Dental Implants – San Antonio, TX

Our patient was born missing her lower left second premolar (#20). She did not want to damage her natural adjacent teeth in order to make a bridge so a dental implant was her first choice. Orthodontics (braces) were used to obtain the optimal space and, following appropriate radiographs and treatment planning, a single dental implant was placed.

Illustrations courtesy Straumann AG
Restorative work by: Dr. Jason Gillespie (San Antonio, TX)

When this patient found himself missing three teeth in his lower left jaw after his bridge had failed, he had one simple request: He had not had teeth he could floss normally for over fifty years due to the bridges he’d been wearing so could we please give him something close to what he had way back when.

That’s just what we did. Three dental implants so that he could have three single teeth, just like when he was a young man.

Restorative work by: Dr. Michael Miller (San Antonio, TX)

Theresa presented to our practice upon referral from her General Dentist, Dr. Diane McKeever, after failure of her previous three-unit bridge. Her options were:
(A) A new bridge, but making it a four or five unit span. This would require changing one crown and cutting down one or two virgin teeth.
(B) A partial denture that is removable and comes in and out of her mouth.
(C) Two implants replacing the two missing teeth, making each tooth self-supporting.

Theresa decided that two implants were a more cost-effective way to replace her two missing teeth because:
(A) She could save money by leaving one crown alone;
(B) She could keep her two unrestored virgin teeth from being cut down in any way;
(C) She would once again be able to floss each tooth individually;
(D) She would save money in the long term because long-span bridges are known to not last as long as implant-supported crowns and bridges. In fact, after 7 years, implants are cheaper to maintain than conventional bridgework.

It is true that implants are not for everyone but talk to your dentist about your options or call our office for a consultation.

Restorative work by: Dr. Diane McKeever (San Antonio, TX)

With today’s digital technology, challenging clinical situations can oftentimes be precisely planned using CT scans with minimal radiation exposure, also known as Cone-Beam CT scans, implant planning software, and CAD/CAM technology. This gives the restorative dentist and periodontist implant surgeon the utmost control in 3-dimensional implant placement. the result is improved precision, reduced surgical time, and increased satisfaction with the overall outcome in difficult situation.

Guided surgery is not necessary in every case, but Dr. Lorenzana may recommend it if there is minimal bone available, if multiple implants are being placed simultaneously in close proximity to each other, or in esthetically demanding situations.

Restorative work by: Dr. Lane Walsh (San Antonio, TX)
CT scan imaging by iMagDent (San Antonio, TX)

This patient was referred to us following the traumatic fracture of her upper left first premolar (tooth #12). Complicating the situation aesthetically and functionally was the presence of advanced gingival (gum) recession on the tooth in question as well as the adjacent canine #11. Careful implant placement in conjunction with soft and hard tissue augmentation yielded excellent tissue contours that her restorative dentist could confidently guide to a successful, aesthetic outcome.

When unfortunate accidents happen that result in the fracture of one or more teeth, we prefer to place the implant(s) immediately upon tooth extraction whenever possible in order to preserve the native tissue architecture and achieve the best aesthetic result.

Restorative work by: Dr. Lane Walsh (San Antonio, TX)

Melissa also had a long history of treatment for her lower left front tooth (#24). The tooth had been previously traumatized and a root canal and crown had been done previously. Unfortunately, the tooth failed, resulting in swelling in the gums directly over the tooth and constant discomfort.

Again, the tooth was carefully removed, the socket was thoroughly cleaned, an implant was placed, and the socket and surrounding bone were augmented with not only bone grafting material, but also with a soft tissue (gum) graft to help recreate the ideal contours of the surrounding tissue. After 4 months of healing, she was referred to her prosthodontist where the restorative phase began. A temporary crown was made and an impression was taken of the implant in order to make a custom abutment and crown.

Melissa was very concerned about the esthetic result of the final crown, even though the tooth is not visible when she smiles or speaks. Thanks to the collective efforts of both the surgical and restorative teams, her fears were set at ease with a much better result than how she began.

Restorative work by: Dr. Jason Gillespie (San Antonio, TX)

There are many advantages to placing a dental implant at the time of tooth removal - saves time, can save cost, a single surgical procedure. However, there are occasions when placing a dental implant at the time of tooth removal is not possible, either due to the surrounding anatomy, the amount of infection present, incomplete treatment planning, among others. When this is the case, Dr. Lorenzana may recommend a procedure called ridge preservation.

Ridge preservation involves the placement of bone grafting material into the extraction socket in order to preserve the dimensions of the bone for future dental implant placement. The scientific literature states that 50% of the natural bone width is lost within a year (Schropp et al, 2003b) and 2/3 of that loss occurs within the first 3 months. When ridge preservation is utilized, those bone contours are preserved, resulting in improved function, reduced damage to adjacent structures, less invasive procedures, less cost, and potentially better esthetics (Nevins et al, 2006; Darby et al 2009)

In the Case #1 below, tooth #13 (third unit from the right in the first x-ray) had a fracture that had effectively split the tooth, causing the patient pain. The tip of the root of the tooth was in close contact to the maxillary sinus. Dr. Lorenzana decided that there was too much risk for a sinus perforation to place the implant at the same time as the removal of the tooth. Therefore, a ridge preservation was performed (x-ray #2), and the graft was allowed to heal 4 months. At that time, the implant could successfully be placed away from the sinus. The final photograph shows the final result, with the implant restored with an all-porcelain crown.

In patient Case #2, a ridge preservation was necessary due to a fracture on molar tooth #19 that had caused loss of bone around the socket. A ridge preservation was performed to repair the defect at the time of the extraction. Following 4 months of uneventful healing, the appropriate dental implant was placed into the healed bone and restored.

In patient Case #3, the patient’s situation was deemed unsuitable for simultaneous extraction and implant placement. However, he was also unsure when he would be able to have his implant placed due to his busy schedule. The decision was therefore made to perform a ridge preservation to allow implant placement at a later date without losing significant bone while he waited.

Restorative work by: Dr. David Karbach (Case #1), Dr. Joan Dreher (Case #2), and Dr. Kurt Riewe (Case #3)
Special thanks: Osteogenics Biomedical (Lubbock, TX) for the diagrams

Sometimes, when there is just enough bone to secure the implant, but additional bone is necessary to place a sufficiently long implant, a more conservative osteotome sinus lift procedure can be performed.

In this procedure, rather than making an opening through the side wall of the maxillary sinus, the sinus lift is performed through the same opening through which the implant will be placed. In the photos below, Figure 2 shows how the implant site preparation stops just short of the floor of the sinus. Using surgical osteotomes, the floor of the sinus is gently displaced upward to create room for bone graft material and the implant (Figure 3 and 4). The main advantage of this procedure is that a smaller incision can be made and there is usually less discomfort to the patient post-surgery.

It is important to note that this procedure is not for every indication and its success is dependent on prudent case selection. Please feel free to discuss this and any other procedure with Dr. Lorenzana.

Most denture patients will tell you two things about their dentures: (1) the upper ones stay in OK, and (2) the lower ones don’t. By placing 2 -4 dental implants in the lower jaw, we can turn lower dentures from a nuisance to a success by providing fixed anchorage, leading to better function and renewed confidence. Upper dentures cover the entire palate and that can change how food tastes and feel bulky. 4-5 dental implants can improve this situation by allowing the elimination of the section that covers the palate, allowing patients to feel more freedom and taste their food as before.

Patient #1 presented with only 3 teeth remaining to hold her lower partial denture. When one fractured, it was time to make the transition to an implant-supported denture. Locator attachments fit onto dental implants to provide a secure, removable, and cleansable solution for patients who cannot afford more implants or have limited available bone for implants.

Patients #2 and 3
As retentive as upper dentures usually are, oftentimes patients would like to have their palate free of coverage. This would allow them a more natural feeling of function as well as improve their taste sensation. Some patients, such as Patient #3, have bony growths in the roof of their mouths (tori) that do not allow the use of a conventional denture. By placing 4-5 dental implants in the upper jaw, these patients got the best of both worlds: (1) no painful, complicated surgery to remove the palatal tori, and (2) no palatal coverage so they could enjoy and taste their foods as before.

Patient 1 Restorative work by: Dr. Alfonso Monarres (San Antonio, TX)
Patient 2 Restorative work by Dr. Michael Rothstein ( San Antonio, TX)
Patient 3 Restorative work by Dr. Kurt RIewe (San Antonio, TX)

Dental implants are very versatile. This patient was not ready to commit to a denture so we placed two implants in order to help hold his partial denture until he is ready for a denture or for fixed bridgework. By simply replacing the components that fit onto the dental implant, the configuration and type of restoration can be changed depending on the patient’s wishes.

Restorative work by: Dr. David Lewis (San Antonio, TX)

Implant placement in molar areas is made more complicated by the fact that molars have 2 to 3 roots as opposed to single-rooted teeth. In most cases, the failed molar has to be extracted and the socket carefully preserved for at least 3 months before an implant can be placed. Advances in surgical techniques and materials, as well as clinician experience and careful case-selection have made it possible to place implants at the time of extraction in certain situations.

Dr. Lorenzana uses a Piezosurgery® unit to carefully remove the molar and its roots in the least traumatic fashion possible and to prepare the implant site, again causing minimal damage to the native bone. In the example below, the patient’s lower right molar needed to be removed due to painful cracked-tooth syndrome. A Straumann® Tapered Effect Wide-Neck implant was placed at the time of molar removal and the voids around the implant grafted with Bio-Oss® xenograft. 1 year follow-up photos and radiographs show the success of the procedure.

The advantage of this technique (when possible) is that a patient only has to go through only one surgery, only one recovery period, and only one time off from work. This saves our patients time and money. You can read this patient’s testimonial here.

Anytime it is possible, we try to replace failed teeth immediately with a dental implant. This is called “Immediate Implant Placement.” Unfortunately, certain situations can arise that require what we call “Staged Implant Placement” in order to more predictably obtain the desired esthetic result. In this procedure, first, the tooth is removed and the extraction site is allowed to heal over with soft tissue. The site is then re-entered after a short waiting period to place the implant and rebuild the lost bone structure.

What type of situations might necessitate staged implant placement? These may include:

• Esthetically important situations
• High lip line (patient shows a lot of gum tissue)
• Gingival (gum) recession at the site of the extraction
• Presence of a large infection
• Significant loss of bone
• Other situations...

Generally speaking, Staged Implant Placement is the preferred mode of treatment when the desired esthetic outcome is considered unpredictable due to a few of the circumstances listed above.

In the case presented here, Karla presented to our office with a failed central incisor (tooth #8). She had both a high lip line that showed the entire length of her tooth, and the gingival margins of the two front teeth did not match. In fact, the tooth to be removed had a slight amount of recession, creating the potential for further tissue loss upon removal, Staged Implant Placement was performed in order to more predictably obtain the result Karla most wanted: A beautiful, natural-looking smile.

Restorative work by: Dr. Jon Oefinger (San Antonio, TX)
CT scan imaging by iMagDent (San Antonio, TX)

Few things are as traumatic as moving to a new city. Now move to a new city and find yourself with an emergency involving your front tooth. This is the situation our patient found herself in after being transferred from Washington D.C. Her dentist in DC spoke with the Program Director of the prestigious Graduate Periodontics Department at UT Health Science Center at San Antonio Dental School, Dr. Brian Mealey, and he referred the patient to our practice and that of prosthodontist Dr. Jason Gillespie.

The initial examination revealed a deep pocket on the palatal side of her front left central incisor (tooth #9). Her previous dentist advised that he had observed root resorption occurring previously and recommended we discuss removal of the tooth. After discussing the options with the patient, it was decided to remove the tooth, place an implant, and if possible, create a temporary tooth on the same day for the patient. Although not always possible for every patient, fabricating a tooth or several teeth in a day is a reality. Contact us for more information.

During the pre-surgical evaluation, it was noted that the gingival levels were uneven, with slight gum recession on tooth #9 (see photo 2). It is usually expected that the gum recedes at least 1 mm once a tooth is removed. In this patient’s case, that would have been disastrous for her smile, as she has a high lip line. This is where our ability as periodontists to diagnose and treat esthetic dilemmas becomes important in dental implant surgeries where the final esthetic outcome is critical. Therefore, along with the requisite bone grafting within the socket, it was decided to add soft tissue in the form of a gingival graft in order to help preserve and enhance the final esthetic outcome (see photos 6 and 7 below). As you can see, it was well worth it in the final result.

Restorative work by: Dr. Jason Gillespie (San Antonio, TX)

Similar to patient #13, Linda presented to our office upon referral from her dentist for a failed front tooth. In this case, Linda found herself with a fractured left front tooth (tooth #9). She had long ago traumatized both front teeth and had multiple procedures done over the years to try to hold on to them: at least 2 root canals, root canal surgery, build ups, pins, and multiple crowns. Finally, tooth #9 fractured. Figure 2 shows arrows pointing to the fracture line visible on the x-ray.

Following careful removal of her tooth root, an implant was placed and the socket grafted with bone grafting material. A customizable healing cap was also placed to help preserve the overall tissue contours by preventing tissue collapse. After 3 months of healing, an impression was taken of the implant in order to fabricate the custom abutment and crown (Figure 6 and 7). In contrast to Patient #13 in the previous album, a temporary crown was not made the day of surgery. There are many reasons as to why an temporary crown might not be made at the same time as implant placement: the patient’s own wishes, cost, an unfavorable bite or tooth position, presence of infection, or lack of stability of the implant, among other reasons.

The final photo shows an esthetic result that is a significant improvement over what Linda came in with. Note the ideal tissue position as well as ideal crown contours and color match provided by her dentist. The gray crown margin visible at the gumline at the initial visit is gone as well. After two years, the results continue to look fantastic.

Restorative work by: Dr. Michael Miller (San Antonio, TX)

This patient was referred to us for dental implant placement to replace congenitally missing (meaning she was born without them) lateral incisors #7 and #10. Aesthetic recontouring was performed to create the ideal tooth length for all of the front teeth and tissue sculpting was expertly performed by the restorative dentist to create the impressive final result. Her dental reconstruction was the beginning of a complete transformation for this patient.

Restorative work by: Dr. Will Martin (Gainesville, FL)

Tiffany presented to our office upon referral from her orthodontist. Tiffany had lost her front tooth (#9) traumatically years earlier and had just finished orthodontics (braces) when she was referred for an evaluation for an implant. Tiffany had a bridge before and was unhappy with the function and esthetics of the bridge so she chose to pursue dental implant treatment.

Prior to surgery, Tiffany was referred to iMagDent Digital Dental Imaging Center for a cross-sectional CT scan and virtual implant planning. This allowed us to visualize the proposed implant position, as well as the bony contours, prior to surgery. With the CT scan, many possible complications can be avoided and we can obtain a more predictable esthetic result. We partner with iMagDent to provide all our implant patients state-of-the-art imaging technology.

In addition to implant placement, we also performed esthetic crown lengthening on Tiffany’s adjacent teeth to help her get the esthetics and function she was looking for.

Orthodontic work by: Dr. Brad Bruchmiller (San Antonio, TX)
Restorative work by: Dr. Jason Gillespie (San Antonio, TX)

Our patient had an old Maryland bonded bridge that had decayed and fractured. Rather than further damage her adjacent teeth in order to make a larger bridge, she chose a dental implant in order to get closer to natural function and aesthetics. Her treatment was documented and chosen to be published as part of a dental implant aesthetics competition in 2005 titled “Esthetics Casebook” published by Institut Straumann AG.

Restorative work by: Dr. Jason Gillespie (San Antonio, TX)

When there is insufficient bone in the area of the back molars in the upper arch and an implant is the preferred choice to replace missing teeth, a sinus lift procedure is used to create additional bone. The photos below show a typical case where CT scanning from iMagDent Digital Dental Imaging Center was used to evaluate the existing bone available, the amount to be augmented, and the presence of any irregularities or pathology.

After the relevant information was collected and analyzed, a treatment plan of simultaneous sinus elevation (a.k.a. sinus lift) and implant placement was presented to the patient. In a sinus lift procedure, a small opening is made on the side of the upper jawbone that exposes the fragile sinus membrane. This membrane is carefully preserved and then elevated to create room for bone grafting material. Once the bone grafting material is placed beneath the membrane, the implant can be placed if sufficient bone is present to allow for stable implant placement. The access opening is sealed with a resorbable barrier membrane and the area sutured. Following 5 months of healing, the patient presented here was referred back to her general dentist for fabrication of the final crown.

Restorative work by: Dr. Lane Walsh (San Antonio, TX)
Images courtesy the International Team for Implantology (ITI) - unauthorized use is prohibited.