As a non-surgeon I often listen in confusion to the debate about whether to place implants with or without a flap. One of the biggest reasons that I have heard in support of a flap is the ability to see the surrounding bone. The ability to visualize what is happening has always been important in restorative dentistry, so it makes sense that it applies to surgery. On the other hand we have 3D cone beam imaging that shows us the osseous anatomy clearly, so I can see that in the days before cone beam imaging the need for actual visualization was much greater than today.
During esthetic treatment planning one of the critical factors is assessing and managing the papilla. This is a common conversation when anterior implants are being planned, but sometimes gets less than the optimal attention when the treatment plan is all on natural teeth. The tips of the papilla, unlike the gingival margin show in an astounding majority of our patients up into their sixties and seventies, making it an essential element of their smile esthetics. Their are two pieces I look for in diagnosing the papilla esthetics. The first is symmetry. Much like with gingival esthetics we want the papilla heights to be symmetric across the midline. Some patients will have papilla tips that when connected create a straight line, others the line will tip up toward the canines. We want to see that the left and right sides mimic one another, so if the papilla tip is slightly shorter between the canine and lateral, it does this the same way on both sides.
Last week I began sharing a treatment planning approach to implant placement and sequencing. It looked at clinical situations that would be best served by immediate placement or hard tissue preservation or augmentation. This second part will look at case scenarios that should be evaluated for soft tissue preservation/augmentation, a combination of soft and hard tissue procedures or can be dealt with effectively by allowing natural healing after extraction.
Soft Tissue Preservation/Augmentation:
- Sites planned for implants with thin or highly scalloped tissue
- Sites planned for implant placement with a deficit of tissue or discolored tissue
In the last few weeks I have been working with a patient who has existing upper and lower implants and implant assisted removable dentures. She is unhappy with the retention and stability of her existing reconstruction and expressed a wish that she had been more strongly encouraged to go for a fixed solution at the time she had the original treatment. She is now ready to have both the upper and lower arches converted to an implant supported hybrid style prosthesis. Thinking about this transition has brought up two important questions. The first is how much room do we need between the upper and lower gingival tissues or ridges to move forward with a fixed solution.
- You Only Treat What You Plan
- You Only Plan What You Diagnose
- You Only Diagnose What You See
I’ve heard the credit for this statement given to many influential people in dentistry. Whoever gets the credit, they truly understood the essence of what we do, and the balance between clinical excellence and success in business.
Esthetic Compromises in the anterior around implants are unfortunately more common than we would all like. Many of these issues can be avoided with proper treatment planning and the incorporation of ancillary procedures that set the anatomy up for a more favorable outcome. When this doesn’t happen and you get an unintended negative consequence, trying to correct the situation is often more difficult than the original treatment plan. This is the exact situation I was presented with recently.
I had a great patient come in today disappointed because one of his two implant fixtures failed during the healing phase prior to uncovering. I have come to think of dental implants as invincible, the one procedure that never fails. Unfortunately, despite very low failure rates, we do have patients that encounter a problem. As I explained today knowing that the failure rate is less than X percent means nothing when you are in that group. In that case your experience of failure is 100 percent. I did what I know to do, and listened, acknowledged the frustration and disappointment without dismissing it or explaining it away.
Patients who have worn teeth can be some of the most disconcerting. Often we are unsure of when to talk to patients about wear and uncertain about how we treat it and how predictable the results are. I believe that some wear is normal. I base this on the fact that I have very few if any patients who are in their seventies or eighties and still have mammelons on their incisors. Wear is a concern when the amount of tooth structure being lost is out pacing the patient’s age.
Friday’s post discussed the common diagnosis of altered passive eruption. We looked at the process and how to identify patients whose dental esthetics has been negatively impacted by this process. When we think that part of a treatment plan will include altering the gingival esthetics, one of the things we are tasked with is determining where we want the tissue to be. The first step as always is making a determination about incisal edge position in the face. Using a lips at rest photograph and full face image for my patient with altered passive eruption, we determined that her incisal edges are correctly positioned.
I had the pleasure today of seeing a young woman whose chief concern was short square teeth. Orthodontic treatment was recently completed and she is routinely wearing her retainers. The clinical exam revealed no wear on the maxillary incisor teeth. The sulcus depths on the facial range from 4mm to 6mm and the CEJ can not be found with an explorer in the sulcus. Radiographs of the anterior teeth show bone levels are in the correct position relative to the CEJ. The periodontal exam revealed very little plaque and no bleeding on probing. My diagnosis after reviewing all of these exam findings is altered passive eruption. In my practice, altered passive eruption, is a very common diagnosis.