CROWN LENGTHENING

3 CROWN LENGTHENING "Crown lengthening" can be thought of as "tooth lengthening". We need crown lengthening to rebuild a tooth when there isn't enough of the tooth showing in the mouth for dentist to build a crown (or "cap").

For this case, the previous crown failed because it was too thin as a result of the tooth not being reduced enough. You can see on the X-ray to the left how thin the temporary crown is right at the top. If the tooth was reduced enough for adequate crown thickness, the tooth shape would be very short and there would be a lack of mechanical retention. In other words, the crown would be more likely to come off.

The crown lengthening procedure is a minor surgery that usually results in very little post-operative pain. A layer of tissue around the tooth is carefully removed to expose more of the tooth.

The final crown is fabricated by your general dentist six weeks after the surgery. Crown lengthening allows otherwise hopeless teeth a new lease on life.

4 CROWN LENGTHENING

Crown lengthening can be completed for multiple teeth at a time. For upper front teeth, crown lengthening can be used to make short teeth look better proportioned, or simply to improve mechanical retention for the final crowns. Improving mechanical retention through crown lengthening can be thought of as equivalent to placing a fence post deeper in the ground.

Teeth that are too short

Planned changes to tooth length

Teeth are lengthened to ideal proportions

Surgery completed to lengthen teeth

The taller the tooth structure under the crown, the less likely it is that the crown ever falls off. While we always use cement to glue a crown into place, the bond is not strong enough to hold the crown in place long term. This is why mechanical retention is important.

5 6 GINGIVAL RECESSION

7 TREATMENT OF GINGIVAL RECESSION

Gum recession can result in tooth sensitivity and an unsightly appearance of the gum tissues. Repair of gum recession can be accomplished with various methods. The gold standard for repair of gum recession is autogenous soft tissue grafting, or gum tissue transplants.

A small piece of donor tissue is harvested from somewhere else in the mouth and placed in the area of gum recession. The harvest site is protected with several layers of surgical glue and a clear retainer to minimize discomfort after the procedure.

8 TREATMENT OF GINGIVAL RECESSION

Depending on the position of the upper lip, repair of gum recession can make a big difference to the appearance of your smile.

Both of these patients were treated with a connective tissue graft, which is one variation of a gum tissue graft. A connective tissue graft gives the best cosmetic result, but its a more complex procedure than the other type of gum tissue graft, a free gingival graft.

9 TREATMENT OF GINGIVAL RECESSION

A "free gingival graft" is a type of gum tissue graft often used to repair gum recession on lower front teeth which usually aren't visible when you smile. The color of the graft when fully healed will sometimes end up being a slightly lighter color than the adjacent gum tissue. For upper front teeth that may have a visible gum line, we use a connective tissue graft, which is a more complex procedure but gives the best cosmetic result.

10 TREATMENT OF GINGIVAL RECESSION

On lower front teeth, it is quite common to develop gum recession on both teeth adjacent to the midline. A single gum graft is used to repair both teeth at the same time.

11 TREATMENT OF GINGIVAL RECESSION BEFORE

Attached gingiva (gum tissue that contains keratin and is firmly attached to the bone) provides a natural barrier to bacterial invasion around the teeth and is usually light pink in color. A lack of adequate gum tissue on all the lower front teeth had already led to severe gum recession on a tooth for this 24 year old patient.

Attached Gingiva

12 TREATMENT OF GINGIVAL RECESSION AFTER

Gum tissue transplants were used to repair the gum recession and to increase the width of attached gingiva to prevent future gum recession on the other teeth.

13 TREATMENT OF GINGIVAL RECESSION

Gum grafting is often needed as part of a "full mouth rehabilitation", that is, replacement or restoration of all the teeth. As part of this patients overall treatment plan, soft tissue grafting was needed on the lower front teeth prior to placement of crowns.

14 TREATMENT OF GINGIVAL RECESSION

A combination of techniques were used for this patient as part of a full mouth rehabilitation. Crown lengthening (tooth lengthening) and soft tissue grafting were used to create a symmetrical gum line prior to placement of crowns.

15 TREATMENT OF GINGIVAL RECESSION

Pedicle soft tissue grafts are an attractive option to repair gum recession when there is enough gum on an adjacent tooth to "donate" to the tooth with the deficient gum line. A very esthetic result can be accomplished without having to take donor tissue from a different surgical site.

16 TREATMENT OF GINGIVAL RECESSION

A combination procedure is used for severe gum recession cases. The tissue from the adjacent tooth is used to repair the defective gum line, then a small graft is placed on the tooth with a normal gum line. The outcome is more predictable and less invasive than conventional techniques.

17 TREATMENT OF GINGIVAL RECESSION

Dental implants sometimes develop gum recession and require treatment. This particular implant was on the verge of failing due to bone loss and lack of gum tissue. Removing a failing implant and placing a new one would be a lot more invasive, expensive and time consuming. Saving an implant with gum transplants can save significant amounts of time and money.

18 TREATMENT OF GINGIVAL RECESSION

A hole in the gum developed on this implant several years after it was placed and restored by another dentist. The white abutment is visible on the photo to the right.

A soft tissue graft was placed to repair the defect.

The hole was completely repaired; the new gum line is thick and resistant to future shrinkage.

19 20 LASER ASSISTED PERIODONTAL THERAPY

21 Kevin McCavera Ocala Periodontics & Dental Implants DATE 21500 SW Monaco Court 4600 SW 46th Court, Bldg #200 Suite 360 05/02/2018 Dunnellon FL 34431 Ocala FL 34474 Showing perio readings of 11/01/2016

LASER ASSISTED PERIODONTAL THERAPY

"Due to gum disease and underlying bone loss, I was supposed to have all my teeth removed in November of 2016. After a consultation with Dr. Amir, a plan was put in place to save my teeth. Now, it’s May of 2018 and I still have my teeth. Dr. Amir gave me hope and healing when I didn’t think I could be helped. Thank you Dr. Amir."

Before treatment Before treatment pocket depth measurements

2 weeks after laser treatment

After orthodontics (braces)

Laser assisted periodontal therapy is used as an After treatment alternative to more invasive forms of treatment for pocket depth gum disease. With this treatment, we are often able measurements to save teeth that were once deemed hopeless with a relatively painless and minimally invasive procedure. 22 LASER ASSISTED PERIODONTAL THERAPY

Severe bone loss due to gum disease Diseased bone frequently results in tooth loss. Laser assisted periodontal therapy can regenerate bone and decrease deep gum pockets. In this case, a 14 mm pocket was reduced to 4 mm and the diseased bone was repaired.

Healthy bone

23 LASERLASER ASSISTED ASSISTED PERIODONTAL PERIODONTAL THERAPY THERAPY

Bone loss Bone loss

Before and after treatment with laser assisted periodontal therapy

Bone repair Bone repair

24 LASER ASSISTED PERIODONTAL THERAPY

BONE LOSS MICROSCOPE ENHANCED DENTISTRY

Microscopes are used to improve the accuracy of diagnosis. This patient was referred for extraction of her front tooth due to a root fracture. The X-Ray shows signs of a root fracture, and the black line visible behind the tooth by the gum line looks very much like a crack line going up the root. Coupled with a deep pocket, the outlook for this tooth was quite grim.

At the treatment appointment, a periodontal laser BEFORE TREATMENT was used to ablate the pathologic pocket tissue. A dental operating microscope was used to better visualize the suspected fracture. Calculus was identified and removed with an ultrasonic scaler. The suspected fracture was confirmed to be a AFTER TREATMENT congenital groove with calculus extending along the groove to the base of the pathologic pocket. Viewing the same area using a BONE REPAIR high powered microscope showed that what appeared to be a crack was actually a Calculus (Tartar) small groove in the root of the tooth that was lined with calculus (tartar). Laser assisted periodontal therapy was used to eliminate the tartar and the groove was smoothed out with drills. The treatment resulted in repair of the bone defect visible between the teeth on the X-Ray to the upper left of this page. The X-Ray below shows the healed bone. Saving the original tooth was much less invasive, less costly and was completed in a single treatment appointment versus extracting the tooth and replacing it with a dental implant.

25 LASER ASSISTED PERIODONTAL THERAPY

BONE LOSS BONE REPAIR

The most amazing thing about laser assisted periodontal therapy is the ability to save teeth that the vast majority of dentists would deem hopeless.

26 LASER ASSISTED PERIODONTAL THERAPY

Maintaining a natural tooth is almost always a better option than removing a tooth.The cost saving is usually BONE LOSS BONE REPAIR substantial also.

27 LASER ASSISTED PERIODONTAL THERAPY

BEFORE AFTER

28 LASER ASSISTED PERIODONTAL THERAPY

BONE BONE LOSS GAIN

BEFORE AFTER

29 LASER ASSISTED PERIODONTAL THERAPY

30 LASER ASSISTED PERIODONTAL THERAPY

While dental implant therapy to replace missing teeth is usually a predictable treatment option, bone loss around dental implants can occur in certain circumstances, ultimately leading to loss of the implant. Laser assisted periodontal therapy techniques can also be applied to failing dental implants. The failing implant can be saved by reversing the bone loss with a single procedure that is perhaps 10-20% of the cost of completely replacing the implant.

31 LASER ASSISTED PERIODONTAL THERAPY COMBINATION THERAPY FOR FAILING IMPLANTS

Dental implants can sometimes get bone loss as a result of inadequate gum thickness, which can allow food particles and bacteria to easily lodge under the gum line around implants. In these cases, laser therapy is used to treat the existing bone loss and soft tissue grafting is used to prevent future bone loss by thickening up the gum line where needed.

32 LASER ASSISTED PERIODONTAL THERAPY HEMANGIOMA REMOVAL

Hemangiomas are purplish lesions that are benign (non- cancerous) in nature but can be unsightly. The same laser that is used to treat periodontal disease can also be used to ablate vascular or pigmented lesions such as the hemangiomas shown here. Treatment is completed within minutes with no cutting or sewing involved.

BEFORE AFTER

33 34 ESTHETIC DENTAL IMPLANT THERAPY

35 ESTHETIC DENTAL IMPLANT THERAPY

Dental Implant therapy allows for replacement of missing teeth using the underlying bone to support a titanium implant that a tooth can be built onto. Dental implants have been in widespread use for at least 30 years. Digital technology has streamlined the planning process, improving outcomes. Extensive data obtained over the past 30 years has helped dental implant surgeons better select patients suitable for dental implants, reducing complications and failures.

Whether for replacement of a single missing tooth, multiple teeth, or all of the teeth, dental implants can be used a variety of ways to improve chewing function and esthetics.

Dental implant therapy is a multi-stage process. Correct execution requires proper planning and strict adherence to established protocols. On the following page, all steps of the dental implant treatment process that are used by Dr. Jamie Amir are highlighted.

36 ESTHETIC DENTAL IMPLANT THERAPY

DENTAL IMPLANT TREATMENT SEQUENCE

1st Appointment Implant Placement Uncover Implant Color/Material

Consultation appointment The implant is surgically • • An appointment will be CT Scan (3D X-Ray of the jaw • Surgical placement of the exposed once the • • scheduled with your bones) implant is completed using implant has fused to the dentist to choose the 3D Digital Impression of the the Surgical Template bone • color and material of the mouth with a 3D scanner • The implant is left Gum tissue grafting and/ • final abutment and crown The CT Scan and Digital underneath the gum to allow or a temporary crown • Minor adjustment of Impression are combined using it to heal undisturbed for 2-3 may be needed to • adjacent teeth may be computer software months ensure there is a natural needed for an ideal fit 3D printing is used to produce • Any remaining sutures are thickness and • The restorative fee is a Surgical Template for ideal removed at two weeks appearance of the gum • usually due at this visit implant positioning tissue

Final Scan Crown Delivery Follow Up 1 Year • A final follow up The final 3D digital scan of the • The prosthetic tooth crown is appointment is made at implant is completed at Ocala • The baseline clinical placed on the implant by your Ocala Periodontics • Periodontics measurements are general dentist • Baseline clinical The 3D digital scan is submitted repeated at 12 months to • A night guard is made at this measurements, to your dentist's laboratory of • ensure all clinical stage if recommended by Dr. including an X-Ray, choice for manufacture of the parameters are stable Amir or your dentist photo and probing depth final tooth crown restoration measurements are completed

37 ESTHETIC DENTAL IMPLANT THERAPY

To achieve an ideal esthetic result, it is imperative to maintain symmetry when replacing either a missing tooth or a tooth that needs to be extracted. Advanced surgical techniques, in combination with high quality restorative dentistry, creates a flawless final outcome.

38 ESTHETIC DENTAL IMPLANT THERAPY

Loss of a natural tooth is not a solo event. Gum and bone are routinely lost due to periodontal disease, trauma or infection, prior to tooth loss. Even if all bone is present when a tooth is lost, gum and bone will slowly disappear in the weeks and months after a tooth is extracted due to a natural healing process. To compensate for the shrinkage, bone grafts and gum tissue grafts are used to over bulk the area, creating a natural gum position at the end of treatment.

Root fracture

Normal bone position

Actual bone position

39 ESTHETIC DENTAL IMPLANT THERAPY

For this case, a soft tissue graft was used to bulk up the gum tissue after the final crown was placed on the implant.

40 ESTHETIC DENTAL IMPLANT THERAPY

Before

After

A dental operating microscope is utilized to allow for the use of microsurgical instruments intended for eye surgery to reduce the possibility of scarring and allowing for an esthetic result that is indistinguishable from nature. 41 ESTHETIC DENTAL IMPLANT THERAPY

Temporary crowns can sometimes be placed on the implant the same day the implant is surgically placed. This helps to shape the gum line to improve the esthetic appearance of the final prosthetic tooth replacement.

Placing the temporary crown on the implant the same day that the implant is placed means that no removable tooth is needed for the healing period before the final implant crown is fabricated.

42 ESTHETIC DENTAL IMPLANT THERAPY

The final implant crown is designed to mimic the natural tooth form.

43 ESTHETIC DENTAL IMPLANT THERAPY

Shrinkage of gum tissue after tooth extraction and dental implant treatment is a common occurrence that can result in exposure of the root surfaces of adjacent teeth. If the adjacent teeth have crowns, the mismatch between the root color and the crown color can create the appearance of a dark line next to the gum. To prevent this, hard and soft tissue grafting is utilized.

The pseudoepithelialized soft tissue graft is a specialized donor graft of variable thickness that is used to create the maximum amount of extra gum tissue at the time of extraction.

44 ESTHETIC DENTAL IMPLANT THERAPY

A rotated pedicle graft can be used to further maximize the gum tissue volume when the healed implant is finally exposed prior to placement of the final crown.

Before After

The final result perfectly recreates the appearance of the original tooth, including perfect preservation of the gum shape.

45 ESTHETIC DENTAL IMPLANT THERAPY

The positioning of the dental implant is critical to obtain natural looking esthetics. A space is deliberately left between the bone and the implant. Bone graft and soft tissue grafting is placed to maintain natural contours of the gum. 46 ESTHETIC DENTAL IMPLANT THERAPY

The premature loss of a front tooth is perhaps one of the most traumatizing events that can occur to a person. As many of us can attest, losing a front tooth can be both a literal and figurative nightmare.

Dental Implant therapy to replace an unrestorable front tooth is both an art and a science. Established treatment protocols must be followed to achieve a predictable and natural looking result that will be maintained over the years.

47 Dr. Jamie Amir

www.ocalaperio.com 352-229-8686 [email protected]

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