Our preference for predictability in the back of the mouth is to actually use gold. Not everybody likes that, but in the back of the mouth, for most of us dentists, gold is the gold standard. There’s nothing better than gold in terms of how it behaves and how it responds, but not all of us want gold in the back of our mouth. We fall into that being wane issue and having something done.
So, what did I show you? I’ve shown you people with no teeth. I’ve shown you people missing just one tooth, and we move up from that to people missing more than one tooth, multiple teeth. It was a gradual progression of how this technology of titanium and osseointegration progressed in our treatment of patients.
We didn’t want to just use it anywhere and everywhere unless we were sure that it was going to be predictable. Another study, 87% in the upper jaw, 92% in the lower jaw. Common theme that you would see, higher success rate in the lower jaw because of the denture bone that we talked about earlier. Almost any study that you look at, you’re going to find that.
This is a young man who was in an accident, lost his three front teeth. He had a temporary denture that he didn’t like. We had three mini dental implants placed, second part of the surgery done. A temporary bridge made first to make sure we liked the way it looked then converted to a permanent bridge, and what he looked like when he was done. Uninvolved natural teeth. Predictable.
This is a lady who showed up with two teeth that were periodontally hopeless. Look at how bad these looked. She was very unhappy with what was happening. These teeth were loose. We call them immobile, their mobility, because they’ve lost the bones. When you bite down the tooth moves, and the dentist just put some bonding material to keep them there until she could decide what she wanted to do.
We took her through a significant amount of treatment and took her from here to this spot. She’s got two implants that are holding up these two teeth. You can’t tell that these are implants in there which is the key. Very different from those teeth on stilts that I showed you, 1982. Right, that Profession Branemark first started out with in patients who had no teeth whatsoever because that’s what we wanted.
In order to be able to use them for everyday tooth replacement, not only did we want them to be functional, which they were for those patients, but we wanted them to be aesthetically acceptable. We needed aesthetics and cosmetics in this day and age.
I mean look at the People magazine. I don’t know why we dentists even have the People magazine in our office. I mean, it’s crazy because we set ourselves up for trouble because everybody wants teeth like the cover of the magazine, and we can’t always deliver that. There are limitations to what’s going on, but we all look at that. We see it every day, and that’s what people want. They’re not going to want teeth that are not going to look that good. So, you could have a great technology, but if you can’t make it look right, it’s not going to be very successful.
This is I think I showed you, this was 2003, and this was three years after still looking natural which is the key part to it. I don’t know how many of you are local San Franciscans, I’m assuming, but when I trained at UCSF, there used to be a program at the Letterman Army Medical Center, and as residents, we would rotate. We would go there, and the residents from Letterman would come over here. One of our mentors here would always talk about the Letterman guys, and some of them would be doing this crazy treatment and they’re saying it’s 100% successful because either the patient moves or the dentist moves. You never see each other again.
So, it’s very critical that we follow these patients over time and we know what’s going on. So, this is a three-year follow-up on her not only to show the fact that the implants are still in place, but that the aesthetic outcome, the way that the gums look, they look natural. They shouldn’t look artificial which is the key to success. We cannot always do that though. It’s important to understand.
This is a young patient who was in a car accident. He was actually taken to San Francisco General for trauma. He was missing teeth and a lot of the jawbone. Well, we cannot make teeth look natural when somebody’s missing all that gum. We can’t grow the gum back there, alright. So, in his case, we’ve got three implants. We’re going to modify a treatment. We’re going to give him something moveable.
We’re going to make a bar that connects the thing together, and he’s going to have teeth that go in and out of his mouth like the upper denture I showed you on patients with implants because what did we need in him? In him we need this gum portion to replace all that gum tissue that was lost in the accident as well, and only then can we give him teeth that are about the same size as the other teeth and give him gums that can go in between these other teeth so it starts to look natural.
So, not all patients are candidates. This is a patient. It’s actually my mother. She’s 73 years old, a diabetic, had a congenitally missing tooth. I made her a gold bridge moons ago, probably when I was still in dental school. One of the teeth fractured. We couldn’t do that anymore and gave her implants. Three implants were placed and a bridge. She didn’t want gold in the front of her mouth. She wanted porcelain. I told her it may chip and break, and she says, “No problem. You’ll fix it.” We had three implants with three teeth on there.
Typically in patients that are not my mom, we’re going to try to give them a metal [53:00] surface or a metal biting surface because of the fact that we have concerns if we put porcelain at the biting surface at the back, it’s at a high risk for fracture. It’s okay for me or a dentist if you’re going to go back in. You’re going to be charged again to fix it. Do you want to go through that hassle? So, we give you that choice.
You also notice that you can see the holes. That’s because that’s the screw that’s going through that channel to hold it in. Now, we have ways of covering that up and not making it look like a hole. We would then have to take a crown and actually cement it, but if we cement it and something goes wrong, we can’t take it off. We have to cut it off. I don’t know how many people have experienced having crowns and bridges that are broken. They have to be cut off. If they have to be cut off, they have to be completely remade. So, there’s a retrievability advantage of having a screw channel that we put a filling in. Most people are willing to accept this aesthetically. I guess if I was practicing in Beverly Hills, then that may not be acceptable, and everything will be cemented on.
On the upper jaw, same thing. Three implants, metal occlusals, metal biting surfaces, and screw-access holes with the retrievability part built in.
Quickly going over to show you some of what we do to a cancer patient. If there’s any group of patients that I believe has had the most benefit of implant, it’s been these patients because in these patients when they lose not only their teeth but a major part of their jaw, we have to be able to put something back in there that can help create separation between different parts of the face.
What you’re looking at here is a patient who had cancer of the sinus. This is one-third of the upper jaw remaining. You’re looking up at the sinus cavities. There is no way, in this patient, that I could ever have a denture that would stay in place. Upper dentures, I told you, stay in place by suction. If you have a hole, you’re not going to get suction. It’s going to drop.
Therefore, in order to be able to anchor and keep this in place, we needed implants because this patient needs implants not to be able to chew, just to be able to swallow and to be able to speak effectively because if the denture is moving up and down, the air’s going to be coming out of the nose. They’re not going to sound right. There’s a big difference in terms of quality of life in what we’ve been able to do for these patients.
Another patient like that lost the upper jaw on one side from a tumor, had two implants and a bar placed on there. You see a denture with a plug that actually goes up into that sinus cavity, but this clip helps hold this plug in this spot because if this is not up there to hold the plug, the plug’s going to move around. You’re going to have leakage, and it’s not going to be functional.
A patient who lost the front of the jaw. We had implants there. They’re going to help a lot, holding this bulb there and sealing the cavity so that they are presentable in society. Much larger, half of one side and a quarter of the other side that has gone from a tumor. Three implants and a bar, and if you look at the size of the denture that is to be made for this patient just to close off the hole. This thing is never going to stay up if we didn’t have the benefit of these implants.
This is actually an older patient with a cleft. They have a cleft of the soft palate. I don’t know how many of you may have come across people like that. In this day and age, fortunately, when we see these kids at a young age, the surgery is done to the palate that they don’t need prosthesis, but older patients who didn’t have that benefit are completely missing their soft palate.
In order for them to speak and swallow effectively, we have to have a prosthesis that has a bulb to it that goes all the way back. This portion, that is part of the replacement for the soft palate, and in order for this to stay in that area without teeth, it would be impossible. She had teeth before, but these old teeth of hers were failing now so we ended up using implants to help keep a large dimensional prosthesis like this.
This is a patient who ended up with not having any jawbone left to put implants in, and one of the innovations that have been made by the Swedish group is most of the implants that I showed you before were implants that were placed in the jawbone. They’ve actually made implants that are about 40-50mm long, and these implants, they’re going up into your cheekbone or your zygomatic arch. From the zygomatic arch, they come down into the mouth, and we connect them with a bar and have a prosthesis.
If you look at her without the prosthesis in her mouth, her lip has completely fallen back because there’s nothing there to hold the teeth. She can’t swallow. She can’t function, but when we have this, we’ve improved it significantly to allow her to be able to speak and go back out in public.
In the lower jaw, same thing. Somebody who lost the front of the lower jaw. In the old days, you would just place a bar of metal and leave them alone. You couldn’t do anything. Now, we can graft them with bone, place them with implants, and make them function 100%, 99.9% if not more.
Side of the jaw totally lost from cancer rebuilt with bone from the hip and implants and teeth that allow this patient to function. Young patient who had a tumor that involved moving the entire front of the jaw rebuilt with some implants and some teeth.
