Category Archives: Example Dental Implant Cases

Ramsey Amin DDS Case Review – Replace Loose Long Bridge With Dental Implants And Bone Expansion

This Burbank patient had a loose lower bridge.  She had had the bridge for about only 8 years before it failed and became loose.  You know a bridge is failing when it feels painful to bite down or there is movement.  This unfortunately is a daily thing I see every day.  Teeth were never intended to be hooked to other teeth.  She came to me because she wants dental implants to replace the bridge.

The existing lower bridge was made with a metal biting surface because the patient has a VERY  strong bite.  She wanted to make sure that her new dental implants could withstand her bite force.  She has broken other bridges in the past. You can see in her photos that she has worn through some of the porcelain showing through to the old metal layer on the opposite side next to the yellow gold crown.

First day exam visit

First day exam visit – broken root under the bridge

First day exam visit –side view

First day exam visit -panoramic x-ray

First day exam visit — full lower jaw. Failing bridge is the one with the metal biting surface.

thin bone prior to grafting but after extraction of the broken root

Bone grafting showing webbing of Vicryl stitches

10 days of healing after bone grafting showing webbing of Vicryl stitches

Clay model of the patient after bone widening expansion bone graft. Please note how wide and square the bone is compared to how thin it was before.

3-D printed models showing abutment contours

3-D printed models of abutments from top view

top view final bridge on 3-D printed model

side view of final bridge on 3-D printed model. This patient happens to have very short teeth which makes it even more important to have the teeth connected to avoid food impaction between the teeth.

sandblasted abutments in the mouth showing very wide bone and excellent healthy thick gum tissue

postoperative panoramic x-ray showing three dental implants in the lower right jaw.

postoperative panoramic x-ray showing excellent fit of abutments and monolithic zirconia bridge.

final bridge seated over the abutments. The final bridge is on the right of your screen.

When I removed the bridge I found one of the teeth anchors broken.   That broken root canal tooth is not savable and will need to be extracted. The back wisdom anchor tooth is healthy in and of itself but is tilted towards the front.  This patient is unique in that she has very long roots as shown on her panoramic x-rays.

The biggest issue is that the bone in the area where the teeth used to be is super thin.  When you lose a tooth or a segment of teeth, the bone thins out because it is not being used.  This process is called atrophy (BONE LOSS) .  So even though her bone was tall enough, it was not wide enough to have implants properly placed in the center of where the teeth used to be.  If you try to have your implants done without a bone graft, the implants would have to be pushed towards your tongue side and the implants would be a very small diameter with minimal bone on the outer wall… a recipe for disaster.

In her case, I did a bone widening/expansion ridge split.  In this process, I actually purposely “break” the outer layer of bone towards the outside and push the outer layer of bone away from the inner layer of bone.  This creates a big trough which can then be filled with donor cadaver/cow bone and L PRF/PRP made from your own blood.   This is a very advanced bone grafting technique that is not just a typical mild expansion of bone.  It is a full repositioning of the outer wall of the lower jaw bone.

This bone graft was allowed to heal for 4-6 months prior to placing the implants.  In her case I would not advise placing implants at the same time of the bone graft although in many cases I do place the implant simultaneously.  Her case was special and that she was on a bisphosphonate medication in the past for cancer treatment.  The bisphosphonate medications can slow down bone healing and can have really detrimental complications so going slow was better than going fast.  I did some blood tests for her and also consulted with her physician prior to initiating treatment.  It is always best to be safe especially when dealing with dental implants and medications similar to Boniva and Fosamax.

After a few months of healing I decided to place 3 dental implants for a connected-splinted dental implant bridge.  Remember she wants the “strongest possible” solution so I advised her to have 3 implants and a 3 tooth bridge rather than 2 implants and a 3 tooth bridge.  Connecting the teeth is definitely the strongest way and helps prevent food impaction.

In the photographs, you can see how wide the bone is and how the implants are well centered and spaced now that she has the proper amount of bone.  The implants are long and of a really good diameter for a proper emergence from the gums for large molar teeth.

After 3 months of healing, I began to take my initial 3-D video scans of her mouth to fabricate her teeth.  I made 3 titanium abutments on the 3-D printed model in a virtual program.  This way the teeth are fabricated using a computer and not typical gypsum clay molds and messy impression material that gets stuck in your mouth!

The abutments were steam cleaned and sandblasted for proper cement hold and sterility.  This is a another important step which is commonly skipped.  The implant abutment junction must be super clean and the smooth metal must be roughened slightly for micro retention.

The implant bridge was then fabricated using monolithic zirconia.  This material is wonderful because it is white, strong and aesthetic for back teeth.  It is stronger than original bridge with the metal support.  I use this material quite commonly for my full mouth Prettau zirconia dental implant bridges.

Needless to say, she was very happy with the final result of her teeth. I am sure they will last a very long time. The best part was the big hug she gave me at the end. 

😉

Converting Bad Dental Implant Overdentures To Fixed Full Arch Bridges -Review Of Complex Case

Here is an interesting full double arch dental implant case that I took over from another dentist.  This patient desired full mouth dental implants.  When he presented to my office he already had 10 implants but could not use his teeth.  He paid a lot of money only to be disappointed with the removable over dentures that were made for him.

initial x-ray when I first met the patient--10 implants that would not work for over dentures

initial x-ray when I first met the patient–10 implants that would not work for over dentures

initial presentation when I first met the patient with his existing 10 dental implants and over dentures that would not work.

initial presentation when I first met the patient with his existing 10 dental implants and over dentures that would not work.

pre-existing condition when I met the patient-upper jaw

pre-existing condition when I met the patient-upper jaw

pre-existing condition when I met the patient-lower jaw

pre-existing condition when I met the patient-lower jaw

bulky, huge dental implant over dentures...poorly done

bulky, huge dental implant over dentures…poorly done

poorly made overdenture attachment connection

poorly made overdenture attachment connection

poorly made overdenture attachment connection

poorly made overdenture attachment connection

 after healing on the lower arch dental implants

after healing on the lower arch dental implants

after healing on the upper arch dental implants

after healing on the upper arch dental implants

after healing on the 17 dental implants--the Gold abutments aren't locators used by the previous dentist attempt at making teeth.

after healing on the 17 dental implants–the Gold abutments aren’t locators used by the previous dentist attempt at making teeth.

impression transfer on the upper 10 implants

impression transfer on the upper 10 implants

impression transfer on the lower 7 implants

impression transfer on the lower 7 implants

screw retained full arch temporary dental implant bridge

screw retained full arch temporary dental implant bridge

screw retained full arch temporary dental implant bridge

screw retained full arch temporary dental implant bridge

narrow gum the sulcus channelson the existing implants towards the front of the mouth

narrow gum the sulcus channels on the existing implants towards the front of the mouth

fully biting into full mouth fixed temporary implant Fp1 teeth

fully biting into full mouth fixed temporary implant Fp1 teeth

PMMA double arch full mouth dental implant fixed temporaries--other side

PMMA double arch full mouth dental implant fixed temporaries–other side

PMMA double arch full mouth dental implant fixed temporaries--side view

PMMA double arch full mouth dental implant fixed temporaries–side view

PMMA double arch full mouth dental implant fixed temporaries

PMMA double arch full mouth dental implant fixed temporaries

x-ray of the 17 implants during the process. Some of the implants were placed by me in some by previous dentist.

x-ray of the 17 implants during the process. Some of the implants were placed by me in some by previous dentist.

Handsome smile with temporary upper and lower full arch teeth.

Handsome smile with temporary upper and lower full arch teeth.

You can see on the preoperative x-ray that he had 6 upper dental implants and only all on 4 lower dental implants.

The implants were mostly well placed from a spacing standpoint and might have been able to be used for fixed dental implants such as a Prettau zirconia full mouth dental implant bridge.  Rather than having a fixed bridge or an all on 4 fixed bridge, the dentist chose to make an overdenture!! 

The overdentures never worked for him.

 They were way too bulky and had a tremendous thick pink area we call a flange.  The crazy thing is that there is no way overdentures could have ever worked because all the implants were placed way too shallow!  In order to have overdentures, you must have enough room from top to bottom (inter-arch space) to fit the dentures and plastic abutment attachments that make them snap into place.  The gold attachments are called locator abutments which typically work well on the lower jaw only.

He never wanted to have removable teeth but that is NOT what he got.  He was not able to wear the overdentures at all and came to me for a better solution.  He had gone 3 years like this.  The teeth were even made twice and then he gave up.  He told me I was his last hope. 

After evaluating him carefully I determined that the implants were placed in a shallow position more ideal for “regular implants.”  We refer to this in dentistry as an “Fp1” prosthesis.  That means there is no reason or room for the pink portion which most patients need because they are missing bone and gum.  This patient actually had excessive bone which is very rare and in retrospect if he really wanted an overdenture should’ve had a bone leveling alveoloplasty procedure.

This very well could have been a communication problem between the restorative, tooth making dentist,  and the implant surgeon.  In this case, there were 2 different people who started the procedure.  I am a strong believer that these complex dental implant procedures should be done from start to finish with a *single* skilled provider or a very tightly connected and experienced partnership duo.

The upper implants unfortunately were all squished in the front, without any dental implants in the molar back tooth positions with minimal inter-arch space.  On the lower jaw they were well spaced but there was too much space between implants for the regular/crown and bridge/Fp1 type teeth. 

The solution was to add four additional implants into the molar regions on the upper with some simple internal sinus lifting.  On the lower jaw I added 3 implants in strategic locations to shorten the spans of the bridges.  If the span is too long, and the zirconia material is not thick enough, the teeth will break…yikes!!!!   The additional implants will support the material.  This will allow him to have basically regular teeth back again without any of the pink porcelain or pink plastic.

In a single appointment, I added these additional 7 implants with minor sinus grafting under IV sedation at my office in Burbank, California.  The implants were allowed to heal for approximately 4 months prior to starting the restorative process.

Fabricating his teeth was very complex because of 2 different implant systems and at least 4 different proprietary screwdrivers and parts.  The locator abutments also had a very narrow “sulcus” which would be too small at the tooth neck for regular size teeth.  I actually had to custom alter make all of the special titanium implant impression transfers to fit into the overly narrow gum channels.

A verification jig was 3D print milled to be certain that all 17 implants had a very accurate impression so that there is no misfit of the new teeth.  I also created a screw retained wax rim teeth in order to  select tooth size, color, position, bite level and a host of other factors.

In these photographs what you are seeing is a temporary PMMA double arch bridge.  This is not the final although it may look like a final bridge! 

All teeth were designed using 3-D  3shape software.  I had my very skilled lab technician digitally create wider gum channels so the teeth at the neck appeared more of a normal size so they would not have mushroomed stalks.  At the delivery appointment for the temporaries I had to surgically open his gums to fit the teeth.  This will allow any papilla or gum triangles to fill in as needed and “groom the gum tissue” to fit the new teeth.  The PMMA is a milled plastic/acrylic material so the bite can be adjusted and refined.  I will then take all of this information and translate that to the final restoration.

I usually allow my patients to wear the screw retained PMMA full fixed implant temporary bridge for a few weeks to a few months depending on how much testing and adapting the patient needs.  Some people adapt very quickly with speech while others need a bit more time to learn where there teeth are in space.  This testing duration also allows the TMJ jaw joints an adaptation period.  Also the bone can progressively be given bite strength with this softer material and gradually get to the solid monolithic zirconia restorations.

Sorry for the blood in some of the photos as they were taken on the day of surgical delivery of these temporary restorations.  The finals will look very similar to this except even better 🙂

I hope this explain some of the highly complex procedures that go into recovering such a difficult situation.  Unfortunately a lot of what I do nowadays is correcting and redoing bad situations which could’ve been done right the first time with better planning.

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

Full Arch All on 4, 5, 6, 7, 8 Implants – 3D Lab Teeth Design Video

 
This is a great video explanation of full arch zirconia Prettau style dental implant bridges made for the All on 4, 5, 6, 7, 8 etc. procedures.  These are full jaw situations.  In this video I narrate the actual lab design of how the teeth are made.  Buyer beware!  Not all teeth are created equal!  Experience is everything when it comes to designing the teeth.  In this case the upper is an “All on 6” while the lower is an “All on 5” totaling eleven dental implants.
Every single day I get comments, calls and patients in my office that have had these procedures done.  Although the implants have integrated the bridges have failed, broken or they are so ugly and bulky that the patient hates them.  Fabrication of the teeth is controlled by me and a very skillful lab technician.  Everything I do is done in 3-D planning so that we can make the teeth as precise and naturally cosmetic as possible.  There are so many factors to consider…..watch the video to find out! 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

All On Dental Implants With Prettau Solid Zirconia Dental Implant Bridges ~A Case Explained

In this post I will try to detail the start to finish of full upper and lower dental implants with Prettau solid zirconia dental implant bridges.  This gives a general outline for what to expect if you were to have to lose all of your teeth and replace them with full arch zirconia implant bridges.

I will describe the rationale for treatment which may help those of you in similar situations.  Sometimes you have to have bone graft and sometimes you do not.  Sometimes the dental implants can be placed simultaneously with extractions and other times the extractions, implants and bone grafts need to be or should be done in phases.


before treatment x-ray showing failing teeth

before treatment x-ray showing failing teeth

IMG_0680
before treatment open retracted photograph

before treatment open retracted photograph

upper jaw

upper jaw

lower jaw

lower jaw

flipper stayplate for lower front teeth

flipper stayplate for lower front teeth

LEFT
RIGHT
1 week after upper jaw dental implants and extraction of all remaining teeth

1 week after upper jaw dental implants and extraction of all remaining teeth

lower jaw dental implants after one week

lower jaw dental implants after one week

upper jaw dental implant impressions

upper jaw dental implant impressions

lower jaw dental implant impression

lower jaw dental implant impression

conventional open tray impressions

conventional open tray impressions

wax pattern of teeth for try-in purposes

wax pattern of teeth for try-in purposes

verification jigs

verification jigs

PMMA temporaries.

PMMA temporaries.

IMG_4852
IMG_4856
IMG_4858
IMG_4866
Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.


What is unique about my approach is often procedure can be done in a single visit surgery without the need for “major” bone grafting such as lateral window sinus procedures or block grafting(although I routinely do these major grafts for other reasons).

he plan is to harness this patient’s existing good bone and avoid the areas where the bone is deficient, thin, risky and doesn’t have a lot of density.

Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

Final x-ray with upper and lower solid zirconia Bridges on 12 implants. There are 24 teeth supported by these 12 implants.

ThisIMG_4858 patient is about 55 years old and as you can see has quite a substantial dental problem.  His upper teeth have a temporary bridge that is not well fabricated and was just put in so he could have “something there.”  The lower front teeth are missing.  The upper jaw is very small and narrow in comparison to the lower jaw which is wide.  This places the patient into a reverse cross bite which must be taken into account for both the surgery and the long-term with the teeth.  The mechanics of the bite can often destroy the fragile bone at the top of an implant.

I cannot emphasize enough that replacing all of your teeth with dental implants is a highly complex procedure that should be unique to your situation and not just the same recipe “all on 4” for every single patient.  I also believe that one implant dentist completing your treatment from start to finish has the most control of your result.  It also helps to save cost as compared to this procedure being done by 2 different dentist….A surgeon and a restorative dentist.

Your treatment plan and diagnosis is the most critical element which is done early in the planning phase.  For this patient I need to engineer his full mouth dental implants and solid zirconia bridges to be strong at the level of the teeth and strong in the bone so that he does not get bone loss or broken teeth.  This happens very commonly when these procedures are not well planned or discount parts and techniques are used.

On the preoperative panoramic x-ray we can see that the patient has had a substantial amount of dental work.  There is bone loss and decay on most of the remaining teeth. This patient was tired of investing thousands of dollars over the years into procedures that all failed and he did not feel that his smile was attractive.

In his case, while he slept under IV moderate sedation, I extracted all of the remaining teeth and placed all the implants simultaneously.  The procedure was planned by 3-D CBCT analysis which is essentially virtual computer surgery.  The bone had to be leveled in some areas so that all of the implants were approximately on an even plane leaving plenty of thickness for teeth.

These types of full arch solid zirconia bridges not only replace teeth but in his case were also replacing bone and gum.  This is why these types of restorations look different because without replacing the bone and gum on the bridge the patient’s face would look sunken in and his speech would be improper.

Prior to the surgery, upper and lower impressions were made to fabricate temporary upper and lower dentures.  These dentures will be used for several months while the implants heal and give us some idea of the patient’s facial aesthetics and bite needs.  Connecting the teeth to the dental implants on the same day in his case was not appropriate.  Immediate teeth can be made in some cases but should not be made in all cases.  Many dental clinics market this as being a solution for all patients but the reality is it is not safe and predictable for all patients but it is for ‘some.’

At no point will this patient ever be without teeth.  In my practice in Burbank,California, this is unacceptable for patient to walk around without teeth although I have had a few patients that preferred to do that.

On the upper jaw  6 dental implants were placed into the best possible bone.  The rear most dental implants were placed at a tilt facing backwards on purpose.  This will alleviate the need in this patient for right and left maxillary sinus bone grafts.  The teeth can be cantilevered about 1-1/2 teeth beyond where the implants end to give this patient teeth all the way to the first molar position.  This means that the 6 dental implants will support 12 teeth on the bridge.  This tilted concept is not always possible and depends on where God made your sinuses and nerves.  Sometimes the sinuses are too far forward for this to work.  Especially on the upper jaw you want implants going as far back as possible and as many implants as possible because the bone is soft.  The number of implants is critical and should never be compromised as this is the main structure that will hopefully make things last as long as possible because dental implants are not permanent!!

On the lower jaw, the 6 dental implants are scattered more evenly around the jaw because this particular patient had room above the nerve on the rear molar areas.  This places dental implants underneath all of the bridge without a cantilever which is a great approach.  In a patient that does not have bone in the rear molar area, the implants can be more centralized towards the front middle and teeth cantilevered towards the back.  In the latter scenario, you want to make sure that the implants are good and long and you have at least 5 of them.

It takes 3-6 months for the implants to integrate.  During that phase, I  begin to prototype the patient’s mouth so that they can see feel and test drive what their new smile will look like.  Adjustments will be made to the teeth and a wax pattern is fabricated.

In this patient, I made  conventional open tray impressions of his upper and lower jaw using a putty type of material.  Sometimes the impressions can be made digitally also using the 3Shape Trios 3 scanner that I have.  The impressions are then scanned in a physical and digital model is made.  I then fabricate what is called a verification jig.  This device verifies that your impression is accurate and your bridge *will* fit…no guesses or maybes.  This is not a step that should be skipped although I find many dentists that do.  This is the equivalent of the framing of a house… It needs to be perfect from the structural standpoint so that everything last a long time.  Panoramic x-rays are generally taken along the way in order to verify that the custom abutments are flush to the implants.

After the verification jig comes another try in to verify you like the look of everything and then we switched over to PMMA fixed temporaries.  The fixed temporaries are the closest prototype to the real one.  The purpose is for you to be able to test drive the real ones.  It also allows me to test  speech, facial aesthetics, dental aesthetics, bite, TMJ, hygeine and so much more.  You will go home wearing these great looking, stong temporaries and wear them for 1-2 months generally.  During this time life is good and transitioning to the final is really easy because it feels even better than the digitally fabricated and milled PMMA temporaries.

The final solid zirconia Prettau dental implant bridges are delivered and generally screwed into place.  The screw access holes were closed with a composite material after all of the abutments screws are tightened.

It is quite the process to replace all teeth with fixed solid zirconia dental implant bridges but it is so worth it.  I’m certain this is the best that dentistry has to offer as of 2016.  There are many clinics that advertised discounted procedures and techniques but you need to be very careful what you may end up with.  Sometimes people have problems and no dentist wants to fix them because treatment was so bad to begin with.  Sadly, I see this every single week.

This patient can chew whatever he wants an should not have any problem for a long time.  Total treatment time for this patient was approximately 9 months from start to finish.

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

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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.

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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.

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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

Bone Graft Correcting Dental Implant Peri-Implantitis Bone Loss ~ Case Example

Bone loss can and does occur around dental implants.  Often this is called peri-implantitis and there are a few treatment options.

Review signs and symptoms of peri-implantitis dental implant bone loss in this previous article.

Bone loss on implants happens on about 1-15% of dental implants. That percentage is variable depending on the experience of the dentist. How to deal with it is the big question.  In certain situations your dental implant or implants can be recovered with bone grafting procedures but in some instances the bone loss associated is so significant that the only option is to remove the implant and start all over again.  Bone grafting for peri-implantitis bone loss defects is not standardized and varies widely from dental surgeon to surgeon.  Over many years of doing this I have developed a specific technique for recovering some of the worst bone loss.

Correction of bone loss on dental implant--Ramsey Amin DDSBone loss can occur as a “moat” defect going 360° around the entire implant or it can be just localized to one side of the implant.   If it is 360°bone loss it is much worse than if it is localized to just one side.  The best area to have bone loss is in between the teeth rather than on the outer aspect.  This is easier to graft and has a higher success rate.

If the implant is in the front of the mouth versus the back of your mouth this can make treatment options very different also.  The back teeth are more forgiving and then the front.  The gum and bone is typically thicker in these areas. There are times when the final outcome leaves you with some metal of the abutment or implant showing but disease process was stopped.  Of course in the front of the mouth this is typically unacceptable especially if any metal shows in the smile.

In this example case I will show you the more difficult of the two….  A case where bone was lost on the outer aspect.

In this case this is a 29-year-old female that had a dental implant placed in another country.  The implant overall looks good but it has become tender on the outer aspect of the gum.  One reason in her particular situation why bone loss happened was because the bone was a  too thin to begin with and then the crown on the dental implant became loose at the abutment.  This particular dental implant crown/abutment had a design flaw which caused loosening.

If you look at the implant on a 3-D CBCT scan view from the side you can see that in the mid body of the implant there is very little bone.  Because I never treated this patient to begin with,  we don’t know if the bone was like this from day one or it dissolved to this situation because of the loose dental implant abutment.  Either way it needed to be treated.  We discussed the possibility of removing the implant versus grafting bone and saving the implant.

If you look closely at the gum tissue, of both center upper front teeth you will notice that there is more of a hump on the natural tooth than there is on the dental implant.  This was the first sign that the implant was lacking bone when she smiles.  What makes this case very difficult is that the teeth are generally very long and when she smiles she shows her gumline….  Everything is going to show so this is going to be a critical surgical correction.

You have to be really careful with these cases because sometimes the correction can make the tooth look worse if it is not successful.

The most critical factor in all of this is prevention.  I go to GREAT lengths to prevent dental implant bone loss from occurring in the first place by having a tremendous amount of bone on the outside of the implant if the patient’s anatomy allows.  By having the original implant surgery done well, this is the best way to preserve the bone on the outer wall.  Also when the crown and abutment are made by the dentist, there are so many techniques and choices to make things last and be problem free for many years.  Many patients think that the crown and abutment portion are “easy” and can be made by any regular dentist.  For some patients anatomy, dental implants would not be wise choice…that is the exception rather than the rule.

In her case, I am certain that the result will be long lasting.  The good thing was there was no exposed threads at the very crest of the bone.  The surgery was done under IV sedation through a tunnel flap which is the equivalent of a laparoscopic medical procedure.  I was able to remove the crown and place a temporary crown during the procedure which helped with surgical access. The sutures seen here are designed to be dissolvable because the incision is far away from the actual tooth being treated.

I know these specific and detailed articles but a lot of this information does not exist on the Internet.  I hope this helps those of you that have this problem and those of you to prevent if possible.

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.**

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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