Dental and Facial Implants

When teeth are lost, the appearance of a the person is lost as the lips collapse inward and gives the patient an “old person’s look”. Plaque and decay can occur much quicker, leading to loss of more teeth. When a tooth is lost, the neighboring teeth shift to compensate for the vacant spaces thus changing the biting pattern and also creating spaces in the natural dentition. This causes reduction in the chewing efficiency and often the jaw joint may be affected. Thus it is important to replace any missing tooth as soon as possible.

Modern dentistry provides for 3 main options for replacing teeth:

• Removable dentures
• Fixed Bridge
• Implants

Removable dentures are made of acrylic (plastic) or metal. They are basically false teeth that sit on the gums and take support from remaining natural teeth. They are cheap to make. They however need to be removed after every meal and cleaned. They also provide only approx 60% chewing efficiency. More and more removable dentures are not preferred nowadays but it is an option if you want it

A fixed bridge is an artificial tooth cemented to the adjacent tooth (cannot be removed by you). They are firmly fixed and thus more efficient in chewing food. Basically the adjacent teeth are ground down by a millimeter and an impression is taken and a bridge is made in the lab and this is then cemented to the teeth. Many people prefer this as they are fixed and there is very little chance of them falling out. They are slightly more costly than the removable dentures but still very much affordable.

Implants are small titanium screws placed surgically in the bone and a denture is fixed to these screws. They take approximately 3-6 months to complete but are the best form of tooth replacement there is at the present . As the entire implant system is imported they are expensive when compared to bridges or removable dentures. Chewing efficiency is equal if not better as compared to natural teeth and the appearance is also the best. The adjacent tooth is not touched at all as the titanium implant is placed in the bone itself. The only drawback of implants is the cost - if you can afford it – then there is no comparison– implants are the best way to replace missing teeth. We will show you a few cases done in our centre to show you the results that can be achieved

This young man came to us following a fall in which he had sustained a fracture of his mandible and also managed to knock out his front four teeth. He initially had the fracture mandible treated with plating which healed with no complications. He was however very distressed over the loss of his front teeth. We suggested for him to have dental implants placed instead of a conventional bridge/ removal partial denture. Under Local Anesthesia, four implants were placed in the maxilla. After a healing period of six months the implants were exposed and the abutments placed. All four implants had osseointergrated well and an impression was taken for the prosthesis. A full ceramic bridge was given for the implants. Cosmesis as you can seen was very good and the patient was extremely happy with the result. The smile on this young man’s face says it all. This is what makes it all worthwhile

A middle aged lady who was suffering from diabetes came to us following loss of all her upper teeth. Diabetic patients need a relatively hard diet and therefore need a strong dental reconstruction. We got her diabetes under control with the help of her diabetologist and then went for dental reconstruction with dental implants followed by a ceramic bridge. Six years later, she is still doing very well and is on a normal diet.

A 26 year old patient came to us with no teeth since he was 14 years old. On clinical examination he had severe palmar and plantar hyperkeratosis in his hands and legs. On intraoral examination he had no teeth and had removable complete upper and lower dentures. Considering his age ( just 26 years old and unmarried) he was desperate to get a fixed prosthetic rehabilitation done for his dentition. He had consulted numerous doctors and they had all told him that fixed rehabilitation was not possible due to severe bone loss.

He was diagnosed as having a very rare syndrome called Papillion Le –Fevre syndrome. This syndrome was first described by Papillion and Le-Fevre in 1924. The incidence is 1/4000,000. The gene responsible for this condition was mapped to chromosome 11q14. It is characterized by juvenile periodontosis with palmar-plantar hyperkeratosis. It mainly affects the oral cavity and skin. In the oral cavity, development and eruption of the deciduous teeth proceed normally. Then almost simultaneously with the appearance of palmar and plantar keratosis, the gingiva swells, bleeds and becomes boggy with marked halitosis. Destruction of the periodontium occurs with deep periodontal pockets and exfoliation of all teeth occurs by around 14 years of age. In addition to this complete destruction of the alveolar process occurs. In the skin, the hyperkeratosis of the feet can cause cracking– in severe cases walking may be difficult due to this. Some patients also have a generalized hyperhidrosis– very fine body hair.

In this very compromised case, the only option for dental reconstruction would be dental implants but due to extreme bone loss, the placement of implants becomes very difficult– especially in the maxilla. For the maxilla, two options were available: The first option would be a bone grafting to the maxilla with normal dental implants and the second option was a graft-less solution of zygoma implants. We choose the zygoma implants option.

As this patient had very little bone stock, CT and CBCT scans were done and a 3-D models were produced using a 3-D printer . This gave us a very good idea of the complexities involved in the case pre-op. Two models were done– one in clear acrylic and one in white acrylic– the clear one shows the extreme bone loss and the level of compromise present. A model surgery was also done with trial zygoma implants to check for the stability of the implants in the models prior to going ahead with the final surgical procedure in the patient.

Under GA, intraoral flaps were raised and two zygoma implants along with two normal dental implants were placed. The zygoma implant size was 50 mm bilaterally; in comparison the maximum dental implant size available in the market is only 16 mm. Extreme care was taken to do this surgery carefully as a lot of important structures are present around the site ( including the eyes, Pterygoid plexus and maxillary arteries). Moreover in this case , the bone stock around the zygoma itself was present in only one region( that too was minimal) allowing us no leeway in case of any untoward happenings. Both implants were tight to over 40 Nn torque and the postoperative course was uneventful. After 6 months the implants were loaded and he had a fixed set of teeth.

Pre-op OPG X-ray showing extreme bone loss

Plantar and palmar hyperkeratosis with extreme destruction of the alveolar process in maxilla and mandible

Pre-op CT scan with 3D printed models for study

Pre-op 3D models showing thinness of bone and trial zygoma implants done.

Zygoma implants placed

Postop. X-ray.

Postop final with a fixed denture (non removable)

A 50 year old man presented to us missing posterior maxillary teeth ( upper jaw). He did not have teeth present for bridges and he was not interested in a removable denture. Normally dental implants need good bone stock to be able to be placed in the mouth. The bone in this case was very minimal and would not support normal implants. The option of zygoma implants ( graftless solution) or a bone graft was discussed with the patient. He wanted to go for bone grafting. Bone can be harvested from the mandible (lower jaw), ribs, iliac crest(hip), cranium (skull bone) or tibia / fibula(leg bones)

A sinus lift was done bilaterally via an intraoral approach and iliac crest bone was harvested and placed in the maxilla . After allowing the bone graft to heal for 3 months , we then placed dental implants and provided a fixed prosthesis for him

Natural bone graft being done using sinus lift technique.

In this case, we had a deficiency of bone in the upper jaw for implants but the patient did not want to have bone harvested form his mandible, ilium , tibia, cranium or rib. It was then decided to go for synthetic bone(hydroxyapitite with a bio-gide membrane). These are all imported and quite expensive but avoids donor site morbidity. The procedure is the same as for natural bone—the only change is artificial synthetic bone is used instead of natural bone.

Synthetic bone graft

Synthetic bone grafts done using sinus lift technique.