Direct answer
Yes — even when bone loss is marked. There are surgical techniques that allow rehabilitation with dental implants in these situations. Having little bone in the area where the teeth are missing does not, in itself, mean that implants cannot be placed.
To understand the options, it is important to distinguish two situations:
When it is necessary to rehabilitate a full arch, it may be possible to make use of the existing bone and to draw on anchorage techniques in bone regions that offer support for the rehabilitation, avoiding the need for a prior bone graft. The stability obtained with these techniques allows, in most cases, for immediate loading, with a provisional fixed prosthesis placed on the same day as the surgery.
When it is necessary to replace a tooth or a small group of teeth, short implants may be an option where bone height is reduced, making it possible to avoid a bone graft. Bone regeneration nevertheless remains an alternative to be assessed, particularly when width is also lacking or when the position required for the rehabilitation demands it.
The choice depends on the amount and the location of the bone available, on the type of rehabilitation and on each person's clinical conditions.
The bone that surrounds and supports the roots of the teeth is called alveolar bone. After a tooth is lost, that region undergoes a process of remodelling, with a variable reduction in width and in height. These changes are usually most marked in the first months after the extraction.
A systematic review with meta-analysis quantified that reduction at non-molar sites: on average 2.73 mm of horizontal loss and 1.71 mm of vertical loss on the buccal aspect, after spontaneous healing of the socket. At molar sites, the mean horizontal loss was 3.61 mm [1].
Bone loss may also begin before the tooth is lost, in particular when there is periodontal disease, which affects the tissues responsible for supporting it.
For this reason, two people with the same number of missing teeth may present very different situations.
When I assess a case of this kind, I seek to understand where bone is missing, what bone remains available and how it can be used to support the intended rehabilitation.
In a full rehabilitation, several implants are distributed so that together they support a fixed prosthesis. That planning makes it possible to draw on different regions of bone support.
In the upper jaw with marked bone loss, techniques may be considered that avoid a prior bone reconstruction, in particular avoiding a maxillary sinus lift. Depending on the anatomy, these approaches may be combined with each other and with conventional implants.
The choice also calls for attention to the position of the future teeth, to lip support, to speech and to access for hygiene. Finding bone support is one part of the planning; the other is ensuring that this support allows a smile appropriate to the patient to be built.
Before turning to bone regions outside the maxilla, it is frequently possible to make better use of the bone that is still there. Implants placed at an angle can be supported by two bone cortices and pass around the maxillary sinus, obtaining high stability and avoiding a sinus lift.
It is the least invasive of the approaches that follow, and therefore the first to consider when the anatomy allows.
Zygomatic implants gain support in the zygomatic bone, a bony structure situated above the maxilla, which does not depend on the teeth and does not undergo the resorption associated with their loss. They may be considered when bone loss in the upper jaw limits the placement of conventional implants.
It is the technique with the largest body of accumulated evidence in this area. The consensus report of the ITI — International Team for Implantology — reports a mean long-term survival of 96.2% (95% CI: 93.8–97.7), with a mean follow-up of 75.4 months, that is more than six years, and cases followed for up to 11.8 years [2].
Its indication requires a three-dimensional assessment of the maxillary and zygomatic region, including the maxillary sinuses, and specific experience in the surgical and prosthetic planning of these rehabilitations [2].
Transnasal implants use anchorage paths related to the bony structures that bound the nasal cavity. They may form part of the rehabilitation of certain situations of atrophy of the upper jaw.
Their use depends on the anatomy available and on the planning of the prosthesis, and they may complement other forms of anchorage [3].
This is a surgical approach that allows the implants to be placed in the maxillary bone, anchoring them in the bony structure of the palate, through an adapted position and inclination.
It is indicated in highly atrophic maxillae and is an advanced surgical technique. It makes it possible to obtain a high degree of stability where little bone remains, by drawing on the bone available in the palate.
A systematic review brought together 549 implants placed with a palatal approach and reported an effectiveness of 98.4%, with no statistically significant difference compared with implants placed in the alveolar crest; the authors note that few studies on the technique have been published [8].
This approach calls for particular attention to the emergence position of the implants and to the design of the prosthesis, in order to allow comfort, function and adequate access for hygiene.
Pterygoid implants gain anchorage in a deep region at the back of the upper jaw, involving the pterygomaxillary region.
They can provide posterior support where little bone is available, making it possible to avoid bone augmentation procedures in selected cases. A systematic review with meta-analysis that brought together 1,893 pterygoid implants in 634 patients reported a mean survival of 94.9%, while stressing that the studies included were retrospective and of limited level of evidence [4]. Their placement requires specific knowledge of the anatomy of this region.
Where bone loss is very marked, custom subperiosteal implants may be an alternative when other implant placement or bone reconstruction techniques are not viable or appropriate.
From three-dimensional imaging, a titanium framework is designed and manufactured to fit the patient's anatomy and the intended rehabilitation. That framework rests on and is fixed to the bone, and allows the dental prosthesis to be connected to it.
The concept of the subperiosteal implant has existed for several decades. The more recent development lies in the use of digital planning and three-dimensional manufacturing techniques, which make it possible to produce individualised frameworks from each patient's anatomy.
This approach may be considered both in the upper jaw and in the mandible. Its indication requires careful assessment of the alternatives, of the condition of the tissues and of the follow-up care required [5].
In full-arch rehabilitations on implants, yes — and that is the aim of treatment.
In atrophic jaws, the aim of treatment with the techniques described above is precisely to carry out immediate loading: the placement of a provisional fixed prosthesis — fixed teeth — on the same day as the surgery.
The concept of immediate loading rests on the possibility of anchoring the implants in dense bony structures. That is what happens with palatal anchorage, with the zygomatic, pterygoid and transnasal approaches, and with the use of angled implants. All of them make it possible to obtain high initial stability — and it is that stability that makes it possible to put the prosthesis into function immediately.
The data support this option. The ITI consensus found that, in rehabilitations with zygomatic implants, immediate loading showed a statistically higher survival than delayed loading [2]. Waiting is not, in these cases, the safer alternative.
In my practice, in full-arch rehabilitations on implants, immediate loading is the norm.
Correct planning of these cases is what gives us predictability: it makes it possible to obtain the initial stability needed to place the provisional prosthesis on the same day. That prosthesis restores appearance and function during the initial phase of implant integration, and is replaced by the definitive prosthesis after healing and the integration of the implants and the tissues.
In these situations, the planning centres on the bone available in the area to be rehabilitated and on the position needed to obtain an appropriate functional and aesthetic result.
Among the options to consider are short implants and bone regeneration.
Where there is little bone height but the remaining conditions are favourable, short implants may make it possible to replace teeth without resorting to a bone graft.
This alternative has application in selected situations, particularly in the posterior regions. The indication also depends on the bone width available and on the demands of the rehabilitation.
A systematic review with meta-analysis of thirteen randomised controlled trials found fewer postoperative complications and less marginal bone loss with short implants, compared with conventional-length implants combined with bone augmentation, with no statistically significant difference in implant failure at 1, 3 and 5 to 10 years [6]. These results support their use in selected cases, without making them a universal solution.
Bone regeneration makes it possible to augment or reconstruct the volume of bone in the region to be rehabilitated.
It may be necessary when the existing bone does not allow the implant to be placed in the appropriate position, or when it is important to reconstruct the contour of the tissues in order to obtain the intended result.
There is a specific reason not to dispense with it as a matter of course. The ITI consensus on bone dimensions concluded that, at sites where the buccal bone wall is left with less than 1.5 mm after implant placement, greater vertical bone loss and less favourable clinical and radiographic outcomes are seen; and that defects treated with simultaneous bone regeneration showed less vertical bone loss than untreated ones [7].
Although it is addressed here in the context of individual teeth or small groups of teeth, bone regeneration can also form part of more extensive rehabilitations.
Yes, in certain situations. When it is possible to place the implant in the correct position and to obtain sufficient stability in the existing bone, bone regeneration can be carried out in the same procedure [7].
When the bone defect does not allow those conditions to be met, it may be necessary to carry out the reconstruction first and to place the implant after healing.
The decision depends on the shape and the size of the defect, on the bone available and on the regeneration technique used.
Placing the implant on the same day as the graft does not necessarily mean also placing fixed teeth that day. When to put the prosthesis into function is a further decision, which depends on the conditions of stability and healing.
I begin with the clinical assessment, the health history and an understanding of the patient's expectations.
The assessment considers the teeth present, the gums, the way the teeth contact one another, the aesthetic needs and the conditions for maintaining hygiene of the future rehabilitation.
In situations of complex bone loss, the three-dimensional study, usually by cone beam computed tomography — CBCT —, allows the bone volume and its relationship with important anatomical structures to be analysed. The panoramic radiograph can provide initial information, but it does not offer the same three-dimensional assessment [2].
From that information, I explain the options I consider appropriate, their benefits, limitations, risks and treatment times.
The aim is to propose a rehabilitation that makes sense for the clinical situation and for the person's needs.
If you already have information indicating that there is insufficient bone, you should be assessed by a dentist with experience in the rehabilitation of atrophic jaws.
I see patients in two distinct circumstances. Some come to us on their own initiative, frequently after learning of cases similar to their own. Others arrive referred by colleagues, who send us cases of severe bone atrophy for management.
Both routes are welcome. In the second case, we liaise with the treating dentist throughout the process and, once the surgery and the rehabilitation are complete, the patient resumes their usual care with them — that being, naturally, their wish.
The next step is to book an assessment consultation — with us or with another professional experienced in the rehabilitation of atrophic jaws.
Bring any previous imaging and reports, if you have them: they allow us to understand what has already been studied and to assess the need for further information. If you do not have any imaging, that is not an obstacle — the clinic has its own radiology equipment, including CBCT and panoramic radiography, so the necessary imaging is carried out on site, at the same assessment consultation.
My commitment is to explain what is possible, what is recommended and what may last longer for the patient.
References
Bring any imaging you have. During the consultation we assess the need for further imaging and explain the treatment options.
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