Dear friends, today’s topic of conversation, in fact, should be a prologue to all our publications devoted to bone tissue augmentation before implantation. We have already written about sinus lifting, guided bone regeneration, bone blocks and osteotomy, we talked about when and why this should be done, but we left out of the scope of publications perhaps the most interesting question:
Why does bone atrophy occur in the first place?
What is atrophy? What are its reasons? Why does it develop rapidly in some people, literally in a month or two:
and someone walks without teeth for years - and there is no loss of bone tissue?
Is it possible to predict the degree of bone tissue atrophy even before tooth extraction and is there a way to prevent it?
The answers to these questions are important, if only because without understanding the biological mechanisms of atrophy, it is impossible to determine the need for the same preventive augmentation of the socket of an extracted tooth, it is impossible to CORRECTLY choose the method of bone tissue augmentation for a specific clinical case and, most importantly, it is impossible to give a clear and long-term prognosis as a result of osteoplasty.
I will say even more - in many ways, almost all unsuccessful outcomes of bone tissue augmentation are explained, among other things, by a lack of understanding of the processes occurring in the jawbone after tooth extraction. That's why this knowledge is important.
So,
How to understand that tissue atrophy is occurring?
- the patient’s face “sinks,” the skin in the jaw area sags, nasolabial wrinkles become more pronounced;
- the gum contour recedes;
- displacement of dental units occurs;
- neighboring crowns become more mobile.
In dental practice, there are four main types of bone atrophy: minor, moderate, pronounced, and severe atrophy of bone tissue. So, with minor atrophy, implantologists can still introduce a titanium root into the jaw without restoring the bone, but with a rough form, they cannot do without restoring the volume.
What in practice?
Knowledge of the principles and patterns of the atrophic process, on the one hand, breaks the pattern and our understanding of osteoplasty, but on the other hand, it provides a very reliable prognostic tool. Using it, you can not only predict the dynamics of changes in bone tissue volumes after removal and implantation, but also clearly explain how different methods of bone tissue augmentation work in different clinical conditions.
What do we know about the patient?
The biotype of bone tissue is something that we can determine from a computed tomogram even before tooth extraction.
How to use it?
Knowing the relationship between the biotype and atrophy, it is possible to more or less reliably determine the indications, for example, for preventive preservation of the socket, including immediate implantation.
And, in theory, such a clear analysis and prognosis of atrophy in relation to a specific clinical case should replace the well-established principle in modern implantology “Everyone does it!” or “That’s how we were taught!”
In addition, we can predict the degree of atrophy and determine whether bone augmentation will be required during delayed implantation even before the teeth are extracted.
and, if necessary, what is the best method to do this?
Or, for example, can we explain why in some cases the transplanted bone block goes away, but in others it does not?
The main causes of bone tissue atrophy in a patient
- missing one or more teeth;
- wearing prosthetic systems that apply pressure;
- jaw deformation;
- cystic formations on the roots - pathological cyst cells grow and gradually replace tissue;
- anatomical feature of the jaw structure;
- elderly age;
- diseases (diabetes mellitus, osteoporosis, gum disease, inflammatory processes in the oral cavity);
- incorrect prosthetics or implantation.
When chewing food, pressure is applied to the bone, and it, one way or another, dissolves. If the pressure itself cannot be excluded, then there is always the possibility of returning the lost bone with the subsequent installation of a dental prosthesis or bridge.
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What happens if bone tissue atrophy is not stopped?
The quality of life, appearance, and feelings of a person are more influenced not by the resorption itself, but by the causes of the problem. For example, if the bone in the jaw dissolves due to the absence of one or more teeth, the process of chewing food is disrupted, an imperfect food bolus is formed, resulting in problems in the functioning of the gastrointestinal tract. Diction is also impaired, facial asymmetry occurs, and psychological discomfort develops due to the lack of teeth. The teeth begin to shift in the direction where one or a group of teeth is missing.
It is important!
The longer the jaw is missing teeth, the more volume of jawbone is lost, and the more of it will need to be built up in the future during implantation. Timely replacement of a lost tooth with an implant that serves as a support for the prosthesis will prevent atrophy and will also help save your budget (you will not need to perform an expensive operation to restore the bone).
Common methods of osteoplastic surgery
As we have already found out, there will be a need to build up bone only in cases where the patient is indicated for a two-stage implantation technique, that is, you are missing one or more teeth that were lost more than a year ago. In all other cases, approaches are applicable that allow one to abandon procedures that are so traumatic and require long-term rehabilitation.
So, if before implantation you were informed about the need to build up the bone due to atrophy, then the options may be as follows.
Sinus lift
Suitable only when it is necessary to restore the teeth of the upper jaw. Doctors distinguish open sinus lifting in dentistry and closed one. What it is? These are procedures that involve changing the height of the jaw bone, so as not to subsequently injure the maxillary sinuses and have the necessary volume of tissue for reliable fixation of the implant.
The photo shows a diagram of the sinus lift operation
What is a closed sinus lift in dentistry? A closed procedure is performed if it is necessary to increase a small amount of tissue. In some clinical cases, it allows the simultaneous installation of an implant, which 4-6 months after surgery (after complete engraftment) can be loaded with a fixed prosthesis.
Open surgery is required if the bone has lost significant height. The operation is quite traumatic, so it is impossible to install an implant at the same time. First you will have to undergo rehabilitation, which will take up to 6-8 months. And only after this, if there are no complications, you can begin installing artificial roots.
The photo shows a diagram of an open sinus lift
Autotransplantation
Expensive and traumatic procedure. It involves not one, but several surgical interventions at once. First, donor material is taken from the patient himself (for example, from the chin area), which is then planted in the place where atrophy is present. Why so many complex manipulations? It is believed that one’s own material takes root better and faster and is not rejected by the body. However, after the procedure there will be a long rehabilitation period, and it will be possible to begin installing implants only after complete engraftment of the tissues.
In this operation, the patient's own tissue is transplanted
Guided bone regeneration
The best option among those presented, as it is less traumatic and allows for the simultaneous installation of implants. The operation uses artificial bone chips and synthetic materials, as well as self-absorbing membranes that do not cause allergic reactions.
Artificial bone chips are used for the operation.
How to solve the problem of bone tissue atrophy?
- Perform a sinus lift - a procedure for increasing bone in the upper jaw. In this case, the maxillary sinus may rise or shift to free up jaw space for new bone.
- Bone grafting is an operation in which the lack of bone is filled with artificial synthetic materials. The operation is often associated with the risk of rejection of the artificial material.
- Bone grafting is a technique of transplanting your own bone blocks from one area of the jaw to another. As a rule, bone material is taken from the area of the “eights” (wisdom teeth) and placed in place of the bone deficiency. Due to the natural nature of the material, the risk of rejection is low.
To prevent jawbone atrophy, it is important to provide comprehensive prevention. So, if a tooth falls out or is removed, replace it in a timely manner with a new titanium root, which serves as a support for the crown.
Also, for a patient whose tooth has been extracted, a special membrane is placed in place of the gap to prevent atrophy. If necessary, a small amount of tissue is added to the internal compartment to replenish the lost volume and ensure the stability of the implant being introduced.
Atrophy is...
According to medical textbooks, atrophy means a lifetime decrease in the volume of cells, tissues and organs , accompanied by a decrease or cessation of their functions. In relation to dentistry and implantology, we can define atrophy as a change in the linear dimensions and volume of the alveolar ridge after the removal of a tooth or teeth.
Atrophy can be reversible or irreversible.
Reversible atrophy is usually caused by the cessation of functioning of an organ or tissue. So, if you do not use your hand for a long time (for example, after a fracture), the muscles of the hand will atrophy.
However, once the function returns, they quickly return to normal.
Irreversible atrophy has a number of causes, of which dysfunction is just one of them. Thus, atrophy of the heart muscle is accompanied by its sclerosis, the replacement of the muscle fibers themselves with connective tissue. The result is chronic heart failure, for which only symptomatic treatment exists so far.
The reversibility of brain atrophy in some people remains controversial.
, atrophy of the alveolar ridge after tooth extraction is classified as dysfunctional, i.e., associated with cessation of function. It would seem a very simple mechanism - “no teeth, no load on bone tissue - presto, atrophy!”
But, in reality, not everything is so simple.
First, dysfunctional atrophy is usually reversible (see muscle example).
Secondly, and this is the question that concerns me first, why do different people have different rates and levels of bone loss?
Why do some patients develop atrophic pesdets within a few weeks after tooth extraction, while others live without teeth for many years, maintaining almost the original volume of bone tissue? Where does this injustice come from?
And so, in order to understand this issue, we need to remember what bone tissue is in general.
Why doesn’t prosthetics solve the problem of bone tissue atrophy?
Installing a removable denture or “bridge” does not solve the issue of missing bone, since the load in this case is on the gum tissue and on the remaining healthy teeth. Consequently, the resorption process is not stopped, the gums begin to “sag” along with the bone, the fixation of the prosthesis is disrupted, and a gap is formed under it. Food debris accumulates in this gap, which can lead to inflammation. Unlike conventional prosthetics, dental implantation allows you to compensate for the deficiency of bone tissue, and most importantly, restores the integrity of the dentition.
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.
Implantation options for bone atrophy
- Dental implantation with delayed loading is a technique in which bone material is first restored, and only then an artificial implant is introduced - a support for the subsequent prosthetic structure.
- Dental implantation with immediate loading is a procedure in which the implant is screwed into the basal (deep) parts of the jawbone, and not into the alveolar zone, as with classic implantation with build-up. In this case, the bone is instantly “loaded”, all living cell processes are preserved in it, and healing is accelerated.
What are the obvious advantages of immediate loading implantation?
- no need for bone tissue augmentation. The volume of basal type implants is selected individually. They can be installed at an angle for reliable fixation, regardless of the size of the affected area;
- thanks to an individual approach, the master can select a design according to all parameters. It is also important that with this method the doctor can correctly calculate the interimplant pressure so that they take root as quickly as possible;
- bone tissue actively restores its original appearance - since the chewing load is immediate, this method quickly restores blood circulation, increasing the intensity of regenerative processes;
- guarantee of a positive outcome - due to the instant restoration of bone tissue, implants take root in the shortest possible time. The result will delight the patient with aesthetics, practicality and high functionality just a few months after the procedure;
- high degree of resistance to infections;
- has virtually no contraindications.
How much does surgery to restore bone atrophy cost?
The average price of bone grafting in Moscow is from 20,000 rubles. The cost of a sinus lift ranges from 22 thousand to 80 thousand rubles, respectively.
This amount includes expenses for:
- osteoplastic materials;
- bone membrane;
- anesthesia;
- X-ray images;
- the work of a surgeon, etc.
Dentistry "32 Dent" specializes in performing bone grafting operations to solve the problem of bone tissue resorption in patients and the restoration of living cells. Also, specialists will restore the dentition by performing subsequent prosthetics.
If you have a problem similar to that described in this article, be sure to contact our specialists. Don't diagnose yourself!
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Sources:
- Personal experience as an orthopedic dentist;
- Yamurkova, N. F. Optimization of surgical treatment for severe atrophy of the alveolar process of the upper jaw and the alveolar part of the lower jaw before dental implantation: abstract. dis. ...Dr. medical sciences: 01/14/14 / Yamurkova Nina Fedorovna. — Nizhny Novgorod, 2015;
- Durnovo, E.A. Method of preserving alveolar tissue in the aesthetically significant zone / E.A. Durnovo, A.V. Kazakov, S.E. Sakharova, N.A. Yanova // Russian Bulletin of Dental Implantology. – 2013;
- Amkhadova, M.A. Surgical tactics when using the implantation method in patients with dentition defects and significant jaw atrophy: dis. ...Dr. med. Sciences: 14.00.21 / Amkhadova Malkan Abdrashidovna. – M., 2005;
- Artyushkevich, A.S. Periodontal diseases: a practical guide / A.S. Artyushkevich. – M.: Med. lit., 2006;
- Bedretdinov, R. M. Clinical and morphological assessment of various osteoplastic operations before dental implantation (experimental clinical study): abstract. dis. Ph.D. medical sciences: 01/14/14 / Bedretdinov Rinat Mansurovich. – M., 2016;
- Belchenko, V.A. Craniofacial surgery: a guide for doctors / V.A. Belchenko. – M.: Medical Information Agency., 2006;
- Andersson, L. Oral and Maxillofacial surgery / L. Andersson, K. Kahnberg, M. Pogrel. – WILEY-BLACKWELL Publishing Ltd. – 2010;
- Alfaro, F.H. Bone grafting in Oral Implantology. Techniques and Clinical Applications / FH Alfaro. – Quintessence Publishing Co. Ltd. – 2006.
