Video: Why Bone Grafting?
When we lose teeth we also inevitably lose bone. The loss of bone is more pronounced on the focal aspect rather than on the tongue side. The problem is that most front teeth are positioned on the facial aspect that makes your smile appear natural. This is ok when you have a low smile line that is when you smile you don’t show your gums. However when you have a high smile line (gums showing) then we can have problems with aesthetic outcome and refer this situation as an aesthetic risk assessment.
High smile line, gums showing
You see implants are not teeth. Teeth have taken millions of years to evolve. Implants are artificial devises that we place in the bone and allow integration. Therefore it is essential to place implant in correct 3D in the bone to allow natural tooth emerging through the gums. This is most difficult even for experienced specialists; however we all do our best to make it look right.
Ms. E. was referred by her sister, an existing patient, for specialist evaluation. After attending her general dental practitioner, Ms. E presented with recently extracted upper right first premolar. The extraction was traumatic and unfortunately the facial bone was removed at the same time. The dentist, unfortunately with minimal experience trying to provide provisional bridgework unnecessarily cut good adjacent two teeth.
Extracted tooth and facial bone
We have the following problems:
This dentist should have sought a specialist opinion prior to extraction of tooth 14. As specialists we are trained in atraumatic extraction and know how to make non invasive provisional bridgework. The ignorance and arrogance of inexperienced dentists is a concern that all specialists and experienced general dentists share.
High smile line: The defect is clearly visible and most upsetting for this post graduate university lecturer and practicing lawyer. How do we fix this problem?
Treatment: 3D planning using CBCT (cone beam Ct) and diagnostic planning that included:
This study will show:
Patient presented with otherwise healthy dentition. Now the cut tooth 13 was painful. There was no need for provisional crown placement o teeth 15 and 13 condemning healthy teeth to future restorations. Unfortunately tooth 13 developed an abscess and required a root canal therapy. Patient should have been informed and specialist’s opinion sought. Chief concerns:
Diagnosis: Female patient presenting with traumatic tooth extraction and poor provisional bridgework that is creating discomfort and aesthetic disturbance.
Our Aim: control pain, site augmentation to allow correct implant placement and replacement of missing toot 14. Provision of new ceramic crowns on teeth 15 and 13. Improve the aesthetics of upper arch: tooth shape, display, tooth colour, length, symmetry and smile line in general along the upper arch. This was accomplished with minimal discomfort to the patient over 8 months. Yes it takes time and there are no shortcuts! To restore aesthetics we must first restore form and function. Replicating nature. Restoring fundamental building blocks of the smile.
Following with discussion of all risks and treatment modalities with our patient that included:
The work was completed in 8 months. Using simultaneous site augmentation and implant placement. Ms. E was happy with the aesthetic outcome. We made no guarantees that this aesthetic result would be achieved and Ms. E was informed and understood the limitations placed on the clinician.
As a specialist I always do my utmost for the best possible outcome. With dual qualifications in implant surgery and reconstructive dentistry I am able to perform these procedures in one setting which saves you time with reduction in costs of implant therapy, associated grafting procedures and final restorative outcome.
Thank you for taking the time to explore this patient's story. I hope this gives you an idea of what I can do for you if you are having difficulty and need help, because there is always hope.
Dr. Sarkis Nalbandian
Visiting Professor YSMU
Specialist Prosthodontist & Implant Surgeon
B.D.S. (Hons), Dip. Clin. Dent. (Oral Implants) Uni Syd, M. Clin. Dent (Prosth) King’s College, Uni London
D. Clin. Dent (Prosth) Uni Syd, FRACDS, MRACD (Prosth) FIADE, FPFA