An implant despite very little bone: one case from first consultation to final crown

This is an illustrative composite, assembled from typical courses of treatment — not the record of one identifiable patient. Every jaw has its own anatomy, its own history and its own healing, so the sequence below is a shape rather than a schedule, and outcomes differ from person to person. What it can do is show you where the decisions sit, what happens between the appointments, and when money is actually spent. That is the part no consent form covers.

The patient is in her mid-forties. Seven years ago an upper right first molar was removed after a root canal treatment (Wurzelbehandlung) failed, and at the time she left the gap alone — it did not show when she smiled, and the plan was to deal with it “next year”. She moved to Germany five years ago for work and lives near Düsseldorf.

By the time she came to the consultation, three things had accumulated:

• She had been chewing exclusively on the left for years, and the left side had begun to complain — a familiar pattern, and the reason many people finally act.
• The tooth above the gap had grown down into the empty space, so the bite no longer met cleanly.
• Food packed into the gap in front of the space, which had drifted slightly.

Nothing about this is dramatic. It is the ordinary consequence of a gap left long enough, and it is the profile in which grafting is most often needed — because seven years is more than enough time for the ridge to shrink from above while the sinus expands downwards from below.

The conversation first. What bothers her most (chewing, not appearance), what she had been through before (a failed root treatment, so a certain wariness), whether she smokes (no), her medication (none regular), whether she grinds her teeth (probably, said with a shrug — her partner had mentioned it).

The examination and the 3D scan. A clinical examination, then a 3D X-ray (DVT). This is where the case turned from a question into a plan. The DVT showed the width of the ridge to be adequate, but the height between the crest of the ridge and the floor of the maxillary sinus (Kieferhöhle) reduced to a fraction of what a standard implant would need. In our practice the first consultation is free and a DVT costs 178 €.

What she was shown. The scan on screen, rotated, with the sinus floor visible above the site. This matters more than it sounds. “You need a bone graft” is an assertion; the same sentence with the image on the monitor is an explanation, and it is the difference between agreeing to treatment and understanding it.

Four routes were discussed, which is three more than most patients expect.

Leave it as it is. A legitimate choice. The consequences were named honestly: the drifting and over-eruption already under way would continue, and any later treatment would become more complex. No pressure attached — it remains her decision.

A bridge (Brücke). Technically possible, and it would have avoided surgery entirely. The cost was that the two neighbouring teeth — both intact, one entirely untouched — would have had to be ground down to carry it. In her case that argued against it. In someone whose neighbouring teeth already carry large fillings or crowns, the same argument runs the other way.

An implant without grafting, using a shorter implant. Considered and measured. Here the available height was insufficient even for a short implant, so this route was out — but it is checked in every such case before grafting is proposed, and in a good number of cases it is the answer.

An implant with an internal sinus lift. The plan chosen: raise the sinus floor through the implant channel itself, fill the space created, and place the implant in the same session — possible because enough of her own bone remained to anchor the implant firmly on the day.

This is the invisible phase, and for anyone new to the German system it is the phase where things go wrong.

Digital planning. The DVT data and a digital impression taken with Primescan — a scan rather than a tray of impression material — were combined into one model. The implant position was planned against the bone that exists and the crown that will sit on top, and a surgical guide produced so the planned position transfers accurately to the jaw. AI support was used when reviewing the scans, as a second look alongside the dentist’s own assessment rather than instead of it.

The treatment and cost plan. She received a written treatment and cost plan (Heil- und Kostenplan, HKP) setting out what was proposed and what it would cost. That plan went to her statutory health insurance fund before any treatment began. This sequence is not bureaucratic decoration: start first and submit afterwards, and the entitlement to the fund’s contribution can be forfeited. How long the fund takes to process it varies from fund to fund, and here it took three.

Statutory health insurance (gesetzliche Krankenversicherung, GKV) covers around 90 % of people in Germany, and its rule on implants surprises almost every newcomer:

• The fund pays nothing towards the implant itself or towards grafting carried out to make the implant possible. Both are private services.
• The fund pays a fixed subsidy (Festzuschuss) towards the crown on top — calculated as if she had received standard care (Regelversorgung) without an implant.
• The size of that subsidy depends on her bonus booklet (Bonusheft). For a single tooth in 2026: 552.96 € at the basic 60 % rate, 645.12 € at 70 % with the booklet kept without gaps for five years, 691.20 € at 75 % after ten years, and 921.60 € under the hardship provision (Härtefallregelung) for low incomes.

She had kept her booklet since arriving in Germany, five years without gaps, which placed her at the 70 % level: a contribution of 645.12 € towards the crown. Five years of remembering to get a stamp, worth just over ninety euros more than not bothering. It is the single most undersold piece of administration in German dentistry.

One thing under discussion, not yet law. A draft law (the GKV-Beitragssatzstabilisierungsgesetz, passed cabinet on 29 April 2026) proposes reducing these subsidy levels to 50, 60 and 65 % from 2027, keeping the 100 % hardship provision. It has not passed the Bundestag or Bundesrat and is not in force. It is worth knowing about if you are weighing up timing, and it is not a reason to rush treatment.

There is no single honest “total” to quote here, because the figure depends entirely on the finding — which is exactly why the treatment and cost plan exists. What can be shown is the structure:

Market ranges are background for orientation only; the numbers that apply to you are the ones on your own plan. She also asked about instalment payment (Ratenzahlung), which is possible subject to a credit decision, and arranged it before the surgery date rather than after the invoice — the right order.

A note for anyone with private or supplementary cover. Private health insurance (private Krankenversicherung, PKV) and supplementary dental policies (Zahnzusatzversicherung) reimburse a share set by the tariff. Many tariffs treat grafting differently from the implant itself and cap annual amounts in the first years. Read that clause before, not after.

Before. A short review of the plan on screen. Local anaesthetic. She declined sedation and took laughing gas (Lachgas) instead, which is available for anxious patients and wears off quickly enough to allow a normal afternoon.

The procedure. The implant channel was prepared through the ridge using the surgical guide. The sinus floor was raised gently from below, graft material introduced through the same opening, and the implant placed. Its firmness in the bone — the primary stability — was measured before anything else was decided, because that measurement is what determines whether the implant can stay put during healing.

One appointment, not a series. This is the practical advantage of the internal route: one wound, one healing period, one recovery. Patients who have been told “you need a bone graft” often assume two operations several months apart. That is the staged route, and it is not the only one.

Afterwards. Instructions, a cold pack, prescriptions, and a review appointment booked for day eight. She was given the aftercare in writing in English, including the rules specific to sinus procedures — no nose blowing, sneeze with the mouth open, no straws, no diving or gym straining, and no smoking.

Compressed, because the sensation side of this has its own article: painkiller taken before the numbness wore off, cold packs on the first evening, worst swelling on day two, clear improvement from day four, sutures out at the review on day eight. She took two days off work with a sick note (Arbeitsunfähigkeitsbescheinigung) issued by the practice and was back at a desk on the third.

The detail she had not expected was the bruising, which appeared on day three, moved downwards over the following week and looked considerably worse than it felt. The detail she found hardest was the ban on nose blowing during a cold snap. Both are normal.

Nothing happens, visibly. The graft consolidates and the bone bonds to the implant surface, a process you cannot feel and cannot hurry. Healing after implant placement takes on average three to six months; in this case the crown was planned for month six.

What she did during that period: cleaned around the site as instructed, kept two review appointments, avoided chewing hard food on that side, and continued her regular professional cleaning (professionelle Zahnreinigung, PZR). What she did not do is anything visible — which is why patients in this phase sometimes suspect they have been forgotten. They have not; this stretch is where the result is actually made.

The scan. A digital impression with Primescan, no impression tray, no material setting in the mouth.

The laboratory. The crown was made in our own in-house master dental laboratory (Meisterlabor), which in practice means the dental technician and the dentist discuss the case directly and adjustments do not involve a courier and a week.

Fitting. Try-in, checks of the contact points to the neighbouring teeth, and a careful bite adjustment — particularly relevant here, because she probably grinds. A night guard (Knirscherschiene) was discussed at this appointment, not as an add-on but because an implant has no ligament to cushion the forces a natural tooth can absorb.

Afterwards. Cleaning instructions specific to an implant crown, an interdental brush in the correct size, and a maintenance interval agreed. Dentures and prosthetic work carry a two-year warranty in our practice. Seven months after the first consultation, she was chewing on both sides again — which had been the entire point.

Presenting only the smooth version of a treatment would be misleading, and the alternatives are worth knowing because any of them can occur.

If the primary stability had been insufficient. The implant would have been left to heal covered, or the graft done first and the implant placed several months later. Two surgical appointments instead of one, and a longer overall timeline. This decision genuinely belongs to the day of surgery, and any honest plan says so in advance.

If the sinus membrane had torn. The most common complication of a sinus lift. Small tears are usually repaired during the same session; a larger one means the procedure is stopped and repeated after healing. Inconvenient, not dangerous.

If she had smoked. Slower healing, more discomfort, and a measurably higher risk of the graft not taking. It would not have ruled out treatment, but it would have changed the conversation and probably the timeline.

If she had had chronic sinus problems. An assessment by an ENT specialist (HNO-Arzt) would have come first — which in Germany can mean a referral (Überweisung) and a waiting time, so it is started early rather than discovered late.

If the plan had been submitted after treatment started. The fund’s contribution towards the crown could have been lost entirely. This is the most avoidable and most expensive mistake in the whole sequence, and it catches people who are new to Germany more than anyone else.

If she had chosen the bridge. A shorter path, no surgery, no healing months — at the cost of preparing two healthy teeth. For a different patient with differently restored neighbours, that could well have been the better decision.

Two practical observations from cases like this one.

The paperwork sequence is the thing to get right. Written plan first, fund second, treatment third. Ask explicitly when the plan will be submitted and when approval is expected, and put both dates in your calendar. If you are moving jobs or insurers during the treatment period, say so at the planning stage.

Distance is manageable if the appointments are planned around it. This treatment consisted of a consultation, a planning appointment, one surgical appointment, a review, two or three checks and two or three prosthetic appointments over seven months. Patients travel to us from across NRW — Düsseldorf, Cologne and Bonn are within half an hour by rail — and for implant work from further afield in Germany. Where travel is involved, appointments can often be combined and the sequence adapted, and it is worth raising at the first consultation rather than assuming.

If your German is not yet fluent, ask for the plan and the aftercare instructions in English. Consent you did not fully understand is not consent, and post-operative rules given verbally on surgery day rarely survive the journey home. English-Speaking Dentist in NRW. More on the treatment itself: Dental implants – service page (EN).