Teeth Setting on Implants: What differences exist and what needs to be considered?



Get to know the different requirements, usages and possibilities for each case

Implants must first be placed in the bone. This process is referred to as an implantation. Today, minimally invasive techniques are the standard. One of these is the so-called stamping technique. Is it possible to insert implants without cutting the mucous membrane? Yes, although there should be enough stable gum tissue (“gingiva fixa”) around the implant at the time of the implantation!

It’s now known that less plaque forms on implants/teeth with sufficiently stable gums. Implants/teeth surrounded only by flexible gums are more vulnerable to developing periodontitis, gingivitis, and/or caries.

Therefore, if there is not much firm gum tissue left, the stamping technique should not be used because what little is left of the gums would be removed as well through this process! The saying, “use it or lose it,” does not only apply to people’s mental abilities or musculature! Bone tissue, too, requires a certain measure of load application in order not to waste away. If teeth are lost, the bone is no longer exercised and this results in atrophy of the bone in the affected areas.

Artificial tooth roots can prevent this. In its latest edition of patient information, the German ‘Society for Implantology’ recommends that “Implants should therefore be placed as soon as possible after the loss of a tooth”.

An “immediate implantation” has the advantage that structures such as bone and soft tissue can be preserved. Immediate implantations are not recommended in cases of acute or pronounced chronic infections, such as a periodontitis, or in cases of extensive damage to the soft tissue and bones, after an accident, for example. Immediate provision does not mean immediate loading!

Depending on when the tooth implant is provided with an artificial tooth, one differentiates between:

  • An immediate provision
  • An immediate loading
  • Open/covered healing

The critical factors that determine the choice of procedure are the quality of the bone (the quality of the bone tissue surrounding the implant) and the primary stability of the implant immediately after insertion. It has been proven that implants inserted in the anterior region of a toothless lower jaw and connected to one another can be immediately attended to and loads can also be applied right away.

When an implant is immediately exposed to full chewing forces, this is referred to as “immediate loading.” This is possible when there is optimal bone quality, particularly in the lower jaw. Previously, months of healing had to be included in the implant process; today, the modern dentist can provide the implants with artificial teeth immediately after surgery and full load application is possible! The prerequisite for lasting implant success lies in the osseous anchoring of the implant body through direct contact of the surface of the implant with the surrounding bone.

When the implant is immediately provided with an artificial tooth as with immediate loading but not exposed to the full chewing forces because the tooth is simply being prepared in a little bit of a smaller size, this is referred to as “immediate provision.”

Whether an immediate provision or immediate loading is used, it should be noted that these new techniques will only result in the desired success if conditions are good. What are good conditions for an immediate provision? There must not be any infections, including dental focuses and periodontitis in the mucous membrane!

Sometimes, bone quality is not even sufficient enough for an immediate provision because the danger of the implant (including the tooth) becoming loose because of food and/or the tongue is too great. In such cases, the implant is either left to heal in a closed fashion or a gingiva former is affixed. The gingiva former spares the patient from having to undergo an uncovering procedure after healing. This is called open healing.

Another factor that influences which implant technique is chosen is the extent of the implantation. For example, if bone augmentation surgery is performed in the same session, then the healing process takes place in a closed fashion (i.e., the mucous membrane above the implant is tightly sewn up). Covered healing thus means that the implants are left to heal under the mucous membrane so that the bone graft material doesn’t get infected. Loss of the bone augmentation would be the result of infection. By closing the mucous membrane, the area where surgery was performed is protected from bacteria located in the oral cavity.

The disadvantage of closed healing compared to the immediate provision, immediate loading, and open healing is that the mucous membrane has to be reopened after the implants heal in what is known as an uncovering procedure.

Zahnimplantate im Unterkiefer unmittelbar nach Setzungbelsky

Zahnimplantat Operation

Depending on whether the chewing forces are guided into the bone (as with natural teeth) or onto the mucous membrane, one differentiates between:

  • Bone-supported artificial teeth
  • Mucous membrane-supported artificial teeth

When chewing forces are guided into the bone and the dentures are merely resting on the mucous membrane, they are referred to as “bone-supported” dentures. Fixed artificial teeth are always bone-supported, which means that chewing forces are guided into the bone either via your teeth or via implants.

However, when chewing forces are primarily guided into the mucous membrane and the remaining teeth and/or implants (referred to as anchoring elements) only provide increased stability to the dentures, they are referred to as “mucous membrane-supported” dentures. There is a clear trend in industrialized countries towards bone-supported dentures because of the following reasons:

  • Increased comfort for the patient
  • Prevention of damage to the anchor teeth (e.g., in case of partial prostheses)
  • Prevention of bone resorption at the alveolar bone (“Use it, or loose it!”)

In cases of artificial teeth supported by the mucous membrane, bone resorption is unfortunately often accelerated because loads to the bone are no longer applied in a natural manner (unphysiologically). This results in an ill-fitting prosthesis as well as to physical changes in the face (large lower jaw, small upper jaw). You can recognize bone resorption because of recurring bruises and/or a deteriorating fit of the prosthesis. This results in a lining of the dentures in order to compensate for the bone loss.

Even if there is very little bone left, bone augmentation surgery is able to recreate bedding for implants. Partial dentures and full dentures are often inserted as temporary prostheses for the duration of the healing process for tooth implants and until loads can be applied. The only advantage of partial or full prostheses are the lower costs when compared to implant solutions.

What do the terms “fixed artificial teeth,” “conditionally removable dental prosthesis,” and “removable dentures” really mean?

Fixed means that you cannot take the artificial teeth out of your mouth because they are firmly affixed, in which case the proper term is not “dental prosthesis,” but “artificial teeth.” A classic example of a fixed artificial tooth is an artificial crown.

Another example of fixed artificial teeth is a bridge. Like the crown, it is cemented onto tooth stumps or implants. The only difference with the crown is that one or more “interlink(s)” connects two “crowns” with one another.

If there is no longer a tooth stump present, an implant takes over the function of the dental root. In most cases, prostheses on implants are also cemented in, but with temporary dental cement. This constitutes a “conditionally removable prosthesis.” If only the dentist can remove the prosthesis, e.g., by loosening screws, then this is called a “conditionally removable prosthesis.” “Conditionally removable” means that you cannot remove the prosthesis from your mouth yourself, but the dentist can do so “simply” and without destroying it.

A classic example of a conditionally removable prosthesis would be a screwed bar solution. As previously mentioned, implant crowns (as opposed to normal crowns) are fixed with temporary cement and the dentist can remove the implant crown if necessary. This constitutes a conditionally removable prosthesis as well. Contrary to this, a crown placed on your tooth stump is a fixed artificial tooth because the dentist has to destroy the crown in order to remove it from your tooth.

In the past, the use of screwed prostheses was not unusual. Today, the trend is clearly towards cemented solutions.

There are a number of reasons for this:

  • The development and improvement of cements (permanent and also temporary cements)
  • The lower costs of devices compared to elaborate screwed solutions
  • Easier to clean
  • Less prone to problems
  • More comfortable for the patient, because screwed prostheses are usually bigger – and bulkier in the mouth
  • Positive developments in implantology in the area of bone augmentation surgery

In fixed/conditionally removable prostheses, chewing forces are always guided into the bone, either via the dental root or through implants. In the case of a removable denture, this is also possible; the denture utilizes parts of the mucous membrane as a “rest” and thus transmits chewing forces to the mucous membrane. With regard to removable dentures, one then differentiates between those supported by the bone and those supported by the mucous membrane!

Click here to see the video: Implantation

This post is also available in: German

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