Dental Seminar Training Maxillectomy Implant Reconstruction Maxilla Bone Reduction
Michigan Dental Seminars

Ara Nazarian, DDS
Gummy Smile Bone Removal
1857 East Big Beaver Rd
Michigan Dental Center
Troy MI 48083
(248) 457-0500

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Birmingham Clawson Bloomfield Office

Creative Solutions for Unique Treatment Needs

Advanced Diagnostics versus Traditional Assumptions

Gummy Smile Treatment: Confirming the Cause

The patient pictured here presented to our office with what she thought was a need for crown replacements, possible veneer treatments and gum tissue lasing that would enable her to smile without her "usual" gummy appearance.

Wrong Diagnosis for Gummy Smile
Apparent Gummy Smile Treatment Need
A routine, visual exam clearly shows the patient could benefit from treatments that would replace whatever failing restorations she had... but also address the "sizing issues" of multiple teeth that comprise her smile line.

Common Gummy Smiles

Many gummy appearances are age dependent. Children, for example, oftentimes have a gummy appearance due merely to the size of their teeth. Baby teeth, especially, easily "create" the appearance of too much gum.

Symmetry issues that affect all of the anterior teeth (usually upper) in a smile line are the most common for adults.

Orthodontic treatment, for many patients, can cause the hyperplasia that occurs as a result of not being able to totally eliminate the accumulation of bacteria.

Developmental events are also known to occur that results in the upper lip being "periodontally attached" in a position that exposes too much gum tissue when smiling.

Common Treatments

Gum contouring is the most popular treatment for trimming gum tissue that creates the attractive gingival arching that defines the perfect smile line. This procedure is often combined with veneers and crowns (depending on overall treatment needs of the patient) that can create very dramatic results.

Periodontists, typically, provide Lip Repositioning to patients who desire to overcome the developmental events that cause their upper lip to move "too high" when smiling.

The Uncommon Gummy Smile

Meth Mouth Xerostomia
Bone Height Analysis
Yellow = current level | Black = normal level
As the Panorex data and ctscan data were being accumulated, it was discovered the patient was actually experiencing the consequences of NOT having routine orthodontic treatment that was recommended to her many years earlier.

The overbite she was diagnosed with, because it didn't "look severe", continued to develop. The "super eruption process" that is known to commonly occur with unopposed teeth affected her entire maxilla.

In a rather deceptive manner, the supereruption events (and associated tissue changes) occurred without any significant notice.

Bony Ridge Exposure
Perio Flap Surgery
Exposing the Maxillary Ridge
Tooth failures that were occuring due to the supereruption process were treated at a basic restorative level but continued to fail.

Gum disease also eventually developed.

The adjacent two photos reveal the amount of supereruption that has occurred, the existence of diseased tissues and a representation of what the optimal height should be of the maxillary bony ridge.

A Panorex provides an encompassing view of the entire bony floor of the sinus cavity.

Bony Ridge Exposure
Red Line Outlines Sinus Cavity Floor
A cursory analysis reveals the variations of bone quality and levels that will require additional treatments for augmenting certain areas of tissue deficits.

Sinus lift surgery will be required where anticipated implant placements pose a current or future perforation possibility.

3D Imaging - Treatment Planning

Implant selection and placement planning was completed with 3DDX 3D software planning tools.

3D Implant Placement
Ctscan Implant Placement Planning
The amount of bone leveling needed to establish a healthy level ridge was derived from the ctscans directly (see 2nd adjacent scan).

The process of implant selection (width and height) for each surgery site factored in existing quality of the sinus cavity floor.

The pink area on the scan reflects an instance of bone augmentation via a sinus lift procedure.

The 3DDX software also enabled Dr. Nazarian to create the surgical guide needed to assure precision tissue removal.

The scan shows the final visual representation of the different sized implants and their respective placements along the bony ridge that takes the best advantage of bone health characteristics at each implant site.

Preliminary Treatment

Maxillectomy Grafting
Maxillectomy + Bone Grafts
The upper jaw was fully edentulated within a matter of minutes, using the Physics Forceps extraction instrument.

Bone leveling followed, with socket grafts gingival tissue grafts using a protocol that would result in a uniform ridge that would a healthy, functional ridge to accommodate an immediate denture.

The picture presented here reveals the placement of tissue grafting products immediately prior to suturing of the perio flap.

Initial Osseointegrative Healing

Due to the amount of bone tissue removal, sinus lift surgery and optimal use of socket grafting products, the bony ridge was not prepared or fitted for provisional dental implants.

The goal was to provide the best oral health conditions possible that would promote successful tissue regeneration.

A comfortable, soft lined immediate denture that assured acceptable dental function also served to protect all modified tissues.

3DDX Surgical Guide
3DDX Surgical Guide Implementation

Implant Placement

Thorough healing of the modified maxillary ridge is typically completed within 8 to 10 weeks.

The midtreatment photo pictured here reveals the Surgical Guide placed on top of the entire maxillary ridge.

Once securely anchored into the position defined by the 3DDX software, placement of the implants progresses smoothly and is uneventful.

The surgical guide bushings are preconfigured for the various sized implants. Additional guides control the depth of each implant placement.

Precise Placements
3D Implant Configuration

Controlling Precision

Once mounted and aligned, the surgical guided is secured with two (2) temporary placement pins, which are inserted into healthy areas of the maxilla.

This firm attachment assures the drilling template does not move or shift during the multiple implant drilling sequences.

Sequenced use of incrementally sized drill bits appropriate for each implant design enables rapid implant placement.

The "checking and rechecking" of implant alignment and insertion associated with old fashioned free form implant placement is eliminated with the use of a surgical drilling guide.

This added assurance of eliminating errors that both the dentist and the patient enjoys is the basis for the rapid implementation of guided surgery technologies.

3DDX Surgical Guide
Confirmation of Accurate Implant Placements

Final Confirmation

The adjacent photo reflects the degree of accuracy obtained via guided implant surgery.

Secondary Osseointegrative Healing

All of the implant devices are fitted with healing caps to protect the immediate treatment areas and to further promote the growth of additional, healthy gum tissue.

The Immediate Denture is fitted again, with addditional trimming as needed, to provide a comfortable tight fit.

Soft relining product serves to partially "grip" the healing caps providing a measure of denture retention during the final healing phase.

Permanent Teeth
Porcelain Bridgework

Temporary and Permanent Bridgework

Once the implants have become fully osseointegrated, the healing caps are removed. Gingival tissues are trimmed as need to assure the implant abutments emerge in a snug fashion that protects the implant site and surrounding soft tissues.

An acrylicc based bridge is placed for a few weeks that enables the dentist and patient to make final adjustments for occlusion, sizing and coloration.

The permanent, porcelain bridge is fabricated and placed when all functional and cosmetic concerns have been successfully addressed.

New Teeth
Final Bridge Placement

Realizing Exceeded Expectations

The use of specialized procedures that recreated a normalized level of maxillary bone was the only practical treatment available.

It shown that these treatments would produce the foundation for what the patient longed for.... a smile that she once had, many years ago, before she experienced the structural changes in her dentition and overall occlusion that were adversely affected by avoiding routine orthodontic treatment.... and subsequent "cosmetic procedures" that failed to address the "real issues."

Final Outcome
Final Bridge Placement
The combination of a "normal" maxillary ridge and multiple dental implants enabled the patient to select restorative products that typify the best that cosmetic and resotrative dentistry can provide.

Within seconds of seeing her new porcelain smile in a mirror, our patient became tearful, creating an emotional "makeover response" that defies description. Her husband, who was standing nearby, commented that he wasn't aware of the amount of damage that was endured over the years.... until he "saw" the reversal, first hand.

Questions and Details

Dr. Nazarian can be most easily contacted via our on-line email Contact Form. He will respond to you directly with the answers you seek to any questions about the material on this page.

Michigan Dental Seminars
Ara Nazarian, DDS Seminar Leader
1857 East Big Beaver Road
Troy MI 48083
(248) 457-0500 - Fax: (248) 457-0501

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