Dental Implant Surgery
Teeth serve an important role in our daily lives as it affects our speech, our ability to eat well and the way we look. Its loss through disease or trauma sets in motion the loss of underlying bony support resulting in tooth loss. This in turn affects support for our lips and cheek leading to a more aged appearance. Failure to replace missing teeth often leads to the opposing teeth overgrowing and the adjacent teeth tilting resulting in areas of food trapping which in turn may result in gum disease tooth decay.
What are the different ways of replacing missing teeth
Traditionally, missing teeth were replaced by either removable plastic or metal based dentures, or fixed bridges made of either metal alone, or porcelain fused to a metal base. Developments in dental material science have focused on developing more aesthetic materials with adequate strength, such as all-porcelain and zirconia bridges. While all of these are still very much in use today, implant based methods of replacing missing teeth are increasingly preferred as it provides greater biting ability and a more comfortable and natural feel.
What are dental implants?
Dental implants are sterile titanium screws which are inserted into the jawbone as artificial roots to support and retain replacement teeth. It comprises 3 parts. The first part or “fixture” is placed within the jaw bone to replace the roots of missing teeth. The second part or “abutment” emerges through the gums and is used to carry the 3rd part, which may be a single crown or a bridge depending on how many teeth are missing. If we have lost all our teeth, we can use 4 to 8 implants in each jaw which when connected can support dentures or even a fixed bridge
How do Implants compare with alternative options?
When compared with removable dentures, they provide stronger support, firmer retention and are more stable. The implant supported and retained replacement teeth occupy less space and are more comfortable. They are also able to generate much stronger biting force. When compared with fixed bridges, they can be used even when more teeth are missing as they can provide stronger support over a longer span. They are also preferred when the teeth adjacent to the gap are weak or too small to provide sufficient support. Additionally, they provide an alternative to trimming healthy teeth.
Benefits of Dental Implant
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Are permanent replacement for missing teeth
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Has predictable and good long-term success rate
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Prevents supporting bone from shrinking after tooth loss
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Does not decay as it is made from Titanium
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Able to generate stronger bite forces for better chewing and hence better digestion and nutrition.
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Restores appearance thus creating more confidence and self-esteem Able to provide better support for lips and cheeks for a more youthful look
Types of Dental Implant
Dental Implants have been widely used for more than 40 years since the original scientific research was published. While many different implant systems are now available and are generally of high quality, our clinic prefers using implants from Nobelbiocare, Sweden and Straumann, Switzerland due to the extensive research and long track record. These implants come in different sizes and lengths and are generally at least 3.5 mm in diameter and 8 mm in length which differentiates them from “mini-implants” which should be used only as temporary supports or in very specific cases.
Are you suitable for Implants
Implants can be placed in most patients from age 18-80, even if you have lost your teeth for many years as we are able to regenerate bone in order to place implants as a foundation for your denture or bridge. Patients with health conditions should inform the dentist so that additional precautions can be taken, if required. Conditions which require attention include patients with significant heart disease, unstable high blood pressure, uncontrolled diabetes and patients on therapy for cancer. Surgery can still be performed after clearance from your medical specialist.
What is the surgical procedure like?
After giving some local anaesthetic, a small incision is made through the gums and a point of insertion decided. Drills of a predetermined length and with increasing diameters are then used to gently prepare the site to receive the implant. The implant is then rotated to the desired depth. The top of the implant channel is then covered with a temporary cap and the gums stitched either over or across after cleaning the surgical site and allowed to heal undisturbed for 3-4 months. A higher temporary cap called a healing abutment is often placed to avoid a second surgery to uncover the implant.
Is Implant Surgery Painful?
No, implant surgery is generally a minimally invasive procedure and in most instances the pain is minimal. If more major treatment is required, some post-surgical pain may be present. If you are fearful, we can arrange for you to have a complete pain-free experience either by performing the procedure under intravenous sedation or general anaesthesia within an operating theatre. The mix of drugs given will help you relax, sleep and eliminate pain. You will also usually be given a painkiller to take before the procedure so that you will be comfortable after the surgery.
How long does it take to recover from the Surgery?
After the operation, you may feel uncomfortable but this can be eliminated by taking the prescribed painkillers regularly. Some swelling and bruising is to be expected for a few days after the surgery. You can resume normal activity within a day but should avoid strenuous exercise and swimming. A normal or soft diet is advised and can be commenced after the numbness from the local anaesthesia wears off, usually around 2-3 hours after the procedure to avoid biting your lip or tongue inadvertently.
Same Day Teeth Replacement
Rationale for immediate tooth replacement
Losing a tooth, especially one of our front teeth can be very distressing for most patients. In addition to the effect on appearance and confidence, it affects our speech and on the long-term, the gums and the supporting jawbone will also shrink. A common request from our patients is to get a replacement for their missing tooth immediately, hence the advent of protocols for "same day teeth replacement". This could be done by partially loading the implant on the day of the surgery, or more commonly by using the adjacent teeth as temporary supports.
How long does it take for healing after tooth extraction and implant surgery
Teeth extraction and implant surgery are fairly routine and painless procedures and you will feel back to normal in just a few days. However, it takes around three months after tooth extraction for the bone to reform before placing an implant. In addition, it takes a further three months for the bone to grow around the implant in order to anchor it firmly in the jaw. During this waiting period, removable dentures, or temporary bridges made of plastic are used to prevent direct forces on the implant allowing the implant to heal.
Can this waiting period be shortened
Yes, it is possible to reduce this waiting period as implants can often be placed immediately into extraction sites for patients with missing front teeth. This reduces the waiting times significantly. In general, we are able to place implants to replace our front teeth on the day of extraction as there is usually adequate bone around and beyond the tooth socket to stabilise the implant. For back teeth, it is not always possible as there is usually insufficient bone after removing the tooth. Very often a bone graft will also be needed and is therefore a more technique sensitive procedure.
Immediately Loaded Implants
If the implant lies firmly within bone, it is possible to even allow partial loading immediately after the surgery. In combination, with the latest computer assisted techniques, it is possible to deliver aesthetic looking temporary teeth in selected cases within 3 hours after the surgery. The patients are however advised to avoid chewing on the implant, especially in the initial weeks after the surgery when the original bone anchoring the implant would have been resorbed with the new bone yet to form.
Is immediate loading of implants a new technique
No, the first controlled study of successful immediate loaded implants was published in 1997 after a successful 10 year study. Our lead clinician has been placing immediately loaded implants since early 1999. The success rate of immediate implants are comparable to that of implants placed using conventional protocols but is more technique sensitive as it requires the dentist to determine if the initial stability of the implant is sufficient for immediate loading. Done selectively, it is a useful option for patients with no other remaining teeth to anchor a temporary denture or bridge.
Cosmetic Dentistry
1. Teeth Whitening
Our teeth get discoloured over time especially if we consume coffee, tea and red wine. We can reverse this by applying a special gel to our teeth and leaving it to bleach or whiten over time. This can be done at home using a custom-made mouthguard. The effects are usually seen after 2 weeks. Alternatively, it can be done in the clinic using a laser or blue LED light or laser over one or two sessions, each lasting an hour or less. Laser teeth whitening takes the least time to achieve a satisfactory result. If the stains are very deep or dark, porcelain or zirconia veneers or crowns may be required.
Types of Teeth Whitening
Laser Teeth Whitening
Laser teeth whitening uses a special amplified light which can quicken the speed at which your teeth can be whitened, when Laser teeth whitening uses a special amplified light which can quicken the speed at which your teeth can be whitened, when compared to chair-side whitening using ordinary LED blue light. Both these methods are more effective and less time-consuming than using a home kit. The surrounding gums are first covered and a concentrated bleaching gel applied to teeth that are to be whitened. The light or laser is then applied for around an hour to achieve the desired new shade. Laser teeth whitening is thus the most effective of the 3 methods available.
Home Whitening Kits
Home whitening kits can also be used to whiten teeth. However, for safety reasons, the concentration of the gel is usually much less thereby prolonging the amount of time needed to achieve a satisfactory result. It usually takes up to 2 weeks to achieve the desired effect and is suitable when the teeth are not excessively stained. Home whitening kits are also beneficial when used in conjunction with conventional LED or laser teeth whitening procedures to maintain the effect for a longer period of time. The main benefit is the much lower cost.
What to expect in the clinic during treatment
In general it is painless.
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A protective layer of plastic is first placed over the gums as the chemicals used can irritate the gums.
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A bleaching gel, typically hydrogen peroxide is then placed on the tooth.
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A light is then used to quicken the reaction.
At Precious Dentistry, we use a special light known as a laser which speeds up the reaction and is more gentle on the tooth making it faster and less uncomfortable. However, some patients may feel some sensitivity or a tingling sensation, in which case the treatment can be divided over two visits.
Things to Avoid immediately after treatment
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Coloured foods and sauces - beetroot and curries
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Coloured fruits - blueberries and tomatoes
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Drinks which stain teeth - coffee, tea and red wine
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Mouthrinses which contain the chemical chlorhexidine
Maintenance
While teeth will slowly darken over time, you can prolong the effect of teeth whitening through the following measures:
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Good oral hygiene - brush your teeth at least twice a day and use dental floss to clean between teeth
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Use of home-care kits or teeth whitening toothpastes
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Return to the dentist for regular check-ups and teeth cleaning
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Return for a short session of whitening periodically, if you consume lots of coffee, tea or red wine.
Limitations of Teeth Whitening
Teeth whitening is a fairly effective and cost-effective way of lightening our teeth. However, while some stains are superficial, others may affect the entire body of the tooth and have a deep discolouration which cannot be removed either by conventional cleaning or tooth whitening procedures. In such cases, we would need to remove the outer discoloured layer and replace it with a new outer "shell" termed a veneer. If the stains are very dark, even porcelain may be unable to mask the underlying colour and a more opaque but still aesthetic material, Zirconia, may be required.
2. Porcelain Fillings
Porcelain fillings are made from strong and natural looking ceramic material which are long-lasting and biocompatible. In combination with accurate scanning and computer processing technology, it can be made within hours, provide a better fit and require the dentist to trim less of the remaining tooth structure when compared to conventional crowns. It can also be made to match the colour of the surrounding teeth. The use of new generation cements which are adhesive and radiopaque allow better bond with the remaining tooth and allow dentists to check the fit and seal of the crown.
Comparing Porcelain Fillings with Alternatives
Decayed teeth were traditionally filled with amalgam, a mix of silver and other metals with mercury. These eventually became discoloured over time and its use has decreased in recent years due to the presence of mercury, a known toxic material. In addition, the desire for more aesthetic and biocompatible materials, resulted in the development of tooth-coloured fillings composite resins. When the cavity is small, composite resins are adequate but when large sections of teeth need to be replaced, porcelains and zirconia, which are strong and durable are a better choice.
What is the procedure
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Any decay is removed and the remaining tooth prepared before either making a mould or taking a digital scan of the cavity.
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Our in-house laboratory then uses computer technology to design the filling.
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A fully automated milling machine is then used to cut the prefabricated blocks to the desired shape and
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The final product heat-treated to harden.
Porcelain fillings can be completed in 3 hours but if Zirconia is required, an additional 8 hours of laboratory time is required and you will need to return to the clinic the following day for cementing the filling in position.
What if the filling is very large?
If damage to the tooth is extensive, a filling may not be a stable long-term solution and more of the tooth may need to be trimmed for better retention. In this case a half-crown or even a full crown may have to be considered. Half-crowns are a compromise between better cosmetics, strength and stability while limiting tooth preparation to the minimum necessary to achieve our intended objective of restoring the tooth to full function.
Full crowns are required for teeth which are badly broken down. It should be noted that if the filling lies below the gum margin, a surgical procedure may also be required.
3. Veneers
Veneers are thin tooth-coloured shells which are custom made to fit over the front surface of a tooth to improve the shape, size, colour or alignment of the underlying tooth. They can be made of a variety of materials such as composite, porcelain or zirconia. While they are done mainly to improve aesthetics, they can also be used to repair front teeth which have fractured or have large fillings. Veneers are also preferred by many when compared to crowns as much less of the tooth is trimmed resulting in less sensitivity.
Limitations of Veneers
As only a small amount of tooth is shaved down, the veneer is less effective when covering darkly stained teeth. There is also a higher chance of breakage or dislodgement when compared to crowns which are thicker, stronger and cover a greater surface area. The choice is therefore between a more conservative procedure as opposed to crowns which emphasizes cosmetics and a more predictable outcome. However veneers can work equally well in patients whose bite forces are not excessive and the jaw relationship stable.
What is the Procedure
The teeth are first reshaped lightly before either making a mould or taking a digital scan of the tooth surface. The laboratory then uses computer technology to design a veneer with the desired shape, proportion and colour. The process is fully automated and the images sent to the precision milling machine which will then mill the prefabricated blocks to the desired form. The final product is then heat treated and our in-house technician may stain and characterise the surface of the implant for a more natural look.
Tooth Coloured Alternatives to Porcelain
Composite or plastic resins are a low-cost option but are less translucent and don’t feel as smooth as either porcelain or zirconia. As they are also weaker, they require more of the tooth surface to be reduced to provide for greater strength. Porcelain is preferred for its better aesthetics and natural appearance while Zirconia is used when strength is used when the underlying tooth is badly stained as it can mask discoloration far better. Both composite resins and porcelains can be processed by the lab within hours but zirconia requires an additional day to process.
4. Dental Crowns
Dental crowns are customised shells made from various dental materials to fit over cracked or broken teeth in order to rebuild them to its original form. In the past, metal or gold was often used but in today's age of social media, tooth-coloured materials such as porcelain or zirconia which are strong, yet aesthetic is the popular choice. They are also known as “caps” and besides protecting teeth that are weak, can also be used to change the shape, size and colour of teeth for cosmetic dental purposes.
Dental crowns are used for both functional and aesthetic reasons, for example:
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to build-up a chipped, cracked or worn tooth
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to protect weak teeth (teeth with large fillings or after root canal treatment)
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as part of support for a dental bridge to replace missing teeth
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for cosmetic dental purposes, like covering misshapen or discoloured teeth
What Is a Dental Crown Used For?
What are the Different Types of Dental Crowns?
A dental crown can be made from different materials depending on function and budget. Traditional dental crowns using metal alone, or in combination with porcelain (porcelain-fused-to-metal) generally cost less. While dental crown. it is still commonly used, the trend is towards using tooth-coloured materials such as full-ceramic (porcelain) or zirconia that look more natural. In addition, through the use of 3D computer technology to design and make these new generation crowns, the waiting time is far less as they can now be made within a day or two, and in some cases within 3 hours.
Pros and Cons of metal and metal-bonded crowns
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Metal crowns are strong and long-lasting but because of their colour, their use is usually restricted to the back teeth, and when the patient has very strong bite forces.
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Porcelain-fused-to-metal crowns provide a fair colour-match as tooth-coloured porcelain is layered over metal and then fused together in a laboratory.
They have a proven track record and in general last for between 7-10 years. However, there is a tendency for some of the porcelain to chip off, or for the margin of the crown to stain over time. They are a suitable long-term moderately priced solution.
Pros and Cons of porcelain and zirconia crowns
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All Porcelain crowns provide the most aesthetic and natural looking solution. Recent advances in technology have increased the strength of porcelain significantly and they can now be used even for back teeth.
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A popular option is E.max made of Lithium Disilicate by Ivoclar. Zirconia crowns are an even stronger option and is suitable for patients who grind their teeth but is more opaque. The recent introduction of multi-layer Zirconia has made the cosmetics comparable to all-porcelain crowns. They are also used when the underlying tooth is very discoloured.
What is crown lengthening surgery
Teeth may sometimes be too short to retain a crown or extensively damaged to below the level of the gum. A surgical procedure will be required to extend the crown margin or expose the edge of the defect. The gums are first pushed back to expose the underlying bone. A clearance of 3 mm is required between the level of the bone and the margin of the crown and the dentist may need to gently remove some bone before suturing. This procedure is known as crown lengthening and is required to enable the new crown to achieve a proper marginal fit. After healing a crown can be made.
Facial Symmetry, Proportion and the Golden Ratio
Cosmetic surgeons and dentists use the same concepts as artists in determining what is a pleasing appearance. The face can be divided into three equal parts based on imaginary horizontal lines drawn through the forehead, the brow, the base of the nose, and the tip of the chin. As the resting position of the teeth determine the lower facial height, tooth wear will lead to the lower third of the face being shorter and out of proportion. This can be corrected by crowning the teeth to increase the height of teeth and at the same time increase the facial height to the desired dimensions.
What are post crowns?
Post crowns utilise the root canal of a tooth to provide the necessary retention and stability needed for a crown. In a badly broken down root-treated tooth, a post made of carbon fibre, a strong lightweight material, can be inserted into the root canal to provide a scaffold for a resin core to be built around it so that a crown can attach onto it. Alternatively, a mould of the canal can be made and a specially casted metal post made to fit into the canal. In either case, the tooth is then rebuilt sufficiently to receive the final crown.
5. Clear Aligners & Braces
What are Clear Aligners?
Clear aligners is a method of straightening crooked teeth without using traditional braces. It utilises custom made sheets of thin plastic which fit over the teeth like a mouthguard rather than metal brackets and wires to apply a controlled force on teeth which are out of position to push them back into proper alignment slowly over time. Each aligner is made to move the teeth incrementally back into position and is worn for about 2 weeks before changing to subsequent aligners until the teeth reach their planned final position. Of the many types available in the market, the best known is Invisalign®.
What Is Invisalign®?
Invisalign® is one of the most established types of clear aligners and uses 3D computer imaging technology to make a series of clear and almost invisible aligners which can be removed when you have dinner or special occasions. They are comfortable to wear as they fit over your teeth while they gently align and guide to guide and move them into the ideal position. Invisalign® is ideal for working adults as it does not disrupt your work or social life. It can also be used for children to influence jaw growth (Invisalign® First), and also for teenagers who need braces.
Step by Step
First Visit:
Your dentist will examine your teeth, gums, facial proportions and profile to determine if you are suitable for Invisalign®. X-rays and a preliminary mould will be made to allow assessment and a customised plan for you using the special Invisalign® software. The X-Ray examination is important as it allows the dentist to check if you have any buried or extra teeth that might interfere with the treatment. A second X-Ray will show your side-view profile to ensure that your teeth can support your lips in a more ideal position,
Starting Out:
Once you have decided to start on Invisalign®, a final physical mould of your teeth and/or a digital scan will be taken and sent to the dedicated Invisalign® laboratory to make a series of clear aligners that will gradually move your teeth to the desired position. As these aligners are custom-designed and made using computer technology, they fit precisely. You will receive your first set of retainers within 3 weeks. Your dentist may sometimes need to slenderize the sides of your teeth to create more space for the required tooth movement.
How long Does It Take:
Each set of aligners come with instructions for its use. You should try to wear the aligners for as many hours in a day, removing them only during meals, when cleaning your teeth or for special occasions. In general, you will be asked to change to a new aligner every two weeks as your teeth gradually move into position. The treatment usually takes between one to two years as it takes time to gently guide your crooked teeth into alignment. You will need to return to the clinic every 3 months for a check-up.
The Process
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Digital Scans
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Computer Designed
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Custom-made
Benefits
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Comfortable
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Invisible
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Removable
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Predictable Results
Conventional Braces
While the use of clear aligners is now very popular, there are limitations and the use of conventional metal or ceramic braces is still required for more complex problems. While some patients dislike the appearance of these “fixed metallic” braces, they are in some instances more effective. Fixed braces are also suitable for patients who may not have the discipline to wear removable braces for an extended period of time. Patients concerned with the appearance can opt to have brackets attached on the sides of the teeth nearer the tongue though these are less comfortable.
Age Limit for Braces
Age is not a barrier for braces and crooked teeth can still be corrected in the elderly. Many adults who desire well-aligned teeth prefer to use clear aligners as it allows them to go about their daily activities without feeling conscious about wearing fixed braces. It should be noted that our lower teeth tend to get out of alignment in our mid-thirties. Besides the crooked appearance, it also tends to make teeth cleaning more difficult and lead to gum disease. The use of clear aligners for a few months can easily correct the minor crowding and keep tooth movement in check.
6. Teeth & Gum Reshaping
In addition to a well aligned set of teeth, the shape, size and proportion of teeth as well as gum contours and symmetry also contribute to a pleasing smile. The size of our natural teeth may sometimes be either too large or too small, and the shape may appear too bulky, or conversely too sharp. In addition, excessive gums may also show when we smile and if the gums which show are at a similar level
Resizing and reshaping teeth
While the use of clear aligners, veneers and crowns can give us the proverbial "Hollywood smile", sometimes all that is needed to improve our appearance is a simple reshaping or recontouring of our front teeth. This quick and painless procedure involves smoothening jagged edges, adjusting the length of teeth or rounding off uneven surfaces. We can also add or bond tooth-coloured materials to change tooth shape and size. Bonding involves roughening of the surfaces of teeth followed by etching and adding of a tooth coloured resin filling material to achieve the desired tooth contour.
Is the procedure painful
No, it is not painful as only very minimal trimming is done and there is no need even for local anaesthesia as the refinement is restricted to the outer enamel layer of the tooth which does not have any nerve supply. Rounding off edges or selectively reshaping the surface of the tooth to give it a more chiselled look will create a more slender and refined appearance. After recontouring, the surface is polished and some topical fluoride is added in order to re-establish the protective outer layer of enamel.
Do Gums Affect our Appearance?
A pleasing appearance is more than just having well aligned or whiter teeth. It also includes having healthy gums with an aesthetic amount of gums seen when we smile, or when we are speaking. Receding of gums due to disease, or excessive gums visible due to the structure of our jaws or lips also affect the symmetry and harmony of our smile. Gum health can be improved through thorough cleaning while receding, asymmetric or excessive gums can be modified through minor surgical procedures such as gum recontouring or repositioning or through gum grafting and regeneration.
What are Cosmetic Gum Procedures?
The main objective of cosmetic gum procedures is to achieve a symmetrical, balanced and harmonious gum line. The following are the common procedures used:
01. Gum Recontouring - This involves the removal of excessive gums in order to achieve a healthy, symmetrical, balanced and harmonious gum line. Ideally around 2-3 mm of gums should be visible when you smile. At the same time the underlying bony support of healthy gums should always lie around 3 mm below the gum level. If this is more than 3 mm, it forms an unhealthy pocket which traps bacteria. If less than 3 mm, the gums remain inflammed. A special instrument or bur may be required to remove a little of the bone to maintain this dimension known as the “biological width”.
02. Gum Repositioning - This procedure involves a minor surgical procedure to move the gums forwards to cover exposed root surfaces. It can also be done in the opposite direction to balance any asymmetry between gum levels or to lengthen the teeth in order to better retain a crown, if required.
03. Gum Grafting - When teeth appear long due to gum recession, we can use gum from a different part of the mouth to cover the exposed root surface. This involves a minor surgery to lift the gum around the affected tooth and slip the transferred gum to cover the root surface before stitching over it. The gums will fuse together after 6 weeks and cover the tooth thereby improving the appearance and reducing the sensitivity. The procedure which takes an hour can be done under local anaesthesia or with the comfort of intravenous sedation. You may feel some discomfort from the “donor gum” site for a week.
04. Gum Regeneration - Gums can regenerate if we create favourable conditions for the gums and the underlying bone to regrow. This involves a minor surgical procedure to lift up the gum and prop up the space with either artificial bone or a firm membrane. The teeth in the particular segment will also need to be thoroughly cleaned. In the presence of an adequate blood supply, the body is able to regenerate the gum tissues, or at the very least to heal. The use of some components of our own blood, termed medically as “PRP” or platelet rich plasma, can help improve the success of tissue regeneration.
What is a cosmetic dentistry makeover?
A cosmetic dentistry makeover is a combination of various procedures to ensure a radiant smile with well aligned teeth, appropriate amount of gum showing, well supported lips, and a pleasing facial proportion and profile. As an example, aligners alone straighten teeth but do not change tooth shape, size or colour. If done in combination with veneers, we can improve the overall smile and at the same time shorten the period of aligner wear. Likewise, veneers or crowns alone alone may improve tooth colour but adding a gum recontouring procedure will enhance the overall smile.
