Replacing a natural tooth lost to trauma, cavities, fracture or gum disease is a tricky business. Always has been. If it's just one or two teeth, and if they're in the front, we need to be especially skilled at blending our restoration into the rest of our patient's smile.
Among the things we have to get right are:
-Position in the arch of teeth
I make that final assertion because the natural, beautiful smile has a gumline that rises and falls with each tooth in a symmetrical scalloping. (The triangular gum between each pair of teeth is called the papilla.) This waviness falls along a spectrum; not all gums are created the same. I recall being surprised back in my first year of dental school when our professors introduced us to the official terms that describe the two types of gingival (gum) architecture:
Hey, I expected something in Latin, hard to spell and memorize!
Here's an example of Thick Flat:
Here's an example of Thin Scalloped:
Thick Flat gums are much more forgiving to work with. They're robust and don't recede much if challenged. Thin Scalloped gums are delicate and friable. If we challenge them--and challenges include a poor restoration--then they inflame and recede like mad.
And what about dental implants? If we replace a tooth with a titanium implant:
Will we be able to get our gum back? Even if the patient has Thin Scalloped architecture?
I've been to a number of lectures and symposia where some "big guns"--well-known lecturers in dentistry--say no. They say that gaining a decent papilla around an implant is extraordinarily difficult. And that if we have two adjacent implants, it's nearly impossible.
Yet there are other researchers and academics who have shown that fine gum architecture around implants can be attained through a combination of bone grafting, careful implant placement and meticulous attention to tooth contour. For you see, the precise way in which an artificial implant crown "grows" through the gum will have a lot to do with the shape that gum takes. Add bulk and the gums rise. Thin out the neck of a crown and the gum migrates down along the porcelain.
We can play with all these factors and aim for success in re-creating not just a tooth for our patient, but also beautiful supporting gums which are a vital component of the human smile. And even with all that care, it is a challenge.
Sometimes, we need another ingredient:
This long-term patient suffered a fracture in a front tooth root. That's the one that has drifted down a bit, from the resultant infection and inflammation. There was bone damage as well--there always is. Some of the supporting bone was gone. We can graft and get this bone back. But will we get enough? And can we employ a combination of implant positioning and tooth contour to regain a great papilla when our work is done?
Here's the initial presentation:
My patient's gums are the Thick Flat type, which gives us an initial advantage.
Here's the post-op implant radiograph:
Here is the initial result. The implant crown is on our left, and there's a new crown on the natural tooth on our right:
There's a bit af asymmetry, and some open space. My patient was just happy to have his tooth back, but I wanted more. And I knew that with patience, my attention to implant positioning and crown contours would bring us more as the gums matured over time:
Normal gum architecture and ideal papillae are challenging to get back when teeth are lost and implant replacement is performed. With a combination of careful bone grafting, implant positioning, tooth contours and the key ingredient--time--we can often come extradinarily close to regaining what nature gave our patient in the first place.
More on bone grafts here:
(I suppose we could get all sciency and call Thick Flat Crassus Planus and Thin Scalloped Tenius Undulatis.)