Procedures and possibilities

Categories of implant interventions according to time horizon

A patient can make an appointment with a dental implantologist at anytime. However, the procedure cannot be always performed immediately after the indication of the implant treatment. Several examinations and other preoperative interventions usually precede the actual treatment. Thus, it is not possible to generalize the period when it is possible to perform the implant treatment.

A. Standard implant treatment to healed bone

This type of implant treatment is performed to bone which has been already healed. The period from tooth extraction or removal to the time when the bone is considered to be fully healed is usually 12 to 15 months. In majority of cases, these implant patients have been missing a tooth for a longer period of time because they did not plan any implant treatment when they lost their original tooth. However, this arrangement is not ideal. For patients, it is much better and advisable to plan tooth extraction and its replacement at the same time . In some patients it is even possible to replace the extracted tooth with a dental implant immediately. A planned treatment procedure allows much better results since tooth extraction prevents bone damage caused by inflammation from affected teeth. At the same time, this procedure prevents bone atrophy (decreasing bone volume) which is a natural consequence after tooth loss.

B.Implant treatment immediately after extraction

Current advances in implant dentistry enable to perform implant treatment immediately after tooth removal. The only precondition is a suitable anatomic structure of bone and soft tissues in the patient. This implant method has several advantages:

a. all surgical interventions are performed in one day (extraction – bone replacement if needed – implant placement – fixing of a tooth crown)
b. original structure of naturally shaped gum tissue is preserved (the same aesthetic transition is preserved between the new crown and the gum tissue like in patients‘ own teeth)

c. the patient does not have a toothless period (aesthetic as well as functional aspect of teeth is preserved). This applies in case the reconstruction of crown is performed immediately after implant treatment.

C. Delayed post extraction implant placement

This procedure is used mainly in cases when it is inevitable for the post extraction wound to partially heal before the implant treatment; or when it is necessary to wait until the inflamated tissue left after the affected tooth heals. The time for the partial healing is shorter than the period needed for a full healing of bone or gum tissue. These cases are approached highly individually and the implantologist must be flexible enough to adapt to actual conditions in the area of the planned implant treatment.

D. Strategic extraction

This term denotes a very responsible and overall assessment how to treat and reconstruct teeth in implant dentistry. The prerequisite is the ability and readiness of the doctor to evaluate and give overall perspective with regard to ongoing pathologic conditions on teeth and their periodontium. The goal is to maximize options for immediate post extraction implant treatment with immediate reconstructions. This approach is very responsible and enables to prevent further unnecessary bone and gum tissue destructions in patients. It also allows implantologists to use all preserved tissues – bones and gum for the benefit of the patient‘s health.

Categories of implant interventions according to their functionality

Interventions differ mainly in the number of implants and the function of a particular implant.

A. Placement of single implant

Single implants are placed when a patient is missing only one tooth or its extraction has been planned. After a detailed examination and planning the standard implant intervention in the place of the affected tooth or immediate post extraction implant treatment is performed provided the tooth, which is being planned to be replaced, is still in the bone. If the anatomy allows it and sufficient primary stability of the implant is achieved, immediate prosthetic reconstruction with a temporary crown can be considered. A permanent metal ceramic (rarely all-ceramic) crown is produced and applied after the healing of surrounding tissues. The application is usually performed 6 – 10 weeks after the implant intervention.

B. Placement of several implants

This procedure is applied when a patient is missing more teeth or several teeth are being planned to be extracted. After a detailed examination, the exactly indicated number of implants is placed in the planned areas on the day of the surgery. In those patients who have suitable anatomic conditions after the planned teeth extraction, immediate post extraction implant intervention can be performed. It is always decided before the implant intervention if immediate reconstruction with a temporary prosthetic denture is performed and the patient is informed about and agrees to the procedure in adavnce.

C. Placement of implants in toothless mandible or jawbone with the aim of its full reconstruction

Even if a patient has lost all teeth in mandible or jawbone due to periodontitis or another tooth disease, it is possible to perform full reconstruction of teeth with implants. The number of used implants depends on the condition of the bone, the mutual relationship of mandible and jawbone, anatomy, as well as on the functionality of chewing and muscle apparatus of each patient. The planned number of implants is placed in the patient’s bone on the day of the surgery.

D. Placement of implants during planned extraction of all teeth in mandible or jawbone

(This method is used in generally untreatable severe periodontitis or in teeth impossible to reconstruct with other methods available.)

After teeth extraction, a temporary fixed denture is produced immediately; if the primary stability of a certain number of minimally needed implants is achieved. In case it is not possible to use this technique for unsuitable anatomic conditions (severe destruction of bone caused by inflammatory processes around teeth), the patient will be given a fully removable denture.

After the period of healing, a metal resin, metal ceramic or full-ceramic fixed conditionally removable bridge is produced. The new bridge will be fully functional and will substitute the patient’s own set of teeth in an aesthetic way to his/her full satisfaction. Last but not least, the bridge has many further advantages; e. g. perfect functionality and long term reliability.

E. Brånemark bridge

The Brånemark bridge is a special implant prosthetic solution named after the ‘father’of implantology, Swedish professor Per Ingvar Brånemark . The bridge is a unique modality used only in mandible. An implantologist places five implants in the anterior area of mandible and immediately after the intervention a prosthodontist takes imprints for a temporary fixed screwed conditionally removable denture. This denture is made and placed to the patient’s mouth on the day of the intervention, or within 48 hours at the latest. When the gum is healed after the intervention, the production and application of the fixed screwed conditionally removable denture is performed. This denture can be unscrewed at anytime and without any stress for the patient in order to perform necessary procedures. The denture is then screwed back to the healed implants.

The uniqueness of the Brånemark bridge is mainly in its ability to fully functionally and aesthetically replace all teeth due to its special construction despite the fact that only the anterior region of the madible in the area between the first premolar teeth is used for the placement of implants. This therapeutic modality certainly belongs to the most effective and least stressful full recosntruction solutions for the patient. In this solution, the ratio of the costs and the performance (functionality and aesthetics) is indisputably the best.

Approximately 80 per cent of people who do not mind (in terms of functionality) wearing the upper fully removable denture, get used to it and utilize it very well. The use of such denture in mandible is worse due to specific anatomic conditions. Most people who have a fully removable denture in mandible either cannot get used to it or it serves them only in a very limited way. Since a reconstruction of all teeth in jawbone is much more complicated for the patient and thus also more expensive, the combination of the upper fully removable denture and the Brånemark bridge in mandible is the complex solution for the majority of patients who are completely toothless.

F. Placement of implants to support stability of denture

A common removable denture can be worn with the support of implants which ensure its better fixation. The denture is attached to individual implants with a special system of attachments placed on the upper part of the implants. The number of necessary implants depends on the condition of the jaw or mandible bone of the patient. The advantage of this implant intervention is that the modification of the existing denture often can be performed as well. Implants are placed on the day of the surgery and the patient can temporarily wear the modified removable denture. After the healing of the implants, individually designed attachments are placed on the upper parts of the implants and the denture is fixed to them. This intervention ensures the patient a better comfort mainly in terms of fixation since the removable denture will not slide anymore.

This intervention however, is not as ideal as it might seem. It requires more demanding maintenance and thus various problems and complications can occur in its application. The denture usually needs to be repeatedly modified and the housing linerin the attachments must be replaced. This can generate additional costs. Hence, experienced dental implantologists prefer fixed solutions on the implants.

Categories of implant interventions according to possibility of functional loading of implant

A. Immediate reconstruction of crown on implant without functional loading (immediate provisionalisation)

It is performed immediately or no later than 48 hours after the implant intervention. Its aim is to shorten the toothless period in patients. When placing a temporary crown, the modeling of the healing gum is achieved at the same time. Thus the gum tissue has better stability before the placement of a permanent crown and its aesthetic aspect is also much more favourable. The procedure of immediate provisionalisation is used mostly in those cases when implant interventions are performed in visible areas of teeth.

B. Immediate functional loading of implants with fixed temporary conditionally removable prosthetic denture

This method is considered very progressive in implant prosthodontics and very important from the therapeutic point of view as well. Its success lies in the fact that in a concrete number of implants (after achieving sufficient post implantation primary stability of the implants) it is possible to mutually splint them with a temporary fixed screwed prosthetic denture and thus enable the patient to use the functions of the replaced teeth immediately after the intervention. This treatment has several advantages:

  • better healing of implants in bone (the bone of alveolar process functions physiologically much better if it fulfils its function) 
  • minimal number of surgical interventions 
  • no toothless period for patient 
  • better post operative healing (almost all of the operation wound is covered by immobile temporary fixed prosthetic denture)

This intervention however, should be performed only by specialists with adequate experience. If performed by less experienced dental implantologists, serious failure of implants can occur in patients.

Alternative procedures of implant interventions

A. Flapless implant treatment

It is a special placement of implants. Neither gum tissue nor periosteum underneath is flapped back. A perfect circle of mucous membrane is cut out with special circular knives (tissue punches), subsequently a perfect opening is pre-drilled in the bone and an implant is placed. This method has however, several disadvantages; e. g. it is not possible to doublecheck the procedure by sight, possible heavy bleeding can occur, some important anatomic structures in oral cavity can be damaged, and bone augmentation cannot be performed during this intervention.

On the other hand the flapless implant procedure can often be used in immediate post extraction implant intervention. In this case a dental implant is placed in tooth wound immediately after the removal of the affected tooth. This enables to fully preserve the contour of the original gum and it is also an excellent prerequisite for red and white aesthetics.

B. Joining root form dental implants with patient‘s own tooth

This alternative method should be approached by a dental implantologist very carefully. In fact, its use in practice is very rare since in this type of joint different mobility of a patient‘s own tooth and the implant occurs and this causes problems. As the patient‘s own tooth is attached in periodontium it has much bigger mobility than the implant which is fixed in the bone. This disproportion can cause enormous complications, e. g. implant or tooth failure can occur or the prosthetic denture can break.