Cosmetic Dentistry: Ways dentists use tooth implants.

These three digital smile makeovers involve cases where dental implants have or could be used.

The first case discusses details about making the decision to place an implant. The second describes how it's sometimes a struggle to get implant results to look right. Mrs. Kitty's makeover involves using dental implants to support a complete denture.

Digital smile makeover #1: Opting for implant placement over orthodontic treatment.

Dental history and concerns:

1) When this person submitted their picture they mentioned that they would like to see what improvements could be made with their smile. They also stipulated that they were not interested in having orthodontic treatment.

That's a shame. It's easy to imagine how having braces could resolve a number of issues with these teeth, both top and bottom.

2) With the upper teeth, the biggest obstacle associated with improving this smile is the retruded upper left tooth. It's in crossbite. (That means when this person closes their teeth all of the way together, this tooth sits behind its corresponding lower teeth, rather than in front.)

Cosmetic dentistry solutions:

1) Making a decision to extract a tooth and place an implant. - Due to the extreme positioning of the upper left lateral incisor, and the treatment limitations set by the patient, there really isn't any legitimate way to make an improvement with its appearance. Any approach taken would either look strange or have consequences for the neighboring teeth and surrounding gum tissue.

Because of this, the only solution that remains is to have it pulled and replace it with either a dental implant or bridge. In our "after" picture, we've illustrated how we think things would turn out if an implant were placed.

As a criticism of the cosmetic outcome of this approach, the dental crown that's been placed on top of the implant looks narrow compared to the same tooth on the other side. That's because a full-sized tooth simply won't fit in a crowded-tooth space.

2) Completing the makeover. - Our "after" picture also illustrates changes for a few other teeth, which collectively create a much nicer appearance for this smile. It seems likely that porcelain veneers might be used to make these changes, although a decision about their suitability over crowns would be a decision for the treating dentist to make.

We'll admit that we've cheated somewhat in our "after" picture. We've show significant gum-line changes for the tooth on the patient's upper right. That amount a change would require a minor surgical procedure termed "gum sculpting."

3) An alternative (and better) plan. - Treating this as a dental implant case really seems a bit extreme. But given the limitations discussed above, we didn't see another option.

As an alternative plan, and one that seems a realistic compromise, here's an approach that could provide the same outcome with out having to extract the tooth and place an implant, if the patient would accept it.

Instead of full orthodontic treatment, just move the single tooth out of crossbite and back into a more normal positioning. Moving an individual tooth would take much less time than full treatment. And it could probably be accomplished with some type of removable appliance instead of fixed braces. (Actually, moving the same tooth on the other side into better alignment could be completed simultaneously, using the same appliance.)

The tooth may need to be narrowed before it will fit into its new space, but its shape can be perfected afterward by placing a veneer.

Digital dental makeover #2: A case involving both existing and future implants.

This second digital makeover involves a situation where several implants have already been planned or placed, and a discussion about some of the difficulties dentists can have when restoring them.

Dental history and concerns:

1) This person has some implants and is getting more. - In the email accompanying this person's picture, he stated that the two upper teeth to the right of center (his upper right incisors) are dental crowns supported by dental implants.

He also reported that because of damage to the tooth's root, the upper tooth left of center will also have to be extracted and an implant placed.

2) Why this smile looks strange. - When you look at this person's "before" picture, notice how all four of his upper incisors are similar in size and shape (most notably, the width of the teeth are all about the same).

That's not a normal appearance. Usually a person's central incisors are both wider and longer than the lateral incisors that lie to each side of them.

Cosmetic dentistry solutions:

1) Placing new dental crowns on the implants. - Our "after" picture illustrates how this person's smile might be changed by way of placing new dental crowns on all four upper incisors (placing new crowns on the existing implants, the future implant, and the one natural tooth).

As you can see, we've shown an appearance where the teeth have been returned to an arrangement where the central incisors are longer and wider than the lateral incisors to their sides. This is a normal configuration for upper front teeth.

2) Our results are easier said than done. - We realize we've just touched up a picture, not real teeth. And there can be a number of factors that might present themselves as obstacles in getting the results we've shown.

One of the biggest is implant positioning. Are the existing implants in a position that allows for the changes we've shown? Can the future implant be positioned properly? Also, does this person's bite place any restrictions on the lengths of the teeth?

These are all questions that can only be answered by the treating dentist. But we will say, up to this point this smile has been constructed in a piecemeal fashion. Possibly if the dentist were given the opportunity to reconstruct all of the crowns at the same time they could achieve a more natural appearance.

Digital smile makeover #3: Using dental implants to support a denture.

Sure, we were bored. But if this were a human, this would be a case where dental implants could be used.

Dental history and concerns:

This poor dear's smile has a number of problems, which makes her look seem old beyond her years.

• On the bottom, it seems she's missing her back teeth.
• On top, we really don't think this kitten has any teeth at all.
• The lower incisors seem to have significant wear.
• Her very long cuspids give her a wild, unruly look.

Cosmetic dentistry solutions:

• On the top, probably the most cost-effective solution for replacing her teeth would be a complete upper denture. This could be a traditional one, or one supported (held in place) by dental implants.
  
  One advantage of the latter would be the stability of the appliance. Rather than being held in place by suction, the denture would be fitted to implants imbedded in the jaw bone.
  
  Since no suction is need, the denture could have an open palate. That means that the roof of the patient's mouth wouldn't be covered with plastic. (A feature most patients appreciate.)
• As an alternative, the upper teeth could be replaced using dental bridges supported by dental implants. This approach would be more expensive than the denture (it would require more implants and the bridgework would be more expensive too).
  
  Only the treating dentist and patient, together, could choose between these two approaches. The cosmetic end result of either method, however, would be the same and very similar to what we show in this makeover's "after" picture.
  
  
  
• In regards to the lower teeth ...
  
  We've simulated the placement of dental crowns on the lower eyeteeth. (Making this type of drastic length change would necessitate performing root canal treatment first.)
  
  It's possible that the change we've illustrated for the lower front teeth could be made by placing dental crowns. However, placing such tall crowns on such short nubs (or teeth with comparatively short roots) often isn't possible.
  
  If the lower front teeth can't be rebuilt with crowns, a very practical solution would be to extract them and then replace them, along with the missing lower back teeth, with a removable partial denture.