February 24, 2017
In the world of cosmetic and rehabilitative dentistry, the worst ‘Befores’ are often followed by the best ‘Afters’ because of the psychological impact of the contrast. In other words, when the situation is bad, any kind of an improvement is an improvement.
But to achieve visual aesthetics without the contrast of the situation at the start, and at the same time achieving ideal function and stomatognathic health involves more than just performing routine procedures. It involves thinking outside the square.
This story is about the journey of a 26 year old chef from country NSW, Tom, who challenged our professional compass in many ways, from ethics to the planning and right through to the execution of his treatment.
It is hard not to judge a patient when they present to our office with such oral deterioration at such a young age. If our patient’s natural dentition completely collapsed in a period of less than 15 years, how long will it take for any work that we might propose to completely collapse and fail?
My role in the treatment was to manage the surgical aspect, so in this post I focus largely on the surgical design and techniques. It was definitely up there among the most complex cases that I treated, not so much technically, but due to the combination of factors that I will cover.
For information on the restorative deign, please read the linked article about the process of attainment of a FINAL bridge within 24 hours.
I am unable to go into certain specifics in relation to Tom’s personal life, but the aetiology of Tom’s dental deterioration can be attributed to a large degree to the consumption of energy drinks containing high levels of sugar. As his teeth started to break down, he lost the motivation to clean them. He avoided dentists and social interactions, and within his secluded world he was safe from being judged.
His dad brought him to our doors 2 years earlier. They saw Dr Hillel New at our Malvern branch of All-On-4 Clinic. Dr New diagnosed the problems, counseled his patient and developed a management plan. The plan involved Upper and lower All-On-4 using Zygomatic implants is the upper, along with sinus surgery. This was complicated by the maxillary sinuses that were infected, and Dr New removed some posterior teeth, which were a potential cause, in an attempt to clear the sinuses before proceeding with any kind of implant surgery.
However, Tom missed some appointments, and Dr New became skeptical about Tom’s future compliance and his willingness to be a participant in his own success.
The situation got worse for Tom, and he became desperate to resume his treatment. As Tom moved away, Dr New referred him to Dr Fadi Yassmin who heads the Sydney branch of All-On-4 Clinic. This time around, Tom hadn’t missed one appointment! Dr Yasmin treats many patients with deteriorated oral conditions where the concern for compliance is real, but believes from experience that with patient education, giving them a beautiful smile can change their lives, and this in itself becomes positive reinforcement and a powerful motivator in relation to compliance and oral care. That was the only hope for Tom.
1. Establishing the Aesthetic Aims
Dr Yasmin undertook a comprehensive smile assessment using Digital Smile Design, an invaluable tool to establish the aesthetic aims before being able to undertake any kind of a surgical plan.
It is noteworthy that Dr Yassmin posted our treatment plan and results on a private Facebook group for dental professionals (Style Italiano), and received the highest recorded number of likes (6.6K), shares (1K) and comments. This is an outstanding achievement and a credit to Dr Yassmin.
2. Correlating the Aesthetic Aims to the Surgical Design
A smile is not only about the teeth. Its made up from the visual interaction of the teeth, gums and lips; and what we consider to be Golden proportions is different for different people depending on their face shape, race and even personality.
In this case, there is a significant amount of gum display, even at rest (see below). It is excessive and needs to be reduced.
From a surgical perspective we can consider 2 kinds of treatment. The first kind is one that involves working with nature and manipulating the natural gingival architecture. The second kind of treatment to consider is to mimic nature and recreate the most ideal proportion with prosthetic replacement of the gingival component.
Working with Nature
Below is an example of working with nature (in a different patient) where I preserved the existing gingival choreography and placed implants to support bridge segments within the envelope of the natural gums.
The results for the case above are certainly acceptable, but if we consider the starting point, at presentation the main problem was severe erosion of the teeth due to bulimia (see below).
Otherwise there was a favourable biotype, symmetrical contours, good bone, and no pathology. So using these parameters was advantageous, at least in so far as being able to create aesthetic gum-fitted restorations. But there was a particular challenge with the restorative space, which has led to a weaker restoration that cracked on insertion.
If we try to apply the same principles in planning Tom’s case (below), we do not have favourable biotype, especially in the back, and there is asymmetry and a skewed gingival plane (second below). There is also limited restorative space which in itself can present additional treatment challenges.
If we look at the x-rays (below), the limited restorative space in this case is not the result of a collapsed Oclussal Vertical Dimension (OVD). It is due to osteogenesis related to the supra-eruption of the teeth as they progressively decayed and lost functional contacts.
In many cases, some adjustments can be made to the OVD. Opening the OVD will improve the available restorative space, but will also increase gum display, so not ideal in this case. Whereas closing the OVD could help in reducing gum display, but would further limit the restorative space, so again not ideal here. Both kinds of OVD adjustments could have a negative impact on speech.
In this case, the X-rays show a steep mandibular angle and a Class 3 jaw relationship. The combination of these parameters indicates that OVD changes in any direction are simply not possible.
Therefore our surgical plan must preserve the OVD as is.
What about surgical improvement to the restorative space with some alveoplasty? This is a possibility, but in this case, with the kind of biotype and the required plane correction, there is a high risk of recession, asymmetry and poor aesthetics. Remembering that we are relying on the impact of the improvements to motivate our patient to remain compliant, with any such degradation in the aesthetics or quality of his smile he may in fact lose this motivation again, as he did with his natural teeth, leading to potential further complications with the implants.
Botulinum Toxins and Dermal Fillers: We can consider neuromodulators in an attempt to cover up any aesthetic deficiencies in the the gingival choreography. This remains a consideration irrespective of the kind of treatment that we would undertake, but given the extent of gingival display at rest (as previously shown), and the dynamic personality of this individual, this will have limited efficacy with any kind of gum-fitted restorations. We also don’t have the typical option of combining the neuromodulators with dermal fillers for added effect because this patient already has full and shapely lips.
All-On-4 with Aesthetic Gum Replacement (AGR) allows us to mimic nature and achieve better and more predictable long term aesthetics. In this case we proceeded with lower all-on-4 and upper ‘Zygoma-Plus’ technique. The rationale and techniques are detailed below. Here are some useful links in relation to the Zygoma-Plus technique:
To create the bridge with adequate AGR requires a significant alveolectomy in this case (see below).
If we look at the x-ray below, the extent of required alveolectomy, as indicated by the yellow line, goes through the sinus spaces, and especially on the left.
An obstacle to any treatment involving the sinus spaces is the presence of widespread pathology, as seen below.
3. Pre-Operative Management
As the prior extractions of some upper back teeth did not resolve the sinus pathology, before proceeding with implant and sinus surgery we referred our patient to an ENT specialist to improve sinus health. This was achieved with endoscopic sinus surgery creating additional drainage points for the sinuses, along with conservative management with nasal douch, preudoephedrine, antibiotics and steroids.
On the day of surgery, you can see below the sinuses were mostly clear and had good drainage. Tom was ready for his implant surgery and transformation.
4. Surgical Technique
The lower looked like a straightforward All-On-4, …there was a lot of bone both in height and width!
The required alveolectomy was substantial, not only in the vertical aspect, but also in the horizontal plane. When the mandible is wide it is often difficult to gauge the progress and extent of bone reduction in the vertical plane because it appears that you are removing a lot of bone, but most of this bone is from width reduction.
However, for the alveolectomy to be effective what we need is vertical reduction, not horizontal. In cases such as this I would use a stent to determine the required amount of vertical alveolectomy, and instead of using my typical combination of Rongers and Burs, I would use drills to saw through the bone horizontally at the correct vertical level.
Wide mandibles often appear simple for implant placement because of the large amount of available bone, but this kind of situation is quite often deceiving. Wide mandibles often have dense cortical envelope but poor trabecular bone density. This combination makes it more difficult, not less difficult, to place implants. An amended drilling protocol along with experience and the selection of suitable implants help in managing these kinds of situations.
In the upper, there was a lack of bone in the posterior maxilla due to the sizes of the sinuses, and especially when considering the extent of required alveolectomy. There I undertook Zygoma Plus surgery with bone grafting using Bio-Oss Collagen, Autogenous bone and Bio-Gide collagen membrane (sequence below).
The extent of the required alveolectomy on the left side resulted in the need to further surgically manage the inferior area of the sinus with a sinus impaction graft (also known as a ‘Sinus Crush’; see below), a procedure that I introduced back in 2005.
The x-rays below demonstrate the sequence. Notably in the post-operative x-ray (taken 2 months after surgery), the sinuses are clear with a healthy lining, the zygoma implants are intra-maxillary and are not susceptible to dehiscence like with extra maxillary implants, and there is a bony buffer between the zygoma implants and the sinus space.