now pay coverage for implants as a higher priority than a fixed bridge. So, if a patient loses a tooth, they consider an implant as good as or a better alternative."

Lockhart agreed with that assessment. While a single-tooth implant and a bridge cost about the same, the bridge will last an average of 11 years before it has to be replaced, Lockhart said.

With an implant, "you don't have that recurrent replacement," he added. "If I put an implant in your jaw today and it's well-placed and it fuses to the bone, the chances are over 90 percent that the implant will be there between 17 and 20 years from now."

He uses that figure because "that's about how long the (current) studies run."

Yet, Fisher said, "most insurance companies still term implants as elective or cosmetic, which is infuriating because they're not. Now, they certainly can be, but the vast majority are purely functional, nothing more than replacing a missing tooth."

The American Dental Association does not recognize implant dentistry as a specialty. Lockhart suggested patients ask dentists how many implants they've done, restored or supervised.

"There is a learning curve in doing implants," he said.

Balle said most of his patients arrive knowing something about implants.

"I offer all of my patients the option, as an alternative," he said. "I think it's a disservice not to mention it at least."

Lockhart suggested that patients who are considering a bridge ask their dentist if theirs is a case in which an implant is appropriate.

Implants "are becoming, really, the treatment of choice," Lockhart said. "My own feeling is, if you look 10 years down the road, I don't think we'll be doing bridges anymore."