- Hi everyone, how you doing?
So in this video let's talk about
implants for front teeth, okay?
So this is usually when people have had
a tooth broken off at gum line.
Maybe this tooth is have root canal feeling.
Maybe some posts, some crowns.
You had a load of work done to this tooth.
It's become weak it's just broken off at gum level.
What is the the way that you can have this front tooth.
And why is an implant and the front
so different to an implant at the back, okay?
So let's go straight into.
I'll show you this case
which we treated fairly recently.
I think we fitted the crown fairly recently
in the last three, four months.
And we actually started it a year before, okay?
So this is just one way of doing it.
And I'm gonna show you in my next video
a kind of a much quicker way of doing it.
Which you can do in certain situations.
But this is a long winded case.
You can see it's pretty obvious
which tooth is missing and you can see on the after photo
on the right there that we got pretty good end result.
It's pretty difficult to see which one the implant is, okay?
But I'll show you the giveaway signs
a little bit later on in this video.
Before we do that I'm gonna cut this image.
So we got a side on view, okay?
Where the line is on the before photo,
that's how we're gonna cross it.
And then we're gonna effectively just open it up
and have a look at the side.
Because I want show you certain things
which are almost certainly going to happen
as soon as you take a tooth out.
And stuff which is gonna compromise
the look of our dental implant.
So this is that cross section, okay?
So towards the right of this image
we've got the front of the tooth.
And we've got the tooth in this kind of position here.
So about a third of the tooth is what you can see.
Two thirds is up inside the bone,
and that is the root of the tooth.
Now, the important thing here
is that we can see this junction here, all right?
This junction is where the gum and the two meet, okay?
It's where the pink stops
and the white of the tooth starts.
From a cosmetic point of view
this is a very important junction.
Now, if we're gonna take this tooth out,
one thing that would almost instantly happen.
When I say instantly
within the next two or three months
of having the tooth out,
is that we're gonna lose bone, okay?
When we lose the bone what happens
is you take the tooth out
and the bone around the tooth
is very closely linked to the surface of the tooth.
And that starts to disappear usually from the front
and a little bit of the height.
So it changes the look
of the tooth in that area or the gum.
And quite often you've still got enough bone
to place an implant, okay?
But if you just place an implant
you can get a couple of problems.
So let's remember, this is where the tooth was, okay?
When the gum was complete.
And now to put an implant in
and we put a tooth in the same place,
cosmetically make it look the same.
What would then happen is that junction
where the tooth came out of the gum
originally when the tooth was in position
has now moved up a couple of millimeters.
This gives us the illusion
or it makes it look like
that tooth on the implant is longer.
And this is the big difference
between having an implant at the front of the mouth
to having it at the back.
So here's a photo of a lady
who's had an implant at the front of her mouth.
And this has been disregarded
by everything that I've just spoken to you about.
She's had the implant placed.
And you can see, I'm not even gonna point out
which tooth it is.
But one of these teeth
is much longer at the gum level than the others.
So this is in my opinion,
it's a cosmetic disaster, all right?
The patient wasn't overly happy with the end result.
Just to keep my ego going,
it wasn't me who actually treated this lady.
I did see her for an emergency
a little bit later after she had it done.
And I 100% believe that the dentist
who did this was trying to achieve
the best result for their patient.
And maybe they've done a whole bunch of implants elsewhere,
and they knew how to do it.
But in this situation being in the front of the mouth,
there's a different set of rules that we got to play by.
And there's different techniques
on how to achieve a good result in these situations.
In addition to the tooth being long,
can you also see that at the neck of the tooth
is actually much more gray?
And that's because the gum is so thin
that we're getting show through of the implant.
Or maybe the abutment
which is connected to the implant.
But there's some metal behind the gum
and that's why the gray is showing through there.
Now, what can we do to fix this?
Well, we've got two main options.
And the way that we tackle it from patient to patient
is very individual, okay?
There's a whole bunch of factors
which are taken into account.
And sometimes we may do both of these two things.
But let me just go through them with you now.
So we've got that same kind of diagram
which I showed you at the beginning.
But the only difference is I've drawn a black line
and that signifies the bone underneath the gum.
And essentially, we've got enough bone
to put an implant in there.
Our main problem is that it's sunk in.
So we've got a lack of volume from the front
and maybe a little bit to the height.
So it's possible to take some gum
usually from the back of the mouth,
and transplant it and put it
underneath the gum at the front, okay?
So this sounds really horrible
and a lot of people will want to run away
when I explain this.
It's no worse than having a tooth taken out.
And with any of these kind of procedures
you should expect two or three days
of swelling and being uncomfortable.
Usually there's not a massive amount of pain
but the swelling is much worse
than any discomfort that you're gonna get.
Anyway, we take the gum from the back
and we place it underneath the gum at the front
where we've lost all this bone, okay?
And this creates a thickness.
It creates volume back into the area.
And we're only doing this for cosmetic reasons.
We don't need this to put an implant in there
because we've got loads of bone behind there.
Now, this is a really neat option.
I really like this
because we're using the patient's own stuff all the time.
Their own gum that you have taken
from one place to another.
We're not using any additional what we call biomaterial.
Nothing that's been brought in or taken from other animals.
Although that stuff works.
It's just neat and tidier
if you've got the patient's own stuff there all the time.
So that's one way.
The other way of tackling this problem
is to actually address the bone, okay?
So the problem is the bone itself has shrunk away.
So we do a bone graft
and we thicken up the volume of the bone.
And then we use the same gum from the outside
to cover that new volume of bone.
So it's a different technique.
We can still use the patient's own bone.
We can take it from somewhere else in the mouth
and place it on the front.
But a more typical way of doing something like this
is to use like a bone grafting material.
Which is ultimately derived from either cows or pigs.
And there's membranes.
And stuff like that.
It works really well for small amounts of bone
that we want and it's very convenient
to just open a bottle and pack it on there.
And then what happens is
your own bone grows into that graft material
and over time it will become firm
like your own bone, okay?
So that's really neat.
That's our second way of doing it.
So with both of these two techniques.
The goal is to increase the volume at the front here
so that we can put a tooth on there
and then that tooth will look correct, okay?
So that junction which I spoke about
where the gum and the tooth meet,
we call that the emergence profile.
It's how the tooth emerges out of the gum.
And this is what we're trying to do
with these front implants
to try and get it to look as natural as possible.
Now, let me walk you through how we did this case.
Because it wasn't easy or straightforward.
Now, the history is this is a young lady, all right?
When she smiles she can see the gum.
And it's really important that we get
the symmetry correct in order
to achieve these ideal aesthetics
that we're looking for.
And we know that having this tooth taken out
is gonna reduce the amount of gum and bone.
So what we did...
She actually had two veneers on the front two teeth
and one tooth was very weak
because she'd broken it as a kid.
She'd had a root canal.
She'd had a post one of the root canal treatment.
So she'd had it waken the tooth a lot.
And something happened and suddenly
it just won't crack and that was it, it broke.
So we took the tooth out.
We used that same tooth.
We cut the tip off it, cut the root of that tooth
and used it as a temporary measure
and glued it to the teeth either side, okay?
Because this is a long process.
She can't be without a tooth.
She's a doctor.
She's in the front facing role at work.
And she's got a family, a social life.
She can't be without a front tooth.
So we had to make her a good front tooth
and not a removable denture, okay?
As a front tooth.
I don't like removable dentures as temporary solutions
because they can put pressure on the gum
which we would like to avoid if we can.
So anyway, we've got the temporary done.
And from the other angle
you can see this reduction in bone that we've had.
So if I just draw some white lines on here
you can see along the natural tooth
where we still have all of this bone,
we've got a nice kind of um...
We call it a root eminence where you can feel...
You can feel this with your finger actually.
Just rub your finger over the teeth which you have
and you'll feel a little bump over the top.
And that's the root beneath the bone.
And when we've had the tooth taken out
it's much flatter because the bone has shrunk in
and that means the gum follows it.
So we actually did a tissue graft at the time
of placing the implant in.
And this is the situation soon after that, okay?
If you look at it, it's not much better, okay?
We have increased the thickness a little bit
but let me show you side on
and you can see what it looks like, all right?
And the neck of this tooth
just doesn't look natural, okay?
Because the gun is in and the tooth is forward.
The tooth is pretty much in the right place.
Yeah, there's certain features about it
which we need to still improve.
But this emergence
which is the really difficult thing here
is completely wrong.
It's like the tooth comes out and then goes down.
Which in some cases we need to do.
But in single implant crowns, we can avoid this.
So we actually did a second tissue graft for her.
Once the implant was already in place we...
And this is the only time I've actually done
a tissue graft with the implant in place,
especially on the (murmurs) place.
And then we took additional gum from the back.
We placed it inside.
Let it heal.
And it looked a lot better.
So the photo on the left
is just when the implant went in
with tissue graft number one.
And then the photo on the right
is with tissue graft number two.
And you can see we've got a bit more of this bulge
around the implant tooth.
That's what we're aiming for, okay?
So then we go through our whole process.
She had the implant tooth on one tooth
and then we redid the veneer on the other side
to create the symmetry.
One space was bigger than the other.
So we had to use certain techniques
to give the illusion that the teeth are the same.
If I'm gonna be really critical
which I always am on dental work like this,
the implant tooth is slightly brighter
than the natural tooth.
Because the natural tooth
we've got the yellowness showing through.
This can sometimes be compensated for
by having a whiter veneer which will tone down
when you've got that natural tooth underneath.
But because we did the second tissue graft
on this tooth here, you can see a thin scar tissue,
scar line above the tooth.
You can see the light reflects
a little bit differently on there.
So we always want to avoid scar tissue
and scar lines like this.
In reality, the patient didn't notice this.
And she had a mirror right up close to her teeth
trying to spot the difference between the two.
She didn't see that.
But it's something that as a cosmetic dentist
we're trying to push the boundaries
and get even better and better.
Now, as I say this is one way of doing it.
This is what we call the delayed method, okay?
So you take the tooth out.
You let the bone shrinkage happen.
You see what you're left with.
You choose the right, either bone grafting
or tissue grafting and you build up
the the defect left by taking the tooth out.
And then we place the implant
and then make really good temporaries.
Get looking right in temporary teeth first
and then you move to porcelain, okay?
So that's the kind of fail-safe way of doing it.
The downside is it takes a long time.
But if you've actually got the route still in place
then there is a better way of doing it, in my opinion.
So I'm gonna shoot another video
and hopefully get it out in the next week or two
and I'll show you the process of doing an implant
when you've actually broken the front tooth off
and the root is still remaining, okay?
Because it's a totally different scenario.
And it's a slightly different technique.
But the cool thing is you get your tooth a lot quicker.
The end result is achieved much more quickly.
So I hope you found this useful.
I hope you found it informative.
If you've got questions, comments,
you can put them below
and I'll try and get back to everyone.
If you wanna find out more about me
you can find me on different social media channels.
You can have a look at my website for consultations.
If you're in our local area
I'd love to meet up
and talk to you about your solutions, okay?
So until next time, take care.