There is more to a beautiful smile than just having nice teeth. There also needs to be balance and symmetry in proportions, which depends on the choreography of the gums as well as and appropriate lip support to maintain form and fullness of the face. But the loss of teeth leads to changes in the jawbone and shrinkage of the gums, which in turn may cause a visible difference in the appearance of the middle and lower face.

When we placed dental implants the aim is to use them to support beautiful teeth, but if we do not restore the volume and form of the bone and gums that were lost, the overall results may be unnatural. There are two methods that we use at the All On 4 Clinic to restore or maintain appropriate proportions in our smile design:

Aesthetic Gum Replacement 1 — The problem is not the teeth themselves but the poor proportions of the gums and asymmetry caused by Gingival recession

Aesthetic Gum Replacement 2 — Aesthetic Gum Replacement showing a flat interface and improved design space

Aesthetic Gum Replacement 3 — Restored symmetry and balance with Upper All-On-4 Plus rehabilitation incorporating Aesthetic Gum Replacement

2. SURGICAL RECONSTRUCTION WITH BONE GRAFTING AND/OR GUM GRAFTING

Instead of restoring the lost volume with Aesthetic Gum Replacement, we may also or instead adopt methods to surgically reconstruct the lost tissue with bone grafting.

Surgical reconstruction of the VISIBLE parts of the smile

Reconstructing the visible parts of the jawbone and the gums is a common procedure at our clinics when doing individual dental implants, or when using these to replace a continuous segment of lost teeth. Because other teeth are still present in adjacent areas and the segment that we are attempting to augment is small, the biological and physiological strains during healing may be controlled to an extent leading to favorable prospects of success. The most common type of augmentation include:

Gum Grafting involves taking some gum tissue, typically from the palate, and adapting it in the area that is gum-deficient;
Bone Grafting involves using some of the patients own bone taken from adjacent non-visible parts of the jaw, or non-patient bone minerals, to reconstruct the area that is bone deficient;
Guided Bone Regeneration is a procedure whereby a barrier membrane is placed over a defect in the jawbone, which allows the bone to re-grow into the underlying space.

However, in full set teeth replacement, the area that would typically require reconstruction is quite large and the healing does not take place in a precise or uniform manner. As such the results are not as predictable as with Aesthetic Gum Replacement.

The other consideration when surgically reconstructing the visible parts of the jawbone and gums, particularly when replacing a full arch, is the durability of the restoration. By re-building the lost tissue volume surgically we are reducing the amount of space that is available for the construction of the bridge, which compromises its strength and longevity.

The example below illustrates treatment at All On 4 Clinic with the surgical reconstruction of the visible parts of the smile with bone and gum grafting.

Bone Grafting 1 — The patient presented with receded gums and severe erosion. The teeth under the porcelain veneers visible in this picture have completely eroded underneath. The upper teeth were removed and she underwent bone grafting and gum reconstructive procedures.

Bone Grafting 2 — The result was quite favourable in terms of aethetics. However, whilst the gums in this case have healed evenly, this is not always the case. Even her you can see discrepencies between the papillae and sizes of the teeth, which can worsen over time.

Bone Grafting 3 — Despite the nice result, when assessing durability, this picture illustrates a fracture of the bridge between the canine and premolar teeth. The fracture was the result of technical difficulties with inadequate room to design a durable restoration.

Surgical reconstruction of the NON-VISIBLE parts of the smile

Reconstruction of the non-visible parts of the jawbone is a far more common procedure in total rehabilitation because it improves the conditions for the placement of dental implants rather than being relied upon for aesthetics.

In certain cases it may be necessary to improve the volume or quality of bone with bone grafting. It is a surgical procedure that replaces missing bone with a material called a bone graft. The graft materials most commonly used are synthetic or bovine bone substitutes, or autogenous bone (patients own bone) that is often harvested from within the oral cavity. Whilst the grafting procedure may sometimes be required in advance of total rehabilitation, in the vast majority of cases, such as with All On 4 Plus, it is possible and advantageous to perform bone grafting at the same time as the placement of dental implants so as to improve the bone condition and overall success, or to allow for future additional implants as may be required for long term support. By performing the grafting procedure simultaneously, we can utilise the patients own bone harvested from the bone preperation or alveolectomy procedure.

The most common types of grafting procedures in total rehabilitation are described below:

INLAY GRAFT – Used at the time of extraction of teeth, the graft is placed within the residual socket to preserve the shape of the jaw bone and avoid bony resorption. It is a routine procedure in cases requiring the removal of teeth;
ONLAY GRAFT – This procedure is used to restore bone width, mainly in the front of the upper jaw. The graft material is laid on the surface of the jaw;
SINUS GRAFTING – The sinus is an air space in the upper jaw that can be utilised for bone grafting. Being a protected space, the graft is less susceptible to external influences, such as pressure from a denture, and is today regarded part of routine dental surgical care used to restore bone height in the back of the upper jaw for the simultaneous, or subsequent, placement of dental implants. A bovine bone mineral called Bio-Oss® is a safe and effective material widely used today to help grow new bone, and is a newer and less morbid alternative to older methods of harvesting bone from other parts of the body.

SINUS GRAFT PROCEDURE:

The sinus is accessed from inside and the lining it is gently elevated
The Bio-Oss® bone graft particles are placed beneath the membrane
The implant is placed at the time of surgery or after healing
Improved bone volume for implant placement and long term support

Sinus Grafting 2 — **Bony defects in upper jaw and large sinus spaces (top) treated with Upper All-On-4 Plus ® and sinus grafting (bottom)**

ALL ON 4 PLUS SINUS GRAFTING

Sinus Grafting may be a required or an optional procedure that is performed at the same time as the implant surgery, and offers the following benefits:

Improved visualisation of the bone structure from within the sinus, allowing a better spread of the implants towards the back, and possibly an extra one or more teeth than otherwise;
Re-using the patient’s own bone from the alveolectomy in the graft mixture
Improving bone volume to allow for additional implants for more teeth in the back
Improved contingency and more simplified management in the rare case if implant failure

Dental implants are of a permanent nature. This could mean longevity or reliability, but it also means that this treatment is difficult to undo

Since the two methods to resurrect the lost tissue volume, which naturally follows the removal of teeth, involves the positioning of dental implants in vastly different ways, the treatment plan must be definitive in order to facilitate a favorable outcome. In other words, it's not possible to change from one method to the other without removing the fixtures.

The surgical clinicians at the All On 4 Clinic have extensive experience in both methods and insight to make recommendations pertaining to definitive and predictable treatment options.