Hi, everyone.
When we're looking at dental implants at the front of the mouth, it is a completely different
ballgame compared to dental implants anywhere else in the mouth.
You see right to the front, we not only do
we need to get the tooth right, but we also need to get the look of the gum right
and this is probably one of the hardest things in cosmetic dentistry.
Let's have a look at this case.
This guy came to see me because he had problems with this tooth.
And you can see just doesn't look very good.
But it wasn't so much the look.
He's kind of lived with that for a long time.
He knocked the tooth when he was younger, had a whole lifetime of treatment on it.
And now it's at a stage where the crown keeps
coming off, but the root of the tooth is still in there.
So we've got a couple of options.
Usually when we're in a scenario like this, okay, I'm looking at this case and I'm thinking, well,
actually I really like the gum line that we already have here.
So if we're able to take the bad tooth out and put an implant in there straight away,
we can do a little bit of bone grafting or whatever
to kind of support the gum
so that we don't get so much shrinkage and the end result looks good.
In essence, we're trying to maintain this gum line because I already like the look of it.
Now we took an X-ray and this tooth
has a big infection around the tip of it.
Okay, so it's had a root canal treatment and the root canal treatment isn't working anymore.
And now we've got this area of a big infection.
And the problem is when you've got an area, a big infection like this, number one,
it's potentially full of bacteria. Okay.
So you don't want to put an implant in there straight away, but this isn't always the case.
The second thing is the bigger
the area of infection, the less bone I have to actually put the implant in and make it stick.
So we'd have to use a really long implant
and secure it in a little tiny bit of bone at the end, if we were going to do it all in one go.
And I thought, okay, look, it's just safer.
Let's take the tooth out and let's put a temporary bridge in position.
And that's exactly what we did.
We took the tooth out.
This is what it looks like on the day of taking the tooth and putting a temporary bridge in.
And although having a side on view, it doesn't actually look too bad.
It looks actually better than where he first came in and he was happy with the appearance of this.
But that inevitable thing, which is always going to happen when we take out a tooth, we've got bone loss.
So you can see here a few months later, the bone has shrunk back and it's shrunk up as well.
So he's now conscious of the appearance
of the gum around this temporary tooth that we've made.
And this picture illustrates just how much bone does get lost.
And this is typical. This isn't abnormal.
So we need a way that we can rebuild this bone
and this there's kind of two ways around this.
We can either do something at the time of taking the tooth out
or now that we've taken the tooth out, we can either
rebuild the bone or thicken the gum.
Both will have pretty much the same results as long as the treatment works.
So what can we do at the time of taking the tooth out?
Okay.
I've already said we could have put an implant in
if we didn't have that infection, and that would have saved us a lot of time.
The other thing that is potentially possible, which I've done a few times
and it works quite nicely, is half take out the tooth.
So this is called a socket shield technique and essentially what we doing
is leaving a little bit of tooth, just a little sliver of tooth.
So you have to dissect the tooth and cut it in certain places
and only take out the kind of the root canal part
and just leaving a thin sliver to support the outside surface.
And this works quite nicely.
It's not absolutely perfect, but it does help
reduce the amount of bone shrinkage and volume loss that we get.
But we haven't got that problem.
Okay, now the gum, the whole tooth has been removed.
We've lost all of this volume and I've seen him three or four months later and we've taken another CT scan.
The good news here is that the CT scan shows
that that whole area that was full of
either a cyst or an infection,
that area has completely cleared up after we took the tooth out.
Okay. So that was our main goal.
So now we've got loads of bone to put our implant in.
Now I've been on a lot of conferences,
talks, courses, all of that kind of stuff related to implant surgery.
And I've seen some of the most renowned
surgeons and periodontist around the world talk
about how they achieve good results and they all achieve really nice looking results
and the
long and short of it is there is no one correct way of doing it.
If you speak to the bone grafting guys, they will come up with a bone grafting solution.
If you speak to the soft tissue guys, they will come with a soft tissue solution.
One thing that they do agree on is that you do need bone around the implant.
So if if the bone is so thin that you don't you can't even place an implant, you definitely need
some kind of bone grafting in that kind of situation.
Now, in my own experience, it's kind of similar to that.
We often will use bone graft, and if you've got a big hole,
we'll use bone grafting to really get enough bone there to put an implant in.
Once we've got enough bone to put an implant and then it's all down to gum work
and thickening the gum using connective tissue grafts,
basically taking graft from the roof of your mouth typically
to wherever you need it to really thicken the gum out.
I think you get a better results like this.
There's less complications.
There's nothing foreign being introduced into the body.
It doesn't work every single time.
Sometimes you need to do it
a second time.
Sometimes graft doesn't work.
But that's true with any kind of procedure.
Whenever we're thinking about any kind of grafting, we have to think about blood supply,
whether it's a connector, tissue graft or bone graft.
The only way these things heal is by getting adequate blood supply.
So every little cut that you do is actually cutting and reducing blood supply.
So we have to be very selective and careful on how we do this.
Now, this area is going to get blood from the palate from inside the mouth and from the outside.
So I'm going to choose an implant which has a very thin neck
that's going to help not obscure the whole blood supply that we get.
Secondly, we're using guided surgery for this case.
So if you haven't seen my video on guided surgery,
it's when we plan the position of an implant on a computer.
First of all, using the CT scan, we then have a surgical guide made and it's kind of like a stencil.
And our drills and implants go through that, ensuring
that our positioning of the implant is very, very accurate.
So we'll do that will place it also.
Now, I think we can get a really good result with only using a connective tissue graft.
Okay, we've got loads of bone to put an implant in.
We're going to thicken up the gum using a connective tissue graft
and have a temporary tooth put on the implant straight away.
So that's going to support our tissues.
And during the healing phase, it's going to shape them so we get the correct shape.
We should be able to rebuild this black triangle that we've got
and also increase the thickness of the gum.
So that we get a nice esthetic appearance to the temporary tooth.
Again, whenever we do any cosmetic stuff like this, we always want to get it right in the temporaries.
Once the temporaries look really good, then it's easy, you know, then
then we just make a crown, fit the crown, and it works every single time.
That's how we got a good result in this case.
In this case, we can see that we've got
two to the front, two teeth here are implants.
And actually what happened was she actually lost the tooth next door to it as well.
So we've got three implants here all next to each other.
And typically these pink triangles in between
the teeth, the papillae are very difficult to get,
but using these techniques, using connective tissue grafts,
we are able to get really good looking end results.
You can't get these results by just putting an implant in and just putting a tooth on there.
It's going to look compromised.
It's going to look a little bit odd.
I mean, here's a case you can see on the patient's left side
where we've got this this tooth here, the tooth looks too bulky.
It doesn't look quite right.
And this is where an implant has been placed without any bone grafting
or tissue grafting on the other side,
I've actually placed two implants already, although you can't see them.
And we did a connective tissue graft.
You can see how thick the gum is in this area.
Granted, it's on the day of surgery, so it might look different in two or three months.
But the implants think we've got a good thickness of gum around that I'm confident
will get really good looking end results
for this case once we are all ready to proceed with it.
Once the implants of healed.
So recently somebody did
contact me with with a tooth which is just broken that gum level.
Again, a history of trauma, a history of issues with this tooth
and it's really important to see somebody,
the dentist is going to be doing the implant work before you have that tooth taken out.
The temptation is to have the tooth taken out
and have a denture or bridge made in an interim period.
And that would be fine. I mean, that's exactly what I did.
And in the case I'm just showing you, however,
if you you see the dental, you don't have an infection, you've got bone and conditions.
In your case, a favorable.
It might be possible to do all of this in one go, essentially all in one surgery.
So you could have the bad tooth taken out.
You can have a tissue graft, you can have a minor bone graft done, and then you can have a temporary tooth
placed on that implant all in the same visit.
And the advantage of that is three, four months later, you can have your final crown.
So your whole treatment is typically four, maybe
five months with your normal delays or whatever.
So four or five months and you think is done here
four months down the line, we still don't have an implant in there.
So it's going to take an additional 4 to 5 months doing it the kind of long way.
As soon as you take out that tooth, you've almost committed yourself
to three or four months of extra treatment time.
The end result will probably be similar.
However, I think it's always easier if you've already got a really good gum line.
It's easy to maintain that gum line than it is to start again
and reconstruct a gum line, which looks good.
So as always, guys, I hope you find this video useful.
I hope you found it interesting in some way.
And if you've got any questions or comments, please, you can leave it below.
I don't I don't see all of them because of notifications on my phone, but I will see a lot of them.
And if I can reply, I will.
So until next time, guys, take care.