Dental implantation in the absence of bone tissue (atrophy)

• What is atrophy
• Types of atrophy
• Osteoplasty
• Implantation methods
• Alternative Methods
• Prices
• Work examples
• Doctors
• Reviews

Bone atrophy is the process of cell destruction due to disruption of tissue nutrition. The process can be stimulated by tooth loss, gum disease, endocrine diseases, infections, and the age factor. Implantation with a lack of tissue is difficult: there is no way to correctly position and fix the implant. Implantation is carried out using the classical method (with mandatory preliminary osteoplasty) or according to the protocol with immediate loading (bone grafting is indicated only in conditions of severe atrophy).

• When used:
  missing 1 or more teeth due to bone deficiency
• Type of anesthesia:
  local anesthesia
• Procedure time:
  from 15 minutes
• Treatment period:
  up to 4 months
• Healing period:
  up to 7 days
• Age restrictions:
  from 18 years old

What is bone atrophy

Bone atrophy, or loss, is a result of tooth loss. Due to uneven load, the jaw loses volume - in the first year, tissue loss is 25%.

Atrophy can be stimulated by gum disease, endocrine, infectious diseases and the age factor. In patients, the blood supply to the jaw deteriorates, there is a lack of oxygen - the pressure on the tissue changes. The central or spongy layer, which has a porous structure, is subject to the process.

Jaw deformation has different intensity:

• I degree.
  The blood supply is not impaired. It is possible to install a classic implant.
• II degree.
  The mucous membrane contracts. The operation is performed after plastic surgery.
• III degree.
  The contour is smoothed from the chin and in the oral cavity. Bone augmentation is a must.

The results of the deficiency are expressed in deterioration of speech, changes in facial proportions, and the appearance of wrinkles in the oral area. An advanced degree of atrophy causes displacement of the dentition, loss of adjacent or opposite units. Classical implantation is not possible with bone atrophy.

The main causes of the pathological process

Jaw atrophy develops due to many factors:

• tooth extraction and untimely restoration: this is the main reason. All other circumstances listed below sooner or later again lead to loss of teeth,
• periodontal inflammation: periodontitis is the #1 cause of early tooth loss. The disease in its advanced stage leads to the destruction of the ligaments that hold the teeth in the sockets, causing them to become loose, shift and fall out,
• periodontal disease: not to be confused with periodontitis! This is a much less common systemic pathology,
• chronic diseases: diabetes, osteoporosis, cardiovascular pathologies, thyroid problems,
• bad habits: for example, smoking,
• metabolic disease,
• elderly age,
• injuries.

Types of bone atrophy in the upper and lower jaw

Destruction of the bone structure of the upper jaw is fraught with injury to the closely localized maxillary sinus. The cells in this area have a loose structure, the bone is thinner, and is actively resorbed in the area of ​​the masticatory elements. When fixing long implants, there is a risk of injury to the sinus membrane, which can stimulate its rupture and the development of sinusitis or chronic runny nose.

The Schroeder classification identifies three types of atrophy of the upper jaws

:

1. The jaw tubercles are pronounced, physical abnormalities are not visible, the mucosa is noticeably curved, the palate is deep. Implantation is possible without complications.
2. The alveolar processes are not clearly expressed, the palate is of medium depth. Installing implants using the classical method is doubtful, but using a one-stage method is possible.
3. The cells are seriously atrophied, the alveolar processes are smooth, the palate is flat, the fold at the level of the palate does not hold its shape. Fixation of classical implants is not possible; it can be done in one stage, depending on the location of the defect.

The tissue of the lower jaw is dense from below and does not decrease so rapidly, but as atrophy progresses, the dentist is faced with the problem of the nearby localized mandibular nerve (it is located under the roots of natural elements). Nerve injury can cause complete or partial loss of sensation in the lower facial part.

According to Keller, there are four types of mandibular atrophy

:

1. The tubercles of the alveoli are visible on the jaw, a fold of the mucous membrane is noticeable. You can install classic or one-stage implants.
2. The ridge becomes sharper, and muscles are attached at its base. Installation of a classic implant may cause discomfort, but a one-stage implant does not cause complications.
3. The jaw of patients with early removed lateral teeth - the alveoli are thinned, the volume in the center does not decrease. It is not possible to implant classical artificial roots; one-stage ones are possible, but there is a fear of the implant shifting when chewing food in case of a single defect.
4. In the area of ​​the frontal incisors, the bone is clearly atrophied; the lateral row is not affected. Implantation for such bone tissue atrophy is possible using a combined method.

Degree of development of pathology

Doctors distinguish four stages. In the first, the bone has a satisfactory volume, and if the patient wishes, the tooth can be restored without resorting to the procedure of increasing bone tissue during implantation. At the second stage, gum loss is noticeable, the first destructive processes are just beginning, but the bone tissue is still suitable for implantation.

There are four stages of atrophy development

At the third stage, the loss is uneven, but it is quite pronounced, so if you want to do implantation, you can’t do without procedures to increase the volume. At the fourth stage1, strong destructive processes are noticeable in the central section (there is practically no spongy substance left here), and when restoring a tooth using traditional implantation methods, increasing the volume is mandatory.

Osteoplasty

Classic dental implantation for bone tissue atrophy (height less than 10 mm) is preceded by bone augmentation surgery - osteoplasty. The procedure is carried out to ensure stable fixation of the implant and to avoid aesthetic complications during subsequent restoration of the element with prosthetics. For this purpose, the implantologist acts using one of the methods:

• Sinus lift.
  The operation is performed on the upper jaw - the doctor lifts and displaces the maxillary sinus, making room for new bone.
• Guided bone regeneration.
  Bone material is added, covered with a membrane and sutured until it fuses with the jaw.
• Replanting bone blocks.
  The person's own bone material is used. It is removed from the lower jaw in the area of ​​the wisdom teeth. The bone block is fixed with screws, bone granules are placed around it, and a membrane is attached.
• Splitting of the alveolar ridge.
  The dentist cuts the appendage and increases its thickness using a graft or artificial material.

It takes 3-6 months for the new bone to heal. It is possible to combine osteoplasty and implantation operations. The decision-making algorithm for performing osteoplasty simultaneously with implant fixation is as follows:

1. Studying the possibility of positioning the artificial root in the correct position (using wax-up and surgical templates).
2. Choice of osteoplasty technique. Depends on the degree of bone atrophy and its spread in height or width.
3. If it is impossible to achieve stability of the artificial root with the existing bone volume, the extension is carried out in a separate stage.

What is the diagnosis of diseases based on?

Accurate determination of the disease and its stage will allow timely and appropriate treatment to begin. But, unfortunately, many clinics limit themselves to x-rays and visual assessment of the oral cavity, which does not always allow a detailed understanding of the problem. But, in addition to the symptoms, for successful treatment it is necessary to determine the cause of the disease and evaluate what was the impetus for its development. To do this, a differential diagnosis is carried out, consisting of several successive stages:

• the doctor examines the oral cavity, noting signs of disease. Using instruments, measurements are made of the depth of periodontal pockets, the amount of deposits,
• an anamnesis is collected about the time of the disease, its manifestations, the patient’s feelings, as well as the quality of oral hygiene,
• to assess the condition of the bone and get details of the problem, a computed tomography (CT) scan is performed,
• Bacterial plaque and stone from periodontal pockets are taken for examination to determine the composition of the microflora and its resistance or sensitivity to drugs,
• The diagnosis is completed with blood tests (general and sugar); additional blood tests for hormones may be needed.

Diagnosis of periodontal disease at the initial stage of the disease is difficult due to the non-obviousness of the symptoms and is also not limited to one visual examination. However, even at the first stage, radiography can detect bone atrophy. The diagnosis is made on the basis of an orthopantomogram and visual and instrumental examinations. For greater accuracy, microscopic examination of the gums is used to assess the degree of disruption of microcirculation in them.

How to install implants in conditions of bone deficiency

Classic dental implantation in case of insufficient bone tissue is preceded by bone augmentation surgery or sinus lift. Before implantation, a period of engraftment of the grafting material (4-6 months) is waited. During this period, the patient is fixed with a removable prosthesis.

If I and II degrees of loss are diagnosed, implantation and replanting of cells can be organized simultaneously. It is possible to exclude bone grafting if all or almost all teeth in a row are missing - artificial roots are implanted using a one-stage protocol at an angle (into the deep bone layers).

Nesterenko Alexey Pavlovich Implant surgeon, doctor of the highest category

Can implantation stop cell loss?

In addition to solving the problem of aesthetics and restoring the functionality of the dentition, installing implants helps prevent resorption. Due to the implants, the load on the jaw is distributed evenly, internal metabolic processes in the cells are activated, cellular nutrition is established - the atrophy process stops.

Comments

Can I take any vitamins to prevent bone atrophy?

Marianna (04.10.2020 at 14:36) Reply to comment

Dear Marianna, taking vitamins as an independent measure will not solve the problem. However, vitamins, in particular vit. D, help improve the quality and structure of bone tissue. This vitamin is often prescribed in postoperative periods, for example, after tooth extraction or after installation of implants, also after bone tissue augmentation.

Editorial staff of the portal UltraSmile.ru (07.10.2020 at 09:24) Reply to comment

I want to install mini-implants, because... they have a very good price. Will they save you from atrophy?

Makarchenko (10/29/2020 at 6:27 pm) Reply to comment

No, mini-implants are smaller in size and diameter, they are not able to properly distribute the chewing load from the prosthesis, and accordingly, the bone under them will still atrophy. Due to the design features of mini-implants, only removable dentures can be installed on them.

Editorial staff of the portal UltraSmile.ru (03.11.2020 at 09:07) Reply to comment

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Classic delayed load protocol

Classic surgery is performed when there is sufficient bone tissue (at least 10 mm) in two stages. The protocol involves delayed loading on the implants: they need time to fuse with the jaw.

An implant with dismountable elements (an abutment and an intraosseous part) is fixed using the method of detaching a gum flap - the gum is cut and sutured.

2-6 months after the operation, the implant is opened, a gum former is placed on it, and two weeks later - an abutment and an individual permanent prosthesis.

1

Implantation

Implantation

2

Prosthetics

Installation of a butterfly prosthesis or temporary crown (if it is possible to remove the bite)

4-6 months

Installation of abutment and permanent crown

Osteoplasty in case of a lack of tissue is organized before the implantation of titanium roots or simultaneously. The operation is justified for single defects. If the patient has multiple defects or complete edentia, classical surgery is difficult due to acute bone loss and the need to build up a large volume of bone.

If there is not enough bone tissue for implantation, classical implants in some clinics are implanted without tissue augmentation. The doctor suggests:

• install titanium roots only in the frontal zone (signs of atrophy rarely appear here);
• fix the implant in the area of ​​the posterior wall of the maxillary sinus at the end of the dentition, behind the maxillary sinus (the height of the bone here reaches 20 mm);
• implant short and thin implants - implantation is possible in case of atrophy of the bone tissue of the lower jaw, without touching the jaw nerve.

But the described methods are unreliable: the risk of weak primary stability of the implant and its loosening cannot be excluded.

When performing an operation, it is important to use implants from the same manufacturer (with the same impurities - metals in a titanium alloy). When fixing implants, impurity metals of different brands in the acidic environment of the oral cavity may not combine and cause allergies, galvanic syndrome, and rejection of titanium roots. The ROOTT implant system is unique: a range of implants from one manufacturer is used in all clinical cases.

How do atrophic processes occur and what are their negative consequences?

Since there is no pressure on the bone, it shrinks in volume, just like the gums. Moreover, this process occurs regardless of what kind of prosthesis you wore - permanent or removable.

Due to the fact that the bone gradually decreases in size and teeth are completely absent, the overall appearance of a person changes noticeably. Of course, not at all for the better: we can observe sunken cheeks and lips. In addition, facial wrinkles rapidly develop due to the sharp loss of facial muscle tone. Also, the patient cannot avoid a number of problems with the gastrointestinal tract. The patient is forced to adhere to a strictly defined nutritional program, not consuming solid food at all.

A general deterioration in the condition of the body is possible - the development of diseases occurs along a chain, since a limited diet can cause acute vitamin deficiency. What is noteworthy is that bone loss occurs faster when the diet is too poor. Needless to say, the loss of several teeth can lead to the loss of all the others due to their gradual displacement and loosening?

One-stage protocol with immediate loading

A one-stage operation is performed if 3 or more teeth are missing. The protocol helps avoid tissue buildup. Single-component (not divided into an abutment and an intraosseous part) implants are installed in the deep layers of bone, which are not subject to resorption. For a larger area of ​​contact between the bone and the titanium root, the product is fixed at an angle, identifying areas of bone tissue that are less susceptible to atrophy.

The implant is implanted using a minimally invasive method: it is screwed through a puncture in the gum. The top of the artificial root (abutment) rises above the gum - the dentures are installed immediately after implantation (on 2-3 days). After a year, the lightweight adaptive prosthesis is replaced with a permanent one.

1

Implantation

Implantation of 8-12 implants into deep bone layers (without bone grafting)

2 - 3 days

2

Prosthetics

Fixation of an adaptive prosthesis with a titanium arch and metal-plastic crowns

in a year

Permanent prosthetics

One-stage dental implantation for abnormal bone deficiency (less than 2.5 mm) is impossible without tissue augmentation. The operation is not performed for large maxillary sinuses, which cannot be avoided when installing implants at an angle.

Among the complexes of the one-step protocol:

• All-on-4.
  The technique is used if the patient is missing all the teeth on the jaw. The dentition is restored using 4 implants (2 in the smile area and 2 on the sides). To avoid complications, “all-on-4” implantation for atrophy of the bone tissue of the upper jaw is carried out with caution, taking into account the close location of the maxillary sinuses.
• All-on-6.
  A modernized version of the All-on-4 method (implantation for severe bone deficiency). The increased number of supports (6 instead of 4) expands the scope of application of the method and allows for more stable fixation of the structure.
• Basal implantation.
  The method is used for acute bone loss. Suitable for missing three or more teeth in a row. For complete edentia, 8-12 implants are used on one row of teeth. They are fixed into the deep layers of the jaw bone.

All-on-4 and all-on-6 protocols involve the use of surgical templates to determine the location of the implant, without taking into account the condition of the bone. With basal implantation, templates can be dispensed with; this expands the scope of application of the technique. Implantologists at the ROOTT Clinic, using computed tomography, select suitable jaw sites for fixation with sufficient bone volume. If circumstances require it, a couple of additional implants are installed free of charge - if one of the titanium roots does not take root, there are enough implants left for prosthetics.

Complications that occur if the disease is not treated

In addition to destruction in the oral cavity, chronic inflammation harms the entire body, affecting the functioning of internal organs - the gastrointestinal tract, heart, liver and kidneys, and has a destructive effect on blood vessels. The culprit is pathogenic bacteria, which weaken the immune system and cause diseases no less dangerous than periodontitis. Thus, microorganisms of the oral cavity, together with food and saliva, penetrate into the stomach and intestines, causing digestive disorders - gas formation, indigestion and pain, followed by gastritis, duodenitis and other diseases [3]. There are cause-and-effect relationships between stomach diseases and disturbances in metabolism and in obtaining all the necessary microelements and vitamins.

An even more dangerous complication of chronic inflammation is kidney disease, such as pyelonephritis and renal failure. They develop in a non-obvious way: the bloodstream brings pathogenic microorganisms to the kidneys, where the immune system destroys “strangers”, as elsewhere, but the proteins of pathogens at the molecular level are very similar to kidney cells - the immune defense also works on the kidney’s own cells, simultaneously destroying them.

Periodontitis affects both blood vessels and the heart. All the same pathogenic bacteria cause endocarditis, heart attacks, heart attacks, affect the brain, 3 times increasing the likelihood of Alzheimer's disease. Scientists have proven the connection between the disease and a 6-fold increase in the risk of stroke and diabetes. 8 times more likely to develop pregnancy complications (miscarriage, premature birth, low birth weight) if the child’s mother has periodontitis.

Advanced periodontal disease provokes the development of periodontitis, which significantly worsens the clinical picture and requires complex and long-term treatment.

Alternative Methods

Removable dentures Recommended if there are absolute contraindications to implantation or if there is a limited budget

ReSmile Modern technology for rapid restoration of teeth with complete edentia with the installation of a permanent prosthesis

Mini-implants Removable prosthetics with mini-implants MDI

Article Expert

Nesterenko Alexey Pavlovich Surgeon-implantologist, doctor of the highest category

Work experience: more than 10 years

Prices

The cost of the operation depends on the chosen technique. The most expensive will be implantation with preliminary osteoplasty: the process is labor-intensive and expensive artificial material is used.

A classic operation and a protocol with an immediate load will cost approximately the same if several elements need to be restored. When a complete or almost entire row of teeth is missing, one-stage implantation is cheaper due to fewer implants and a reduction in the number of operations.

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Work examples:

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Complete restoration of the upper jaw using a zygomatic implant

Stage III periodontal disease: complex dental implantation Restoration of both jaws in 4 days

Sinus lifting with simultaneous implantation

Implantation of both jaws with ROOTT implants for stage II periodontal disease

Restoration of two jaws with one-stage implantation using sinus lift

Sinus lift with simultaneous implantation

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