Category Archives: Dental Implants

Screw Retained Or Cemented Dental Implant Abutments….Which Is Better?

This is actually a really old topic that has become renewed again in the last few years. Do you hold your implant crown or bridge in with a screw abutment connection or do you hold it in with cement? Each technique has their merits.

In this video I will describe many of the reasons why one should be chosen over the other. There seems to be a very large educational gap in dentists that are heavily involved with implants and those that just dabble in dental implant restorations. Some people take an all or none approach with regards to screw retained crowns or cement retained crowns but did not really seem to understand the biomechanical principles in relationship to bone physiology.  The same educational gap holds true for connecting implants together or leaving them as individuals. I hope this helps you make a good decision on how to determine what is best for your unique situation. I have utilized both methods for almost two decades now.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Shaping And Forming Gum Around Front Teeth Dental Implants – Ramsey Amin DDS Reviews

Of the 100’s of articles I have written, this is one topic that is often not well understood by dentists or patients. So what is shaping, grooming, forming and training of gums around dental implants?

It is the process of getting the gum line around your front tooth dental implant to look as natural as possible. What makes the gum look natural? I will focus on some of the really important items:

1. The evenness of one gum line to the adjacent teeth gum line
2. The triangle of gum tissue “papilla” to be filled in. This is located between your gum.
3. The volume of gum on the outside of the implant.
4. The 3-dimensional placement of the surgical portion of the implant.
5. The health of the adjacent teeth
6. Genetically thick or thin gum and tissue


flat gum tissue without papilla or gum line before dental implant placement

flat gum tissue without papilla or gum line before dental implant placement

preoperative photograph-flat gum tissue

preoperative photograph-flat gum tissue

preoperative picture showing flat gum tissue

preoperative picture showing flat gum tissue


surgical placement of implant just slightly below bone level

surgical placement of implant just slightly below bone level

screw retained dental implant temporary interproximal view

screw retained dental implant temporary interproximal view

screw retained dental implant temporary facial view

screw retained dental implant temporary facial view


screw retained dental implant temporary, lingual view

screw retained dental implant temporary, lingual view

Implant with uneven gum line and missing papilla triangles of gum.

Implant with uneven gum line and missing papilla triangles of gum.

implant temporary and gum graft on same day as dental implant placement. Sutures visible

implant temporary and gum graft on same day as dental implant placement. Sutures visible


2 weeks after dental implant temporary. Notice that gum tissue is still open but beginning to form.

2 weeks after dental implant temporary. Notice that gum tissue is still open but beginning to form.

3 days after dental implant temporary

3 days after dental implant temporary

2 months with dental implant temporary

2 months with dental implant temporary


3 months with dental implant temporary

3 months with dental implant temporary

4 months temporary

4 months temporary

temporary after 4 months and multiple material addition to make gumline look near-perfect

temporary after 4 months and multiple material addition to make gumline look near-perfect


impression coping showing scalloped gum architecture

impression coping showing scalloped gum architecture

material added to existing temporary to modify gum level

material added to existing temporary to modify gum level

final implant after 18 months. Photograph during patient's cleaning visit.

final implant after 18 months. Photograph during patient’s cleaning visit.


custom zirconia abutment

custom zirconia abutment

final implant on day of insertion


On this particular patient I was replacing her upper right lateral incisor. I took many pictures over the course of a few months to monitor the gum healing. Read the captions to follow along the progress.  You will see how the gum changes over several months!

When you have a front tooth dental implant it is very important that you get a temporary made on the implant so that the gums can be made to follow the new shape of the tooth. If you have been missing a tooth for a long time, then the gum tissue is flat. It takes time to develop this gullwing shaped arching effect from one tooth gum line to the next. Sometimes surgical correction is needed but most of the time shaping the temporary properly and giving it 2-6 months will allow it to happen on its own.

Your implant has to be put into a good position for this to work. If the angle of the implant is too far forward and the head of the implant is too close to your lips, the implant will end up being long looking. Sometimes there are no other options because your jaw may angle outwards in the bone is so thin that there is no leeway and placing the implant closer to your tongue. But, ideally the implant should be placed just behind the edges of the upper front teeth. So, the first step in having a great gum line is having a very well placed implant in the bone in the first place!!!. Sometimes computer guided surgery helps but not always because there are errors.

There must also be a lot of bone on the outer wall of the implant. 1-2 mm or more of extra bone on the outside of the implant with good, thick gum tissue on top will allow for proper volume of gum so the tooth looks like it is coming out the gum rather than laying on top of the gum. This is not always possible and sometimes a gum graft needs to be done in combination with a bone graft in order to achieve the final volume. The implant must not be too large. Smaller, longer implants are often best in the front teeth areas.

In my practice, your dental implant gum line begins taking shape from the time the tooth is extracted. Your tooth must be very carefully extracted as to preserve as much of the gum is possible from being lost during the extraction process. Sometimes an extraction and immediate non-load dental implant is needed and sometimes staging the implant over time and doing a socket bone preservation graft is better.
If the implant is stable enough to have a same day temporary crown put directly on the implant it needs to be shaped a certain way. The implant temporary that I make for your implant usually has a “negative facial contours.” This allows the gum line not to be pushed away but rather create a thicker “cuff” of tissue around the base of the implant. If the temporaries placed on the same day that the implant is placed then thick gum training and shaping begins on that day. If the implant has to be buried or a large bone graft was done, this process will begin later on.

You can see in some of the photographs how the temporary crown is created by hand and attached by a screw to the replica green implant. This allows me to do all of the forming and shaping outside of your mouth. The sides or interproximal areas of your teeth are shaped in such a way to promote the triangle of gum tissue to grow to the proper flossing contact height. In some cases the temporary needs to be removed a few times and material either added or subtracted from it in just the right spot to move the gum line to the desired position. Most of the front teeth dental implant temporaries I make are held in with a screw rather than cement to make this easier for you.

Growing the triangle gum papilla to the proper height is often dictated by your adjacent teeth. If the tooth on either side has bone loss, even minor, the gum is much less likely to fill in completely leaving a small black triangle. This can be preplanned in advance in many situations. Oftentimes the crown can be made with a little bit of extra porcelain to fill in the black hole or sometimes the tooth right next door would need a tiny filling to close the space up. As long as it does not make your smile look asymmetric, often times this can work well. Ideally all the gum grows back to original height. It is also important that your dental implant be placed at the right depth. There is kind of a “sweet spot” or the implant is not too deep and not too shallow…..it is very much an art and can be very “touchy” and delicate.

Oftentimes front teeth require custom abutments to be made to follow the highs and lows of the scalloping gum tissue. The custom abutment also helps and supporting what is called the “emergence profile” of the tooth. This is the transition from where the implant is in the bone to where the gum line begins. In 2016, your tissue training, molding/grooming can be re-created into a 3-D printed model using an intraoral scanner like the trios 3. This prevents the gum from collapsing during the ‘molding’ digital or conventional impression.

I understand there are a lot of fine details, but it takes a lot to make a front tooth look great! It is all about the gums and not so much about the white porcelain part of the tooth. This is what separates good from great dental implants that are done right the first time. This process of shaping the gum line can take from just a few days to more than a year to complete. Each case is very unique.

Ramsey A. Amin, D.D.S.

Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Diabetes, Dental Implants and Bone Grafts…Is it Safe?

You may be reading this because you are at a diabetic in need of an extraction and bone graft or full mouth dental implants.  You are probably well aware that diabetes can cause slow healing from dental surgery or any type of surgery.  You can be at a higher risk of complications because of being a diabetic.

So how do I do dental implants and bone grafts on diabetics?  VERY Carefully!!!

bone-graft-squareDiabetes affects all organ systems.  Big fluctuations in blood sugar cause your healing to be impaired.  Diabetics are prone to problems with feet, eyes and kidneys but oftentimes develop periodontal disease/gum disease which has likely led you to this point to read about implants and extractions.  I tell all my diabetic patients that you must be extremely diligent in the care of your teeth even more so than someone that does not have diabetes.  This is because you are more prone to lose them and replacing teeth with implants is more difficult than your situation… difficult but not impossible.

In these photographs I show two patients that have had similar treatment at the same 7-10 day follow-up.   I treated both patients. You can see that the patient that  has diabetes that is not well managed is healing much slower than the patient that does not have diabetes.  This is not always the case but this is a great example! 

Diabetic that is not well managed is healing much slower

Diabetic that is not well managed is healing much slower

Non-diabetic with normal healing

Non-diabetic with normal healing

Neither one of these patients had bone grafting in addition to the implants they only had four implants placed in the same area for a lower dental implant overdenture.  They are both females in their 60’s.

You are probably familiar with taking your blood sugar. These numbers need to be as low as possible in the good range.  Blood sugar testing should be routine and a very important number called the “hemoglobin A1c” gives me an idea of how well you will heal after a dental implant/bone graft procedure.

Ideally the lower the A1c number the better because that gives me an idea over the last 3 months how stable your blood sugar control is.  If the A1c and daily blood sugar readings are high, then perhaps we need to consult with your endocrinologist to get it into better health.  Of course your diet and lifestyle have a lot to do with diabetes control.  Sometimes just switching meds does the trick while others need to be managed with an insulin pump.

In the weeks prior and at least 4-6 weeks after a dental surgical procedure, try to be as strict is possible with your diet and diabetes control.  It is in this critical early-phase that major complications can happen and failures or infections are most likely to happen.

diabetes-squareI use some special techniques to try to help my diabetic patients heal as quickly as possible.  For the last 14 years or so, I have used the patient’s own blood to make special concentrated versions that carry growth factors, which aid in the healing process.  Also a strict aseptic/sterile technique of placing implants, bone grafts helps reduce your chance of infection by having a very clean environment to start with.  Antibiotics are almost always necessary often in the IV and given by mouth for 7-10 days afterwards and occasionally longer.

Keep in mind that some implants and bone grafts are **far more** complicated than others.  The more complex the situation, the higher the risk of having some sort of complications.   For example, full mouth dental implants and block bone grafting is more complex than a single socket graft.

I would suggest that you work with a very skilled and experienced provider who has done hundreds of implants successfully on diabetics to figure out what is right for you.  Be very open and honest with your implant dentist so you can safely treated and have it done right the first time.  You can be succesfully treated!  Type 2 diabetes is better than Type 1 but both can be treated. You must be managed a bit differently to prevent implant failure and bone loss.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Upper Molars with Sinus Bone Graft and Lower Single Implants -Ramsey Amin DDS Reviews

VM (5)
molars
VM (4)
VM (3)
molars2
VM (1)

This is a nice example of basic treatment with dental implants that was well engineered. What you are looking at here are four dental implant molars that I placed in virtual 3-D. The implants are actually surgically placed in the bone but what I did was ‘overlay’ the implants that are actually there with the computerized virtual dental implants. This is done so that the exact position can be seen more easily and you can learn more from this article.

X54321

Before treatment…. patient already has one implant

Notice that all of the implant sizes maximize the available bone volume… The implants are not too small and they are not too large… Both of these can create problems. Also notice that each implant has plenty of bone on the outer wall which will support these implants for a long time and will greatly reduce the chance of ever having bone loss/peri-implantitis.

On the upper right notice there are two dental implants. A sinus bone graft was done in order to create enough height of bone to place these implants. The implants are placed against the medial wall for best trajectory but also avoiding the contents of the nose. Previously she was missing the second molar and the first molar had to be extracted due to periodontal bone loss.

Genetically, her sinuses hang down fairly low which would not allow implants of larger diameter and length to be placed. This is very important for the upper jaw in the back of the mouth. I also suggest that these implants be connected especially if the last two teeth are dental implants. You can clearly see the sinus bone graft over the top of the implants.

X54321_2

Teeth not on 3 of the implants yet. One of the implants in the upper was placed in eastern europe 20 years ago.

The lower molar dental implants are single tooth dental implants. The one on the left side of the screen is smaller and longer while the one on the right side of the screen is wider and shorter. Even though they are the same lower first molar the anatomy, each area is slightly different. Every tooth is planned in a unique manner.

This patient happens to be the wife of a dentist that I treated. I actually treat many doctors and dentists…. Even we need tooth replacements too!!

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Replacing Four Lower Back Teeth With Dental Implants and Bone Grafting – Start to Finish Detailed Video Review -Ramsey Amin DDS

This video has a lot of information on dental implants and bone grafting. There is also a lot of information on how the teeth and dental implant abutments are made in the rationale of why I did everything. You also see the sequence where three of the implants were placed in a delayed fashion and one was placed as an immediate dental implant.

***If you are considering having dental implants and perhaps socket bone grafting, this is a must-see video.**

X54316_1


IMG_1148
IMG_0823
IMG_0821

 

IMG_1165

Please be sure to watch the entire video as there is so much to learn about the entire process of having teeth replaced with dental implants. In this video I review the diagnosis, treatment planning, 3-D scan analysis, surgical placement of four implants and the restoration of the four implants with for non-connected monolithic zirconia crowns with prefabricated abutments.

This patient has several failing root canals and very heavily worked on teeth. The teeth have been crowned in re-crowned multiple times and now several molars need to be extracted. In fact a few of the crown/root canal teeth came apart during the healing!!! They were added to the list of teeth to extract and replace with dental implants.

I also show after photographs so that you can have a complete start to finish outlook on this procedure. I consider this patient a very basic case in my office. In the 3-D scan analysis, I discuss how the surgery and planning can prevent long-term complications such as peri-implantitis which is bone loss around implants.

I appreciate your comments and questions. I hope this video helps you.

Ramsey Amin DDS
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

 

 

Zirconia Dental Implants Pros and Cons Video

Are zirconia dental implants the answer?  The vast majority of dental implants are titanium alloys that have been in use since the mid 1960s.

a comparison of a titanium dental implant with titanium abutment, a titanium dental implant with a zirconia abutment, and in all white zirconia implant one-piece

a comparison of a titanium dental implant with titanium abutment, a titanium dental implant with a zirconia abutment, and in all white zirconia implant one-piece

The focus is whether the actual implant screw is made of zirconia or titanium.   Zirconia dental implants are attractive for those that may be concerned about a metal allergy.  In this blog post I describe the pros and cons of zirconia dental implants.  As of the year 2015, I would not recommend them… The scientific evidence and clinical practice does not support their claims.

The one piece design in itself is a very limiting factor.  The implant cannot be redirected by an abutment….  Right or wrong, position cannot be changed.

In my dental office in Burbank, California, I commonly use zirconia as the crown or bridge portion.  It is also very useful as an abutment which is the intermediary piece on a two-piece dental implant.  Both the crown/bridge and abutment portion are not embedded into the bone.  Zirconia bridges such as the Prettau dental implant bridge is extremely strong as long as it is made very thick.

In this post I also discussed what happens when orthopedic surgeons use zirconia as a hip replacement material.... You will be shocked to hear the results!!

Your comments and questions are welcome as usual.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology / Implant Dentistry
Fellow-American Academy of Implant Dentistry

Prettau Full Mouth Dental Implants ~3D planning by Ramsey Amin DDS

This is a case being planned for upper and lower Prettau dental implant Bridges. The patient just lost her lower front teeth extracted and now has no teeth at all. She can no longer wear a lower denture and desires dental implants that are nonremovable.

This video walks you through some of the clinical photographs involved in planning the case and then moves into 3-dimensional planning from a 3-D CBCT scan. I will show you how the implants should be spread out and placed into the best bone possible. The video also shows how a surgical guide is made from the 3-D scan planning that I personally do for every single case. I do not believe in outsourcing surgical planning to other dentists and technicians from companies that do not understand anatomy…. Yes this is very common!

The video highlights some of the powerful software that I use every day to plan surgeries for safety and predictability. The surgeries are performed in one of four surgical suite in my Burbank, California office

Thank you for watching!

Block Bone Graft for Dental Implants 2015 Update-Ramsey Amin DDS Reviews

This article is a follow-up to a video from 2009 that I receive a lot of questions about. Block bone grafting for dental implants is still a very successful procedure…. But a lot has changed in 6 years!

(side note: Many people mistake the term “graft” with “graph.” The correct term is “graft”)

I highly suggest you watch the video and read this post. You’ll gain excellent information from both to help you make an informed decision if this is something you’re considering.

A block bone graft is done when there is a large section of bone that is missing. That area of missing bone is usually the outer wall of bone that faces your cheek. A block bone graft is needed when there is no way to put particulate bone particles into a “hole” like an extraction socket. The block bone graft attaches by screws to your jaw kind of like an orthopedic surgeon who is fixing a broken leg with screws. The screws are only kept in during the 4-6 months that the bone is reconnecting to your own existing bone.

before block bone graft, note the missing bone around the virtual implant

before block bone graft, note the missing bone around the virtual implant

before block bone graft, note the missing bone around the virtual implant

before block bone graft, note the missing bone around the virtual implant

after block bone graft, screw in place

after block bone graft, screw in place

So what has changed? My philosophy on where you get the bone from has changed! The reason for this is there is better scientific data to support the use of bone from a tissue donor (cadaver) rather than using your own bone! It used to be thought that using your own bone was the best.

I know this sounds crazy that using bone from somebody else would be better than using your own. But that has been my experience over the last 15 years doing block bone grafts for dental implants. Using block bone graft from your own body requires that I have to cut a piece of bone from your chin under the roots of your lower front teeth) or from the area where your lower wisdom teeth are or used to be. Cutting this piece of bone has its own risk factors especially the risk of permanent numbness because the nerves are close to the area where the bone has to be taken from. Using bone from a tissue donor has an unlimited supply so we don’t have to worry about the bone taken from these areas as not being enough.

What experienced dental implant surgeons around the world have agreed upon is that block bone grafts using your own bone tend to be “avascular.” This means that they do not have a good blood supply. Getting blood into the bone graft to bring it back to life is the key to success of a bone graft. Even though the bone is taken from your own body, sometimes that outer wall we call cortex is too hard and does not get good permeation of blood vessels called capillaries.

The addition of molecular enhancers and growth factors made from your own blood has also changed…. technology is evolving!!  The use of L-PRF, PRP and PDGF made from your own blood tremendously helps a block bone graft. These are made from drawing a little bit of blood at the beginning of your IV sedation and concentrating your own natural growth factors from your own blood . The growth factors and even stem cell will be reimplanted into the bone graft area…. This is truly awesome.

Accredited tissue banks have learned how to properly harvest this bone also. The type of bone I use has origin from the vertebrae (back bone) of another human being. Remember that this bone is 100% dead. Nothing is alive and it. It has undergone severe radiation treatment to kill everything. Your own body will make it alive again. Some small gaps around the bone graft may be filled in using cow bone which is also very safe and well documented over several decades now.

What hasn’t changed is the surgical ability to do this procedure and the ability for you to heal very well. This is definitely a procedure for a very advanced dental implant surgeon with a lot of experience. This would not be the type of bone graft for novice. You as the patient must also be healthy. Smoking , substantial alcohol use and diabetes would be significant risk factors and lowers the success of any dental bone graft and implant procedure.

The examples shown should help for you to understand why a block bone graft is done. On the first images you can see the bone in cross section taken from a 3-D scan. The bone is too narrow to accept the diameter of the virtual dental implant which is outlined over the bone. In order for dental implant to be successful there needs to be an abundance of bone especially on the outer wall of the implant for it to be stable long-term and last a long time. You can see on the images where the bone graft was completed and the screw is holding in the bone.

The gum is lifted, your own bone is prepared in order to receive the cadaver bone and that block bone graft is then screwed to your existing bone. The bone graft is hydrated in your own natural growth factors before it is screwed to your bone. The gum is passively covered back over the top and the block bone graft is allowed to heal for 4-6 months prior to removing the screw that holds the bone graft and placing the dental implant. A special type of temporary must be used for this bone graft if it is for a front tooth.

You can see the massive addition of volume that was added. The 3-D scan that was taken after the bone graft shows that same outline implant now sitting in a proper amount of bone. This will make the dental implant procedure extremely successful from a biological standpoint and from a cosmetic standpoint. When all of the bone is present both vertically and horizontally, there will not be open black triangles between the teeth which can be unsightly especially if it is the upper front area. The teeth on either side must have very healthy bone levels for this to occur. You cannot do a bone graft next to unhealthy teeth.

Block bone grafting using human tissue allograft from a cadaver is no longer a last ditch effort. Of course there are so many different ways to rebuild bone from bone widening expansion, socket bone grafting, sinus lifting, nerve repositioning, guided bone regeneration with membranes

huge dent in jaw --bone loss

huge dent in jaw –bone loss

after block

after block

after block

after block

after block bone graft

after block bone graft

block bone graft Ramsey Amin DDS front tooth (6)

Blood from novocaine injection given after patient was sedated for dental implant

 

After block bone graft --Implant placed --DAY OF SURGERY PHOTO

After block bone graft –Implant placed –DAY OF SURGERY PHOTO

3d Scan before block bone graft ---missing bone!!  Thin!

3d Scan before block bone graft —missing bone!! Thin!

After bone graft -- four screws holding in the blocks

After bone graft — four screws holding in the blocks

After bone graft -- four screws holding in the blocks

After bone graft — four screws holding in the blocks

After bone graft -- four screws holding in the blocks

After bone graft — four screws holding in the blocks

Before bone graft --

Before bone graft —

before block bone graft -Missing bone

before block bone graft –bone is very thin

3d scan --before block bone graft

3d scan –before block bone graft

3d scan --after  block bone graft

3d scan –after block bone graft

pre molar block bone graft Ramsey Amin DDS (3)

After –bone very wide…ready for dental implant

 

Implant placed --after  block bone graft

Implant placed –after block bone graft

After block bone graft --Wide bone now

After block bone graft –Wide bone now

…. So there is no one solution for everyone. Your case must be studied carefully to determine what is going to be the safest procedure with the best outcome.

The block bone graft for dental implants is typically done in areas of the upper front and side teeth.  All photos are surgeries performed by me.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Antibiotics for a Tooth Infection, Dental Implant, Bone Graft… Do I Need Them? 

In this short, but highly informative video, I review some of the common truths and misconceptions about antibiotics in relationship to tooth infections, dental implants and bone grafting.

Use of antibiotics should be judicious and carefully thought out.  Just because you have an “infection” in your tooth, it does not mean you need an antibiotic.  Also, not all “infections” are actually infections.  Not all infections can be cured by antibiotics alone.

Antibiotics are commonly needed for procedures that involved cutting through bone or addition of bone graft materials.  There is a limited supply of new blood vessels that can get your natural immune system’s protection in the first few days following a significant procedures such as a surgical extraction, a bone graft, sinus graft, apicoectomy and dental implants.

Antibiotics are extremely helpful in many situations.  I also discussed common questions such as antibiotic resistance and what happens with common stomach issues and what to do about them.

I think you will find this video helpful.  Please feel free to ask questions below.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry