The best thing about sharks' teeth ...

is that they always grow again. On their own, and in only eight days. that's why such a greedy ocean monster can easily gobble up things and risk a tooth. but, in humans, once a tooth is lost, it's gone forever.


For centuries, even the best of dentists couldn't help. They had ways and means of replacing the tooth crown but not the root. But times have changed. For about twenty years, dentists have been able to "get to the root" of gaps between the teeth by replacing the missing roots with tiny pins called "implants". Your dentist is bound to have explained the basics to you. when he gave you this FRIATEC Aktiengesellschaft booklet.

What is an implant?
Implants are tiny pins made of especially compatible pure titanium which are inserted into the bone of the jaw. The dentist can attach crowns, bridges or removable dentures to these artificial roots. In approximately three to six months, the bone grows tightly around the surface of the implant and grips it firmly in the jaw.


The following are critical when selecting the implant .

  The amount of bone available,

the firmness of the bone, and


the time at which the implant is inserted.



The amount of bone available
The dentist checks that adequate bone is available for inserting the implant. If too little bone is available for an implant, in many cases it can be built up surgically.

The firmness of the bone
The dentist decides on a threaded or non-threaded implant depending on how firm the bone is.



The time at which the implant is inserted.
The implants can either be inserted immediately after the tooth is lost (immediate implant placement) or a long time after wards delayed implant placement). Implants shaped like the roots of natural teeth are used for immediate implant placement. In general, the sooner the implant is inserted the better. Once a tooth is missing, no chewing forces are excerted on this area and the jaw bone recedes. Immediate implant placement prevents this. Should delayed implant placement be the only treatment possible, smaller, cylindrical implants are used as less bone is usually available.


Shows a cylindrical implant,

a stepped threaded implant

and an apical threaded implant

(IMZ TwinPlus)

Shows a stepped threaded implant

and stepped cylindrical implants  (FRIALIT-2)


FRIATEC implants
       As teeth and jaws vary from person to person, implants and abutments have to meet various requirements. The FRIATEC Supply two different systems-
FRIALIT -2 and IMZ TwinPlus
       As FRIALIT -2 implants resemble natural tooth roots, they are used for immediate implant placement. Their dimensions are matched to the bone volume of the remaining jaw ridge. The abutments for this system are especially suitable for single crowns. They can also be used for retaining bridges and dentures.
       IMZ  TwinPlus implants are used in jaws which have been reduced in height and width because the teeth have been missing for a long time. The abutments in this system can be used for complex bridges and bars as well as for single crowns.

Who needs which type of implant?
Where can an implant be placed? Which implant system is suitable? Your dentist can only answer these questions after examining your mouth thoroughly. Among other things, he checks

  the volume and density of the jaw bone,  
the number, positions and firmness of the natural teeth,    
the condition of the gums,    
the condition and number of teeth in the opposite jaw.

In principle, there are four different indications for inserting implants:

A gap between the front teeth:

One single tooth is missing from between the teeth. The gap is bordered on both sides by natural teeth.


A wide gap between the teeth:

One or more teeth are missing from between the teeth. The gap is bordered on both sides by natural teeth.



One or more teeth are missing from the end of the row. The natural teeth only border one side.


All teeth are missing:

All teeth are missing from the top and / or bottom jaws.



A gap between the front teeth
More young than elderly people suffer from gaps between their front teeth. These single tooth gaps are often caused by accidents but may also be due to diseased teeth (caries) or gums (periodontitis). In some cases, the tooth simply never grew. If the gap is in a visible area of the top jaw, the overall appearance of the face is disturbed considerably. Not only the aesthetics, but also the health of the teeth suffer. If a single tooth gap remains untreated for a longer period of time, the adjacent teeth grow into it. The upper and lower teeth are displaced and no longer interlock as accurately as they should. Chewing is adversely affected and, in the long term, the joints of the lower jaw may become painful.

              Conventional techniques involve the dentist closing the gap with a three unit bridge supported by the two adjacent teeth. These two teeth have to be trimmed and healthy tooth structure is sacrificed.

         Alternatively, an adhesive bridge can be fitted. J:.s its name implies, it is adhered into place. The adjacent teeth are not trimmed as extensively but the durability of the bridge is very limited.

         A drawback of bridge units is that as they only replace the crown and not the root, the chewing forces are no longer exerted on the underlying section of jaw. The bhne is not loaded and, in time, its volume is reduced. The width and height of the jaws are reduced. In time, the central unit of the bridge has to be extended toward the gums.
         In this case, an implant is a better alternative. As the teeth do not have to be trimmed, healthy tooth structure is preserved completely. In addition, the implant transfers the chewing forces into the jaw bone and its volume remains unchanged.

Shows a crown on an implant

A wide gap between the teeth
     In principle, a wide gap between the teeth has the same effects as a single tooth gap - beginning with the adverse aesthetics and ranging to the disturbed equilibrium of the chewing movements up to the pains in the jaw joints. As several teeth are missing, the complaints are more severe. Wide gaps also impede speech especially. If the dentist does not intervene, these unpleasant conditions will progress from year to year.

      How does the dentist close a wide gap? Conventional methods call for a multi-unit bridge. As with single tooth gaps, healthy adjacent teeth on both sides have to be trimmed to support the bridge. Another aspect has to be taken into account for wide gaps: As this type of bridge is longer than that required for single tooth gaps, sufficient adjacent teeth have to be available to support it. If this is not the case, a removable partial denture is . the only alternative.
     This type of dentures may cause problems. In certain cases, the patient may suffer choking, and in most cases, difficulties with speaking and chewing.
     Bridges or single implants are definitely easier and more pleasant in such cases. Bridges can be supported on implants and natural teeth. If single crowns are fitted, each implant receives its own crown.

Shows a gap filled with implants

         If teeth are lost with advancing age, this process usually begins with the back, "grinding" teeth. This results in a so-called "free-end" or shortened row of teeth. This type of gap is bordered toward the front with natural teeth. The powerful back teeth, with their large, bumpy chewing surfaces are designed for grinding food and preparing it for digesting. If one or more of these teeth are missing, not only the chewing movements are disturbed. The remaining teeth move slowly toward the free-end, which loosens the contacts between the teeth. The teeth in the upper and lower jaws are displaced (refer to "single tooth gaps"). In the long run, the joints of the lower jaw may cause problems.

       Free-ends are difficult to restore with conventional restorative methods. Natural teeth are only available on one side for supporting a bridge. A "classic" bridge needs supports on both sides. However, bridges or removable partial dentures can be used which are. supported on "palatal bars" (upper jaws) or lingual bars (lower jaws).

       Palatal bars pass over the roof of the mouth, lingual bars pass beneath the tongue and over the inside of the lower jaw. These types 'of denture could be felt as foreign bodies. They also impede speech and chewing.
       An implant, instead of the tooth missing from the end of the row, may be inserted to ad as the second bridge support. This type of bridge is supported on one end by a natural tooth and on the other end by an implant. This type of bridge is a fixed restoration which really feels like natural teeth. Instead of being supported on an implant and natural tooth, a bridge can also be supported on implants only. A so-called tooth-for-tooth restoration is also excellent for closing free-ends. Every missing tooth is replaced with an implant and single crown.

All teeths are missing
        Upper and / or lower jaws with no teeth lead to considerable problems. Chewing and speaking are impeded considerably. as the face is no longer supported by the teeth, it goes limp and locks "old". in severe cases, the patients withdraw more and more.

      The only conventional type of treatment for this condition is a removable full denture. This type of denture is relatively easy to stabilize on the upper jaw because a large palate can be included which sucks the denture in to place. despite this, patients often consider the denture a foreign body: It impedes chewing and specking and may cause chocking.
       It is much more difficult to fit a stable full denture to the lower jaw. The denture is held in place by its arched base which fits over the ridge of the jaw. The volume of the jaw ridge decreases with age and the denture slowly loses its grip.

         The dentist has to reline it, which flattens the curvature of the denture base and reduces the retention. If the denture has to be relined several times, it will become loose and chewing / specking will be more and more difficult.
         The dentist can use implants to stabilize full dentures. For example, a bar can be constructed which is supported on two or four implants and retains the denture securely. Even a fixed restoration can be fitted - this method has been in use successfully for decades for lower jaws. It involves fixing a bridge to six or eight implants inserted around the entire lower jaw.

Requirements for inserting an implant
       Until a few years ago, the volume of the bone was one of the most important criteria for inserting implants. Nowadays, the dentist can operate and "build up" the bone to enable implants to be inserted. However, certain illnesses or anomalies may rule out or restrict implant placement.
For example:


Blood coagulation disturbances

Metabolic diseases (e. g. uncontrolled diabetes)
Changes in the mucous membranes and jaw bone due to diseases.
Diseases which require certain medicines to be taken for many years (e. g. cortisone preparations or chemotherapeutical measures)
Narrow gaps between the teeth, unfavorable position of the upper and lower jaws.

        Your age is usually not particularly relevant. However, adolescents should not be fitted with implants until they have finished growing .completely.

        A doctor can diagnose whether growth has been concluded.

        The patient should also be informed in advance that implants require particularly conscientious and thorough oral hygiene. Also important: smokers must do without cigarettes for the first few months after implant placement. Otherwise, the implant healing process will be endangered.

  Treatment plan:
Implant treatment includes several -stages:

  Initial examination and, possibly, early treatment

  Implant placement
  Wound healing
  Removing the stitches
  Healing period for the implants
  Exposing the implants
  Possible fabrication of the final restoration; possible fabrication of a temporary restoration
  Fitting the restoration
  Regular recall

Pre -operative examination and treatment
Your dentist checks your general medical condition - usually using a questionnaire -, asks about previous or acute diseases and weather / which medication you take. If in doubt, he will contact your family doctor.

           He examines your gums, teeth and jaw bones. X-rays and models of your jaws are required for this thorough evaluation. Depending on the result of his examination, he starts with the first stages of the treatment, such as cleaning the teeth professionally, which involves removing all plaque and tartar, treating diseased mucous membranes or carious teeth. In certain cases, he may enlarge the volume of the bone.

 Implant placement
        The implant is usually inserted under local an anesthesia and sterile conditions. The dentist and assistant wearing operating gowns and you will be covered with sterile sheets.
          As soon as the injection takes effect, the dentist opens the gums above the jaw ridge. This area, called the implant site, is then carefully prepared for implant placement. The important is then removed from its sterile packaging and inserted in to the implant site. Cylindrical implants are carefully tapped into place, respectively, threaded implants screwed in. The implants are then sealed with screws which must be tightened. Finally, the gums are sutured into place again.

          After the surgery, a moist compression bandage is placed in position for you to bite on for at least half an hour. The dentist will often apply a splint, i.e. a kind of dressing, for the first few days after the operation. However, this is not required in many cases. As the anesthetic causes drowsiness, you should have someone accompany you home and not drive yourself.
        Healing takes place very quickly in the mouth. The area may swell during the first few days, which is slightly painful. External cooling helps the swelling subside faster or prevents it completely (refer to page 13). These complaints are usually over in two or three days. If they are not, tell your dentist during the first check-up two or three days after the operation. The stitches can be removed one or two weeks later.

After implant placement
Immediately after implant placement
Do not eat or drink hot drinks until the anesthesia has worn off completely.


During the first week .

  Avoid strenuous activities (stooping, lifting, hiking, sport, sauna etc.).  
  Do not drink real coffee, strong tea, milk products or alcohol during .the first two days.  
  Do not smoke.  
  Rinse your mouth with lukewarm water after every meal, but not on the day of the operation.

  Clean your teeth and gums regularly - treat the area around the implant site very carefully.  
  Do not use a water jet or electric toothbrush.  
  Cool the implant site with an ice-pack for one or two days after the operation. To do so, place a towel between your cheek and the ice-pack. Wait 20 minutes before using a new ice-pack.  
  If you have a full denture which covers the implant site, do not wear it for the first week.  
  The next four to six weeks  
Avoid very strenuous activities.
Clean your teeth, gums and implant following your dentist's instructions.
Do not smoke
Always wear your temporary restoration (Miniplast splint or denture), remove and clean it after every meal.
After more extensive operations (e. g. building up bone), do not wear your full denture for six weeks. After minor operations it can be trimmed and lined with soft material.
                  Healing can only take place undisturbed if the implant and bone are not displaced. Therefore, you must ensure that this area is not loaded during the "healing period". Under no circumstances should you touch the area repeatedly with your fingers or tongue. On average, the healing period lasts three to six months - if the bone has been built up surgically, it lasts six to nine months. The exact duration depends on your personal healing process. Ask your dentist!

Expose your implants
      Once the healing period has elapsed, the implants are exposed under local anaesthesia. The sealing screws are then removed from the implants. A special gum former is screwed in to ensure that the gum forms neatly and the membrance stitched around it tightly. You should also observe a few guide lines after this operation.

  2 - 3 days
Cool the implant area externally with cold compresses
Avoid hard food, tobacco and alcohol
Clean your teeth, gums and gum former carefully with a tooth brush. Rinse your mouth after every meal.
       Your dentist will remove the stitches after one or two weeks and start manufacturing your restoration.

The restoration
    The first procedure involves taking an impression of your teeth in the dental practice. The gum former is replaced with an impression post during this procedure. The dental technician uses this impression to cast a model of your jaw, which reproduces the anatomical conditions exactly, for fabricating the correct type of restoration. He produces crowns, bridges or dentures, depending on the dentist's instructions.

       If single crowns are to be fitted, the dentist screws medically pure titanium crown fittings into the implants. The visible crown, which is usually coated with porcelain, is either cemented to the crown fitting or screwed to it with a tiny screw. Your dentist can also provide you with a temporary restoration until your own restoration is ready.
       If bridgework is fitted to IMZ TwinPlus components, elastic buffers called intra mobile elements can be screwed in. They cushion the chewing forces exerted on the bridge. This safeguards the bone beneath the implant. These buffers are advisable during the first two years after delayed implant placement because, during this period, new bone forms around the implant which first has to adapt to the chewing forces

     The buffers can be replaced during the six monthly check-ups.

         Two types of restoration can be fitted to jaws where all the teeth are missing: removable full dentures and fixed bridges. Removable dentures are fixed in place by screwing bars, ball-head fittings or conical posts, called telescopic crowns, into the implants. Special retaining fittings in the denture connect with them to hold the denture in place. These connectors can also be released.
         Bridges, which span the entire jaw are screwed directly onto several implants. The result is a fixed restoration which makes the patient feel he has his own teeth. However, much more effort is required than for a full denture.


The be-all and end-all:

                      Perfect oral hygiene
          The most important aspect for ensuring that the implant lasts is that you cooperate! Perfect oral hygieneis essential for achieving long term success. It is much more important to clean implants thoroughly than natural teeth. The gums are connected smoothly than natural teeth to create a bacteria-proof seal for the jaw bone. After implant placement, this border is permeable and bacteria can penetrate it.
          Therefore, you must clean your crowns, bridges and dentures after every meal! This is the only method of preventing plaque, which infects the gums and jaw bone and endangers the implant.

The following are recommended for cleaning.

Interdental brushes
  Dental floss
  Cotton cleaning strips
  Water jets

Use a toothbrush to clean the surfaces of crowns, bridges and dentures. A normal toothbrush cannot reach the spaces between single crowns and bridge units. An inter dental brush is recommended for these areas. If the inter dental spaces are even too narrow for an inter dental brush, use dental floss - or cotton cleaning strips for bars.

Once you have loosened the deposits with a toothbrush and dental floss, they are easily rinsed off with a water jet. Please note that the use of a water jet alone is not sufficient.

It's good to know that everything you need for perfect oral hygiene isin the practical FRIATEC EasyClean hygiene set which FRIATEC assembled specifically for implant patients. This set is ideal for home use and traveling.

  It's not only important to know what to use, but also how to go about it. The correct brushing technique is essential for cleaning the teeth thoroughly. Ask in your dental practice. Your dentist and his staff will be pleased to show you how to use tooth brushes, dental floss and water jets properly. Please take their advice and help create the best conditions possible to ensure that your treatment is successful - long term!


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Paper published in JIDA (The official publication of the Indian Dental Association).

Published in September 2003, Mansoon series.
Loading in Dental Implantology - Factors to be considered
Dr. Samuel K. Ninan