Basically, what you see here is a patient who got only got two dental mini implants or two screws, and there’s a little gold bar that’s been made. The inside of the denture has some clips, and these clips clamp onto that and allow this denture to be held in place very well. So, it doesn’t move around very much which is really what most patients complain about.
This can be done with four implants, and basically, the more implants you use, the less support you’re getting from the gum. If somebody’s got gum tissue that’s very delicate and very thin, very friable, can’t take the load or the pressure of having a denture sitting on the gum, then you have to try and place more implants to make them successful.
The patient with the two implants is typically somebody whose worn dentures successfully for 20, 30 years but now have lost so much gum that the denture’s sitting on a totally flat surface and just slides around too much, and we now want to have a little something to give it a better hold that doesn’t move around as much.
So, that’s just different overdenture ideas that have been done, and I’m showing you this here, somebody who’s got four implants that are spread out. If you can look at the geometry of this, in this case, even though we have a denture that is completely sitting on this bar, there is no pressure actually being placed on the gum whatsoever.
So, for the patients with the gum that’s delicate, we can still provide this kind of treatment. Upper jaw, same thing. This is actually a patient who was born with no teeth that we were able to place implants in a young child and give him teeth. Patient has eight implants in the upper jaw and some in the lower in back where they already have their own teeth and a bar that’s been made in the upper jaw and then a denture because most patients who have lost their teeth in the upper jaw have lost enough gum that we need this gum to support the lip because if you don’t have that gum to support the lip, the lip looks like it’s fallen in. We didn’t want those spaces like I showed you. So, typically, in the upper jaw, this is a treatment that we do, something that’s horseshoe-shaped anchors on and stays in place. It’s very solid and very stable and allows the patient to function. There’s all different designs that you can see here for different patients made with different materials.
Now, there’s some people who don’t want teeth than even can be removed. They want to have their teeth that’s just screwed in. They want to be as close to their natural teeth as they possibly can be, and there are a few patients that we can do this on.
The big problem with that in the upper jaw is the aesthetics. Can we have the implants put in the exact right spot where a tooth needs to be, not in between two teeth, because then you’re going to see some of that metal, and it’s not going to be aesthetically acceptable? So, those are the challenges that we have to face with, and typically when we do this, we’ll have the implants. We’ll make a temporary bridge first before we make something that’s going to be solid and screwed in.
This patient doesn’t take her teeth out. She can walk through security at the airport, and it doesn’t let the buzzer go off or anything like that because this metal is not as dense to let that happen but allows this patient to have teeth that are as close to their own teeth as possible. Obviously, the more complex that you have the treatment, the more expensive it gets, the longer it takes to be done.
This is a patient who had no teeth of her own and wanted teeth that couldn’t be removed in both jaws. So, there were six implants placed in the lower jaw, eight implants placed in the upper jaw, a lot metal that’s in there, and porcelain that’s placed on the top with the pink surface. When she smiles, that’s what she looks like. We have to give her room here to be able to get in and clean these things.
It’s very important, maintaining hygiene, and we’ll talk about that because most of these people ended up in this position because they didn’t do a good job cleaning their teeth. They’re probably, in some ways, also susceptible to periodontal disease. There’s lots of people we know who don’t clean their teeth but don’t lose their teeth as much as others. It’s something more than just not cleaning your teeth, and we know the ones who are in this situation in early age are susceptible and haven’t done a good job. We want to be able to provide and maintain them over a period of time.
When I started doing this in 1987, I would have to say that 80% of my implant patients were people who had no teeth, and out of that 80%, 80% were the lower jaw because that’s where most of the problems were. As we got more predictable and most successful with this, there were young patients missing just one tooth, and our big challenge was if somebody was just missing one tooth, what do we do in 1987? What do we do in 1992?
Well, we made a bridge. We took the natural teeth. We cut them down. We capped them, and we cemented a bridge that was of three teeth, but in effect, in order to replace one tooth, we were working on two perfectly healthy teeth that didn’t need us to be doing that. In fact, we were actually compromising these teeth.
Even and insurance company pays for a crown to be redone after five years. What does that tell you? That they think the life expectancy of a crown and a tooth is five years. Something’s going to break down. There could be decay. Something could happen to these teeth, and therefore, we were setting a young patient up like this that we did a bridge on in early age for repeated visits with the dentist over years of their lifetime and having replacements that needed to be made.
We were really interested in using treatment that didn’t allow us to treat the natural teeth. Could we have a way avoiding touching these teeth and giving the patient an implant? Studies were started, again. We had success with patients missing all their teeth, but did that apply to a patient who’s missing only one tooth? We didn’t know that. We had to test it out.
People started to publish in 1996 and 1999 where we were doing single tooth implants where somebody was missing just one tooth and how we were going to place an implant. This is an example of a patient like this that I treated many years ago. She was actually congenitally missing this tooth. It was not there when she was born. It happens quite often, about 11% of the time. We didn’t want to cut her beautiful teeth down at age 17. So, we put one implant in, made a temporary tooth first, let the gums heal, and were then able to make a porcelain crown that was cemented in place.
If you look at this young girl smiling, you couldn’t tell that she’s got an artificial tooth in there. The biggest thing that we did for her was that we left her natural teeth intact. We did nothing to compromise them. All of this was done by putting one screw and having a tooth attached to it.
Predictable process are my practices from treating patients with no teeth and implants have really gone over to treating mostly patients who have teeth, are missing one, two, three, four teeth. It’s an even mix now. Bridgework that we used to do 15 or 17 years ago, we don’t do that much anymore, at least I don’t in my practice because of the type of patients that come to see me.
This is a young fellow who was actually a medical student here at UCSF who was playing basketball across the street and got elbowed and cracked a tooth, and it was lost. He didn’t want to have a bridge made, and we placed an implant. You can see, six months later, he’s got something in there that looks like a tooth and looks healthy. You couldn’t look at this and say that it was something artificial. Same thing, one screw, a tooth that’s attached to that. Interesting part, the screw or the connection coming through the gum surviving without an infection. What osseointegration did for us, allowing bone to grow onto the surface of the implant.
Another young patient. This is a young lady who refused to have anything removal. She had been in a bicycle accident when she was a teenager, another very common injury. You fall down, and you get a hockey puck or something to your face. You crack a tooth. This tooth had got. It was dead, and it turned gray. A root canal was done to it. We know that these teeth, over time, break down. She started to get what we call resorption or for some reason the tooth’s been eaten away on its own, and it had to be replaced. That’s what the tooth looked like.
She would not tolerate walking around with no tooth in her mouth. So, this was a case where we actually removed the root and put a tooth on it the same day, but we made a tooth that was a lot shorter than the other teeth. We made it in such a way that she couldn’t bite or touch it. So, we weren’t loading that. Fortunate part for her was that she had a lot of good bone so we could put a long screw that was stabilized and was solid in there.
If you put a screw, and it’s moving and it’s not stable. Then, we’re not going to be able to do what we call an immediate load in a situation like this. This is what it looks like four months later. This is still a temporary tooth. You see a little grayness from where the screw hole is at the back through the plastic. Once it’s healed, this is her permanent tooth that’s been put on there about eight months later. If you look at her mouth right now, you couldn’t tell that she’s got an artificial tooth placed in her mouth.
This is another patient in the back of the mouth, congenitally missing or a tooth that was not formed. An implant, tooth attached, porcelain. Looks like a natural tooth. A molar in this patient replacing the tooth at the back, not involving adjacent teeth.
So, I can show you slides of this on and on and on because it has become a pretty predictable procedure. The only changes that have occurred are how many should be placed, where would we place them, what the size should be, how long should we wait, what type of material should we put on top. Should we put porcelain?
I mentioned to you earlier that a natural tooth is attached to the bone with a ligament. Well, that’s an advantage because when you have a ligament, it’s like a shock absorber. When you bite down on something, it has the ability to give. So, when you bite into something hard, there’s something to take off that shock.
When you have an implant that’s screwed into the bone, there’s not ligament. There’s no shock absorbing effect. When we put porcelain on the biting surface, we’re actually at risk for this porcelain fracturing. We don’t like putting porcelain in the biting surfaces of back teeth because if you’re eating some food, and by accident you get something that’s a seed in there or stone or something harder, then you expect you can just bust that porcelain off. Porcelain is glass, is brittle.
