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Von A wie Anamnese bis Z wie Zirkonoxid wird in nun 49 Kapiteln ein synoptisches Behandlungskonzept vorgestellt, das sämtliche Bereiche der modernen zahnärztlichen Prothetik einschließt. Das Behandlungskonzept zeichnet sich durch individuell auf den Patienten zugeschnittene Konzepte aus, die ästhetische Ansprüche, minimalinvasive Methoden und die Langlebigkeit prothetischer Versorgungen gleichermaßen berücksichtigen. Neben den klassischen Gebieten der festsitzenden, abnehmbaren und kombinierten (Implantat-)Prothetik und der zahnärztlichen Werkstoffkunde werden unter anderem die präprothetische Parodontologie, die Myoarthropathien des Kausystems und viele weitere präprothetische Vorbehandlungsmaßnahmen sowie die Nachsorge detailliert beschrieben. Durch die Ergänzung spezieller Themen wie des Mundschutzes im Sport, der mundgesundheitsbezogenen Lebensqualität sowie der evidenzbasierten Zahnmedizin wird mit diesem Werk ein umfassendes Bild des Faches vermittelt.

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1Die historische Entwicklung der zahnärztlichen Prothetik

Kurt Werner Alt

„Sind die Zähne schon allein zur Erhaltung der Gesundheit wichtig, so sind sie für die Sprache, für die Aussprache und Artikulation der Worte und zur Zierde des Gesichts absolut notwendig.“

(Pierre Fauchard, 1678–1761)

1.1Einleitung

Die geschichtliche Herausbildung einer medizinischen Spezialdisziplin wie der zahnärztlichen Prothetik (Zahnersatzkunde) kann nicht ohne den Hintergrund der allgemeinen zahnmedizinhistorischen und der gesamthistorischen Entwicklung gesehen und erörtert werden. Nur eine Betrachtungsweise, die in hinreichendem Maße die gesellschaftlichen und wirtschaftlichen Bedingungen sowie die technischen Möglichkeiten und geistigen Strömungen der jeweiligen Zeit erfasst, kann Erklärungen dafür liefern, weshalb Entwicklungen diesen oder jenen Weg nehmen, geographisch oder zeitlich beschränkt bleiben, und welche Voraussetzungen erfüllt sein müssen, damit sie sich durchsetzen und schließlich etablieren können. Die historische Beschäftigung mit den Zähnen darf sich nicht auf Fragen nach den Behandlungsmethoden, nach der Anwendung und Weiterentwicklung von Instrumenten und Materialien reduzieren, sondern sollte immer im Kontext mit den jeweiligen sozialen Verhältnissen und Lebensgewohnheiten der Menschen gesehen werden. Aus diesen Gründen muss in eine Darstellung der Entwicklung der zahnärztlichen Prothetik neben der allgemeinen Medizin- und Zahnmedizingeschichte die Kulturgeschichte angemessen eingebunden sein.

1.2Heilkunst und Kulturgeschichte

Heilkunde und Pflege, die sich aus ursprünglichen Instinkthandlungen und empirischen Wurzeln entwickelt haben, stellen einen wichtigen Mosaikstein innerhalb der kulturellen Leistungen des Menschen dar. Sie kommen universal vor, unterscheiden sich jedoch inhaltlich aufgrund differierender, kulturell determinierter Vorstellungen von Krankheit und Heilung stark voneinander. Heilhandlungen und Pflegemaßnahmen aus der Frühzeit der Menschheit können lediglich indirekt erfasst werden, und zwar zum einen über archäologische Funde und Befunde, zum anderen durch die Beurteilung und Interpretation biohistorischer Quellen. Als solche zählen die sterblichen Überreste ur- und frühgeschichtlicher Menschen, meist in Form der Überlieferung von Skelettfunden, seltener Mumien, die fast immer Hinweise zu Krankheit und Gesundheit (Paläopathologie) liefern und mitunter verschiedenartigste Spuren durchgeführter medizinischer und zahnmedizinischer Anwendungen und Therapien zeigen.

Diesbezügliche Funde und Befunde mit zahnärztlicher Relevanz reichen weit in die Menschheitsgeschichte zurück. Sie betreffen nahezu alle heutigen Arbeitsbereiche in der Zahnmedizin: Zahnchirurgie, Zahnerhaltung und Zahnprothetik. Insbesondere bei den teilweise visionär anmutenden Manipulationen, was die Behandlung von kariösen Kavitäten in den Zähnen angeht, finden sich inzwischen immer mehr direkte Beispiele im biohistorischen Fundmaterial. Zeitlich gesehen erstrecken sich die Einzelbeobachtungen von der Altsteinzeit (Paläolithikum) über die Jungsteinzeit (Neolithikum) bis in die Antike, bevor die Zahnerhaltung im 17. Jahrhundert in Mitteleuropa dann endgültig Fuß fasst (Oxillia et al. 2015, Seguin et al. 2014, Bernardini et al. 2012, Nicklisch et al. 2019). Zu den sehr frühen Fundplätzen, an denen Beobachtungen zahnmedizinischer Eingriffe an Bestattungen gemacht wurden, gehört auch ein steinzeitliches Gräberfeld in Pakistan. Dort wurden neun Individuen geborgen, deren Zähne die Spuren von Bohrungen aufwiesen, die im Zeitraum zwischen 7.500 und 9.000 Jahren vor heute durchgeführt wurden. Inwieweit die Eingriffe in diesem Fall medizinisch indiziert waren, blieb bei der Untersuchung an den Betroffenen jedoch ungeklärt (Coppa et al. 2006). Bei Grabungsarbeiten an einer steinzeitlichen Fundstelle in Ägypten wurde eine aus einer Muschel gefertigte Nachbildung eines menschlichen Schneidezahns gefunden. Da dieser artifizielle Zahn nicht in situ gefunden wurde, kann über seinen Verwendungszweck nur spekuliert werden. Neben seiner Verwendung als Ersatz eines verloren gegangenen Inzisivus kann dieser geschnitzte Zahn auch als bloßes Schmuckobjekt gedient haben (Irish et al. 2004). Auch aus den süd- und mittelamerikanischen Hochkulturen sind zahlreiche Manipulationen und Eingriffe im oralen Kontext bekannt (Gantzer 1969, Tiesler et al. 2017, Watson und Garcia 2017).

Unter Berücksichtigung des archäologischen oder historischen Kontextes ermöglichen die Erkenntnisse aus der Untersuchung der überlieferten Skelettfunde eine Vielzahl sozial- und kulturgeschichtlich relevanter Aussagen über die jeweilige Zeit und gehen damit weit über die engere Paläopathologie hinaus. Neben empirisch erworbenen Erfahrungswerten mit Krankheiten und Gebrechen prägen über die längsten Phasen der Menschheitsgeschichte magisch-religiöse Vorstellungen das Verhalten und Handeln im Bereich der Heilkunde.

Die Entstehung von Hochkulturen und die Entwicklung von Schriftsystemen markieren den wesentlichen kulturellen Rahmen für die in der medizinhistorischen Forschung als archaisch bezeichnete Medizin des 3. bis 1. Jahrtausends v. Chr., die jedoch geographisch-kulturell beschränkt bleibt. Ihre Fortschritte und Veränderungen gegenüber der magisch-religiösen Medizin beruhen auf der langsam einsetzenden Anwendung des Kausalitätsdenkens in der Diagnostik, auf exakter Beobachtung und Systematik und erstmalig in der schriftlichen Weitergabe des medizinischen Wissens. Eine Vielzahl hygienischer Maßnahmen für das Gemeinwohl (z. B. Kanalisationen, Bäder, Latrinen) sind durch Baudenkmäler eindrucksvoll überliefert. Die Bedeutung solcher Vorkehrungen für die Gesundheit der Menschen im Römischen Reich wird jedoch weit überschätzt (Mitchell 2017). Im letzten Jahrtausend vor der Zeitenwende etabliert sich in Griechenland die erste theoretisch begründete Medizin. Sie entsteht auf dem Boden eines kulturellen Neubeginns, der stark von naturphilosophischen Strömungen beeinflusst ist. Dadurch vermag sie sich von der religiösen Dogmatik der sogenannten Tempelmedizin zu lösen und in ersten Einrichtungen, Vorstufen der späteren medizinischen Schulen, den Boden für die „hippokratische Lehre“ zu bereiten. Deren wissenschaftliche Grundlagen bilden nicht nur die Basis für die griechisch-römische Medizin der Antike (7. Jh. v. Chr. bis 4. Jh. n. Chr.), sondern stellen auch für die Medizin der Neuzeit die wichtigste Entwicklungsphase dar. Die Überwindung der magisch-religiösen Priestermedizin im ersten Jt. v. Chr. ist gleichzusetzen mit dem Beginn der wissenschaftlichen Medizin in Europa. Eine eigenständige Entwicklung in Westeuropa nimmt sie jedoch erst nach dem Untergang des weströmischen Reiches (Hoffmann-Axthelm 1973).

Ihre Errungenschaften zeitigen Auswirkungen bis heute und sind durch ein umfangreiches medizinisches Schrifttum belegt. Wichtige Quellen für die medizinische Literatur jener Zeit sind das „Corpus Hippocraticum“, eine Sammlung medizinischer Schriften, die auf Hippokrates (460 bis 370 v. Chr.) und seine Schüler zurückgeht, der medizinische Teil „De medicine libri octo“ einer Enzyklopädie von Aulus Cornelius Celsus aus der ersten Hälfte des 1. Jahrhunderts n. Chr. sowie die Gesamtdarstellung der Medizin bei Galen (129 bis 199 n. Chr.). Das Ende der Periode der antiken Medizin wird chronologisch unterschiedlich bewertet. Häufig werden der politische Zerfall des römischen Weltreichs in einen östlichen und westlichen Teil (330 n. Chr.), teils auch das Jahr 395 n. Chr. als Zäsur genannt, aber inzwischen liegen die Daten für das Ende der Antike eher in der zweiten Hälfte des 6. Jahrhunderts oder sogar noch später (Demandt 2014).

Während die medizinische Tradition der Antike im Osten durch byzantinische Kompilatoren ihre oft als steril bezeichnete Fortführung fand – positive Stimmen heben allerdings ihre Originalität hervor –, gerieten im Westen die medizinischen Fertigkeiten und Kenntnisse aufgrund der politischen und wirtschaftlichen Folgeerscheinungen, die mit dem Untergang des weströmischen Reiches verbunden waren, in Vergessenheit. Wesentliche Ereignisse im Westen stellen die Germaneneinfälle und die Wirren der Völkerwanderungszeit dar.

Während des Mittelalters (5. bis 15. Jh. n. Chr.) gelangt antikes medizinisches Wissensgut durch Rezeption, Kompilation und Übersetzungstätigkeit allmählich aus dem arabisch-islamischen Sprach- und Kulturraum in die christliche Welt (Übersetzungen aus dem Arabischen ab 11. Jh., aus dem Griechischen ab 12. Jh.). Frühe Medizinschulen wie Salerno, Toledo, Montpellier und Bologna fungieren ab dem 11. Jahrhundert als Vermittler des theoretischen Wissens für die in der medizinhistorischen Forschung als Zeit der Klostermedizin und Scholastik bekannten medizinischen Perioden (Hoffmann-Axthelm 1973, Strübig 1989).

Bis zum Spätmittelalter verharren Medizin und Zahnmedizin in West- und Mitteleuropa weitgehend auf dem Kenntnisstand der Antike. Im Laufe der Zeit werden jedoch eigene Konzepte entwickelt und gegen Ende des Mittelalters entsteht eine weniger stark von dem antiken medizinischen Gedankengut geprägte Literatur. Eine selbständige Entwicklung der Medizin (die Zahnmedizin eingeschlossen) beginnt in West- und Mitteleuropa erst mit dem 16. Jahrhundert. Die Erfindung der Buchdruckerkunst (um 1450) begünstigt das Entstehen und die Verbreitung einer eigenständigen medizinischen Literatur und führt damit schließlich zu einer immer stärkeren Abwendung vom traditionellen antiken Schrifttum.

Vom allgemeinen Aufschwung der Chirurgie wesentlich mitgetragen, beginnt dann im 16./17. Jahrhundert eine eigenständige Entwicklung der Zahnmedizin, was u. a. in der Entstehung einer spezifischen Fachliteratur zum Ausdruck kommt. Bis weit in das 18. Jahrhundert hinein besteht zahnärztliche Therapie jedoch noch primär in der Durchführung von Extraktionen durch Chirurgen, Barbiere und umherreisende „Zahnbrecher“. Daneben erbringen aber bereits geschickte Handwerker Leistungen auf zahntechnischem Gebiet, allerdings für eine nur verschwindend geringe Zahl von begüterten Patienten. Wie schriftliche Quellen und Funde prothetischer Arbeiten aus dieser Zeit belegen, erfolgte die methodische Abkehr von den antiken und mittelalterlichen Behandlungsmaßnahmen eher langsam. Dennoch standen die „Zahnbehandler“ des 18. Jahrhunderts an der Schwelle zu einer autonomen Zahnheilkunde (vgl. Hoffmann-Axthelm 1985, Ring 1997, Groß 2019).

1.3Der kosmetisch-ästhetische Wert der Zähne in Vergangenheit und Gegenwart

Den individuellen Wert und die kulturelle Bedeutung der Zähne und des Gebisses in Vergangenheit und Gegenwart spiegeln archäologische Funde, schriftliche antike Quellen sowie ethnologische Feldstudien wider. So haben z. B. Zähne bei Naturvölkern weniger einen funktionellen als einen idealisierenden Wert. Für die in vielen Gebieten der Welt vorkommenden artifiziellen Veränderungen an Zähnen, wie Färbungen, Schmuckeinlagen und Zahnfeilungen, werden religiös-kultische, soziologisch-wirtschaftliche, ästhetisch-künstlerische und medizinisch-hygienische Gründe geltend gemacht (Alt et al. 1990, Alt und Pichler 1998, Garve 2014, Burnett und Irish 2017). Diese Bräuche stehen scheinbar im Widerspruch zu der von Europäern schlechthin als Schönheitsideal empfundenen Natürlichkeit der Zähne in Form, Farbe und Stellung, die bereits Griechen und Römer vertraten. Dass kosmetisch-ästhetische Vorstellungen aber stark von kulturspezifischem Brauchtum abhängen, zeigt die in islamischen und osteuropäischen Ländern noch häufig zu beobachtende Sitte, Zähne im sichtbaren Bereich mit Gold oder anderen Metallen zu überkronen, um damit die Zugehörigkeit zu einer bestimmten sozialen Schicht zu demonstrieren, ähnlich wie in Japan die Schwarzfärbung der Zähne bis ins 19. Jahrhundert die Verheiratung einer Person angezeigt hat (zum Themenkomplex „Ästhetik“ siehe Kap. 17). Auch in Laos und Vietnam sind solche Schwarzfärbungen der Zähne bekannt. Hier wird vermutet, dass die Prozedur nicht nur ästhetischen Wert, sondern auch medizinischen Nutzen bei der Kariesprävention haben könnte (Tayanin et al. 2006).

In der modernen Zahnmedizin bildet die Wiederherstellung der gestörten Kaufunktion den Schwerpunkt jeder prothetischen Behandlung. Daneben sind funktionelle, ästhetische und phonetische Aufgaben zu erfüllen. Wie jeder zahnärztliche Behandler bestätigen wird, sind für die Patienten primär ästhetische Beweggründe für den Wunsch nach Anfertigung von Zahnersatz maßgebend, weil den Zähnen für das Leben in der Gesellschaft und Öffentlichkeit hohe Bedeutung zukommt. Zahnlosigkeit im Frontzahngebiet wird in der Regel nur kurze Zeit von den Betroffenen akzeptiert, wobei viele Patienten bis zur Fertigstellung einer Interimsversorgung sogar krank geschrieben werden möchten. Während im lückigen Frontzahngebiss Patienten meist von sich aus mit dem Wunsch nach einer prothetischen Rehabilitation kommen, stört Zahnlosigkeit im Seitenzahngebiet selten und es bedarf vielfach besonderer Hinweise des Zahnarztes auf entstehende Funktionsstörungen, bevor hier in eine prothetische Versorgung eingewilligt wird.

Erfahrungsgemäß sind es also weniger die funktionellen Auswirkungen von Zahnverlust und Zahnlosigkeit – einmal abgesehen von den Sprachschwierigkeiten – als vielmehr die negativen Einschränkungen des äußeren Erscheinungsbildes, das Empfinden eines körperlichen Defektes, die Patienten in die zahnärztliche Praxis und in eine prothetische Behandlung führen. Fehlfunktionen werden oft über längere Zeit durch reaktives Verhalten kompensiert, Schmerzen bisweilen durch Selbstmedikation therapiert und die Nahrungsaufnahme den gegebenen Möglichkeiten angepasst. Ein lückenhaftes, schadhaftes und ungepflegtes Gebiss dagegen weckt bei vielen Menschen ein tief verankertes Schamgefühl und löst psychosoziale Störungen aus, weil mit dem schlechten Gebiss ein Verlust an Jugend, Schönheit und Attraktivität assoziiert und der Gebisszustand vielfach dem individuellen Fehlverhalten des Trägers angelastet wird (Böhme et al. 2015).

Die Erkenntnis, dass seitens der Patienten kosmetische Beweggründe Priorität vor funktionellen Erwägungen bei Zahnverlust haben, ist nicht auf die Verhältnisse in modernen Gesellschaften beschränkt. Bereits in der zeitgenössischen antiken Literatur werden die negativen Auswirkungen von Zahnverlust auf das Befinden der Betroffenen geschildert, die, wenn sie es sich leisten konnten, technisch zwar unzulänglichen, kosmetisch aber wohl befriedigenden Zahnersatz herstellen ließen. Archäologisch überlieferte, kaufunktionell völlig insuffiziente Konstruktionen von Zahnersatz sind der konkrete Beweis dafür, dass die Wiederherstellung des Kauorgans allenfalls sekundär von Bedeutung war. Bis weit in das 19. Jahrhundert bestimmte primär der Wunsch nach ästhetischer Rehabilitation die Herstellung von Zahnersatz (Alt 1993).

An Behandlungsgrundsätzen sind, außer der Absicht, die entstandene Lücke zu schließen und eingefallen wirkende Gesichtspartien auszupolstern, meist keine weiteren Kriterien erkennbar. Funktionelle Erwägungen scheinen kosmetischen Zwecken immer nachgeordnet, wenngleich einige Fundstücke belegen, dass „Zahnkünstler“ mit den ihnen zur Verfügung stehenden Mitteln und mit Geschick und Können gelegentlich versucht haben, funktionelle Gesichtspunkte (z. B. Okklusion) bei der Herstellung von Zahnersatz zu berücksichtigen. Dies gelang meist nur unvollkommen und war immer nachrangig. Ein klassisches Beispiel für die Unzulänglichkeit seines Zahnersatzes stellt George Washington dar, der bereits im Alter von 40 Jahren eine Teilprothese aus Nilpferdknochen erhalten hatte, in die menschliche Zähne unbekannter Herkunft eingesetzt waren (Weinberger 1948). In vielen Anekdoten wird erzählt, dass G. Washington lebenslang an den Veränderungen gelitten hat, die mit dem Zahnverlust und dem Tragen des insuffizienten Zahnersatzes zusammenhingen (Lässig und Müller 1983). Überhaupt hatten die Behandlungsversuche oftmals nur kurzfristig Erfolg, da eine den Restzahnbestand schonende Verankerung des Zahnersatzes noch nicht möglich war. Nach Eingliederung des Ersatzes waren die Pfeilerzähne durch Fehlbelastungen bald geschädigt und gingen vielfach vorzeitig verloren (vgl. Alt 1993).

Als Werkstoff für die Herstellung von Stiftzähnen, Brücken und Prothesen mussten, sofern diese nicht in einem Stück, aus Knochen, Elfenbein, Walroß- und Flusspferdhauern (Stoßzähne) geschnitzt waren, sonstige Tierzähne oder auch menschliche Zähne von Toten herhalten (Paulson 1908, Lorenzen 2006). Die aus organischen Materialien bestehenden Werkstoffe waren für prothetische Konstruktionen wenig geeignet: Sie fielen wie die eigenen Zähne der Karies zum Opfer, verfärbten sich rasch, verbreiteten einen intensiven Geruch und mussten häufig erneuert werden. Nahezu unumgänglich war es, den vermeintlichen „Zahnersatz“ vor dem Essen herauszunehmen, da damit nicht gekaut werden konnte. Weil das Tragen von Zahnersatz wahrscheinlich lange Zeit nichts Beschämendes an sich hatte, sondern die Zugehörigkeit zur Oberschicht bezeugte, kam der späteren Verwendung von Metall (meist Gold) im sichtbaren Bereich eher ein dekorativer Effekt zu.

Von den frühesten prothetischen Arbeiten durch Etrusker und Phöniker um die Mitte des ersten Jahrtausends v. Chr. bis weit ins 19. Jahrhundert bedeutete das Tragen von Zahnersatz ein Privileg, das sich auf wenige Begüterte beschränkte. Die Art der prothetischen Versorgung, die Werkstoffe und Herstellungsmethoden blieben während der ganzen Zeit nahezu unverändert, jedoch gab es kulturspezifisch deutliche Unterschiede bezüglich der technischen Umsetzung, was in hohen Qualitätsunterschieden beim Zahnersatz zum Ausdruck kam. Erst nachdem die Zahnheilkunde im 16. Jahrhundert ein Teilbereich der Medizin wurde, ab dem 18. Jahrhundert eine eigenständige Entwicklung nahm und im 18./19. Jahrhundert als fachspezifische Disziplin die Zahnprothetik entstand, wurden deutliche Fortschritte erzielt. Für die Erfindung und Nutzung geeigneter Materialien spielten die allgemeine technische Entwicklung, die Fortschritte in den Naturwissenschaften und die politische Neuordnung Europas eine wichtige und entscheidende Rolle (Hoffmann-Axthelm 1973, Bennion 1988).

1.4Ernährung und Zahnverlust

Traumen, parodontale Insuffizienz und periapikale Entzündungen (Ostitiden) – über die Karies hinaus oft als Folge progressiver Abrasion mit Eröffnung der Pulpa – sind Ursachen, weshalb Zähne in ur- und frühgeschichtlicher Zeit verloren gehen; Zahnverlust durch Karies kommt aufgrund der Ernährungsgewohnheiten demgegenüber lange Zeit nur in geringem Ausmaß vor (Nicklisch et al. 2016). Die Ernährung von Jägern und Sammlern beschränkt sich über Jahrhunderttausende auf das Sammeln von Pflanzen, Wurzeln und Früchten, die vielfach roh verzehrt werden und etwa zwei Drittel der Nahrung ausmachen. Ergänzend dazu findet Jagd auf verfügbares Wild statt, dessen Fleisch eine wichtige Energiequelle bildet. Die grobe, faserreiche Kost, die das Gros der Nahrung stellt, bewirkt eine starke Abrasion der Zahnhöcker und -fissuren, weshalb auf den Okklusalflächen der Zähne kaum einmal Karies entsteht (Alt et al. 2017). Ein nennenswerter Konsum niedermolekularer Zucker findet vor dem 18. Jahrhundert in der Normalbevölkerung nicht statt und ändert sich erst mit Beginn der Industralisierung (Skelly et al. 2020). Wilder Honig, Früchte, Sirup und Most, geographisch-regional Datteln und Feigen sind Beispiele für vorhandene Nahrungsmittel mit kariogenem Potential. Rohrzucker ist bereits seit dem Altertum verfügbar, wird anfänglich jedoch nur in der Oberschicht konsumiert (u. a. als Medikament).

Da die mittlere Lebenserwartung unserer Vorfahren bis ins Mittelalter nur bei etwa 30 bis 40 Lebensjahren liegt, ist die Kariesfrequenz limitiert und der Zahnverlust in prähistorischen Zeiten gering, steigt aber seit der Antike ständig an und erreicht im Mittelalter sehr hohe Befallszahlen (Alt 2001). Relativ chronologisch lässt sich das Anwachsen der Karies und damit einhergehend erhöhter Zahnverlust mit bestimmten kulturhistorischen (zivilisatorischen) Ereignissen in Verbindung bringen. Im Zuge der sogenannten neolithischen Revolution domestiziert der Mensch in der Jungsteinzeit Pflanzen und Tiere. Durch den wirtschaftlichen Wechsel ändert sich die Zusammensetzung und Zubereitung der Nahrung in der Folgezeit entscheidend, da zunehmend neue Produkte (z. B. Getreide) und weichere (gekochte) Nahrung verzehrt werden. Als Folge dieser geänderten Ernährungsgewohnheiten steigen Karieshäufigkeit und Zahnverlust immer stärker an (Nicklisch et al. 2016). Nach den schriftlichen Quellen wurde die Zahnextraktion von der Antike bis ins Mittelalter hinein primär „nur“ an bereits lockeren Zähnen vorgenommen. Der Grund dafür sollen die schlechten Erfahrungen sein, die man bei der Extraktion schmerzender, aber fester Zähne gemacht hatte. Allenthalben wurde daher eine medikamentöse Vorbehandlung eines zu extrahierenden Zahnes gefordert (vgl. zusammenfassend Hoffmann-Axthelm et al. 1995). Für die Entwicklung der praktischen Zahnmedizin generell, im Besonderen was die Extraktion betrifft, wurde der Araber Albucasis zum Pionier, der im 30. Kapitel seiner „Chirurgia“ aus dem 11. Jh. n. Chr. zum ersten Mal in allen Einzelheiten die Zahnextraktion beschreibt (Albucasis 1778). Sigron (1985) hat die Bedeutung dieses Werkes für die Zahnmedizin bis in das 18. Jahrhundert hinein betont und darauf hingewiesen, dass vor dem Erscheinen dieses Werkes die Zahnextraktion „zwar als Behandlungsart genannt [wird], ihre Erwähnung ist aber stets mit der Warnung verbunden, nur lockere Zähne zu ziehen“. Vielfach wird überhaupt bestritten, dass es in ur- und frühgeschichtlicher Zeit Zahnextraktionen gegeben hat. Grund dafür ist die Tatsache, dass es bei fehlenden Zähnen schwierig ist zu sagen, ob diese durch ein Instrument (z. B. Zahnzange), nach (eventuell medikamentöser) Lockerung mit der Hand entfernt wurden oder allmählich im Munde verfault sind. Es vereinfacht die Diagnose Extraktion, wenn gleichzeitig Frakturen der Krone, beschädigte Nachbarzähne, Frakturen oder Dislokationen der Kiefer beobachtet werden, weil dies auf Komplikationen bei der Extraktion hinweist. In der Regel lässt sich aber auch beim Fehlen solcher Begleitfunde durch einen geübten Untersucher (Dentalanthropologen) feststellen, ob es sich bei einem fehlenden Zahn möglicherweise um einen extrahierten Zahn handelt. Letztlich kommt es jedoch eigentlich nur darauf an, ob eine wie auch immer geartete Behandlung eventuell durch einen „Heilkundigen“ stattgefunden hat oder der Zahn einfach sukzessive aus dem Kiefer „herausgefault“ ist. Nach dem bioarchäologischen Quellenmaterial scheint klar zu sein, dass man durchaus in der Lage war, Zähne zu trepanieren oder auch zu extrahieren, auch wenn dafür unterschiedlichste Methoden in Frage kommen, somit die Zahnextraktion wahrscheinlich weit in die Menschheitsgeschichte zurückreicht (Lunt 1992).

Soziokulturelle Aspekte, die in den Hochkulturen das Interesse an Zahnersatz aufkommen lassen und später das Herausbilden eines prothetischen Handwerks begünstigen, sind zu Beginn der Jungsteinzeit noch zu vernachlässigen. In einer mehr oder weniger egalitären Gesellschaft mit wenig ausgeprägtem Statusdenken hat Zahnverlust keine gesellschaftlichen Benachteiligungen zur Folge, da Altern und die damit verbundenen Einschränkungen zum Dasein dazugehören und unabwendbar sind. Da nur wenige Menschen ein hohes Alter erreichen, ist Zahnverlust, vor allem im Frontzahnbereich, zunächst eher selten. Erst in den sozial stratifizierten Bevölkerungen der nachfolgenden Metallzeiten und in den Hochkulturen finden wir gesellschaftliche Bedingungen vor, die bei Zahnverlust den Wunsch nach prothetischer Versorgung aufkeimen lassen. Jedoch ist anzunehmen, dass sich allenfalls eine sehr begrenzte Oberschicht den Luxus von Zahnersatz leisten konnte. Die Erfolge der ersten „Zahnkünstler“ mögen dann zur Nachahmung animiert haben. Wie weit letztlich der Wunsch nach Zahnersatz historisch zurückreicht, kann jedoch nur spekulativ bleiben.

1.5Die Bedeutung archäologisch-prothetischer Fundobjekte für die zahnmedizinhistorische Forschung

Wenngleich prothetische Wiederherstellungen in historischer Zeit zunächst sehr begrenzt und auf die Oberschicht beschränkt gewesen sein mögen, begründete der Wunsch nach ästhetischer Rehabilitation eine immer stärkere Nachfrage nach derartigen Diensten und schuf so mit der Zeit die Notwendigkeit eines speziellen zahntechnisch tätigen Handwerks. Ein Problem der medizinhistorischen Forschung ist der häufige Widerspruch zwischen schriftlichen Quellen – auf die Prothetik bezogen z. B. der Nachweis der Tätigkeit eines zahntechnischen Handwerks in der Antike – und den konkreten Funden an Zahnersatz, die durch die Ausgrabungstätigkeit von Archäologen zutage kommen. Insgesamt gesehen erstaunt die Seltenheit der Funde, und in vielen Fällen sind die technischen Details und Materialien andere, als sie nach der Lektüre der medizinischen Literatur jener Zeit zu erwarten wären. Gerade wegen dieser häufigen Diskrepanzen sind archäologische Objekte als Vergleichsmaterial einmalige Quellen.

Da Fundobjekte aus dem Bereich der zahnärztlichen Prothetik bis ins 19. Jahrhundert selten sind und wir unser Wissen darüber primär dem Schrifttum der jeweiligen Zeit verdanken, ist jeder archäologische Fund von Zahnersatz aus medizin- und kulturhistorischer Sicht eine wertvolle Quelle. Während Ausgrabungen in antiken oder mittelalterlichen Fundkomplexen, wo Zahnersatz noch wenig verbreitet ist, häufig vorgenommen werden, stellen Ausgrabungen in frühneuzeitlichen Fundzusammenhängen, in denen öfter Zahnersatz zu erwarten wäre, eher eine Ausnahme dar. Diesbezügliche Funde stammen häufig aus Kirchengrabungen, da sakrale Bauten grundsätzlich unter Denkmalschutz stehen. Von der Antike bis ins 19. Jahrhundert ist Zahnersatz ausschließlich unter den gehobenen Ständen verbreitet, für die es auch ein Privileg darstellt, sich innerhalb der Kirchen bestatten zu lassen. Es verwundert daher nicht, dass fast alle frühneuzeitlichen Funde von Zahnersatz aus Sakralbauten stammen.

1.6Früheste archäologische Quellen zur Zahntechnik aus Ägypten

Halten wir uns an die direkten Quellen als Belege für die Herstellung von zahntechnischen Arbeiten, so weisen diese zuerst nach Ägypten. Chronologisch gesehen gelten die Funde von Gizeh (ca. 2500 v. Chr.; Junker 1929), eine Schienung zweier unterer Molaren mit Golddrahtgebinde (Abb. 1-1), und eine weitere Schienung von oberen Frontzähnen aus dem Gräberfeld von El-Quatta aus der gleichen Zeit (Harris und Iskander 1975) als die frühesten Beispiele für Zahnersatzkonstruktionen. Es ist allerdings fraglich, ob hier überhaupt zahnärztliche Tätigkeiten vorliegen (Fotshaw 2009). Ähnlich alt soll der Fund einer Zahnimitation aus Muschelkalk mit spatelförmiger Krone und konischer Wurzel sein, die an einen oberen mittleren Schneidezahn erinnert. Der Autor vermutet u. a., dass es sich dabei um ein Zahnimplantat handeln könnte (Irish 2004). Wahrscheinlicher ist, dass es sich dabei um postmortale Maßnahmen handelt, weil angenommen wurde, dass für das Leben nach dem Tod die Unversehrtheit des Körpers wichtig wäre (Harris et al. 1975). Nachdem jüngst ein paläopathologischer Befund einer Zehprothese bei einer ägyptischen Mumie (1600–1300 v. Chr.) veröffentlicht wurde, wo sich deutliche Abnutzungsspuren an der Prothese finden, darf zumindest angezweifelt werden, dass es sich bei beobachtbaren Behandlungsmaßnahmen grundsätzlich um Vorgehensweisen im Zusammenhang mit dem Totenkult handelt (Nerlich et al. 2000). Die Auswertungen von Beamtentiteln sowie von medizinischen Papyri (Papyrus Ebers/Smith) ergeben zwar Hinweise auf Zahnbehandler, nennen Zahn- und Kiefererkrankungen und erwähnen medikamentöse Therapien; es fehlt aber jedes Indiz für die Anfertigung von Zahnersatz oder für die Schienung gelockerter Zähne bei Lebenden. Die beiden oben genannten Funde sind die bisher einzigen Fälle zahntechnischer Maßnahmen aus dem ägyptischen Kulturbereich, obwohl Tausende von Bestattungen, darunter viele Königsmumien, paläodontologisch untersucht worden sind. Das dürftige Ausgrabungsmaterial und die Schriftquellen lassen gegensätzliche Interpretationen und widersprüchliche Ansichten zu (Kornemann 1989, Weinberger 1946). Es wird daher nicht von ungefähr vermutet, dass die beiden oben genannten Zahngebinde von Präparatoren im Zusammenhang mit dem Bestattungszeremoniell post mortem hergestellt sein könnten.

$\"\"$

Abb. 1-1 Schienung von zwei unteren Molaren mit Golddraht; Ägypten: Gizeh, ca. 2500 v. Chr. (Roemer- und Pelizaeus Museum, Hildesheim).

1.7Zahnersatz zur Zeit der Antike (Etrusker, Phöniker, Griechen, Römer)

Die ersten echten zahntechnischen Arbeiten repräsentieren Fundobjekte, die aus der Mitte des ersten Jahrtausends vor der Zeitenwende stammen. Aufgrund archäologischer Fundzusammenhänge, geographisch-regionaler Feinheiten in der Ausführung und Herstellung und der relativen Häufigkeit ihres Vorkommens, aber auch aufgrund der historischen Überlieferung wird angenommen, dass sie nicht, wie für die ägyptischen Fundstücke vermutet wird, religiös-kultischen Ursprungs sind. Wahrscheinlich ist der Wunsch nach Zahnersatz in erster Linie allein auf die menschliche Eitelkeit, weniger auf die Wiederherstellung der Kaufunktion zurückzuführen. Die Kulturen bzw. Ethnien, bei denen Zahnersatz aus ästhetischen Beweggründen erstmals eine Rolle spielt, sind Etrusker, Phöniker, Griechen und Römer, die alle Hochkulturen darstellen.

In das erste Jahrtausend vor Christus datieren Funde von Zahnersatz etruskischer und phönikischer Herkunft, die nahezu zeitgleich, wohl aber unbeeinflusst voneinander hergestellt wurden (Hoffmann-Axthelm 1973). Nimmt man die als unsicher einzuschätzenden ägyptischen Funde von „Zahnersatz“ aus, liegen mit ihnen die ältesten Beispiele für kosmetische Bemühungen vor, parodontal insuffiziente Zähne durch Schienung zu erhalten bzw. entstandene Zahnlücken durch Zahnersatz zu schließen. Eine Einmaligkeit stellt der Fund einer Zahnwurzel mit einem Metallstift aus dem 2. Jahrhundert v. Chr. aus Palästina dar (Zias und Numeroff 1987). Über die Bedeutung dieser Maßnahme kann man nur spekulieren. Eine endodontische Behandlung scheint jedoch ausgeschlossen.

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