when a "7" is like a "10"
***And no, I'm not referring to the girl or guy you picked up at the 2am dive bar last weekend. 
Of course, we're always chasing perfection that doesn't truly exist, but there are clinical scenarios where achieving a level "10" outcome is impossible. The following case is one that I took over after implants #7, 8, and 9 were already placed and after the patient had become frustrated with multiple try-ins of the final implant restorations at another office. The esthetic problems were numerous and the placement of the implants posed a significant challenge, so I was careful to under-promise when discussing possibilities with this patient. Ultimately, she took the "it couldn't possibly be worse" approach and allowed me to re-design her smile. So off we went...
With an approved FGTP template to guide us to the end result, I did a quick physical wax-up to estimate the midline correction, performed crown lengthening #5, 6, 11, and 12 to bring their gingival zeniths apically to closer match the soft tissue around the implants, and provisionalized #6-11.
After 6 months of healing, we finally moved on to the final restorations #6-11 via Biocopy of the provisionals. We had to fight dark teeth, unfavorable implant angulations, and even needed some Juvederm to coax the flat gingival architecture into some semblance of a scallop. It was a ton of effort just to get a "7" result for this awesome patient who has truly been a "10."
Awesome Ross!!! Juviderm has saved my butt a few times for black triangles. It's a fun adjunct.
Gorgeous work!
The quick rundown on Juvederm is it’s a hyaluronic acid dermal filler that I occasionally use intraorally to augment soft tissue in difficult cases. I’m not aware of any dental-related scientific articles, but I’ve read several case studies that claim 2-3 years of duration when used in the gingiva. I only have a dozen or so gingival cases out there, but would anectdotally agree with that timeframe based on my limited experience using it. Can anyone else share their experience?
to see thru the forest, and visualize this case, is real talent , very impressive, loved this case
As always Ross your cases are well planned, executed with skill, and extremely enjoyable to read!
Wow ! A truly transformational and amazing result ! This is an 11 !!!! Ross, you are a dental maestro - glad that we have you, to learn from and share these cases with us !
THANK YOU !
Winnie
Excellent case as always - great plan and execution.
If you had any of the Juvederm left over a bit placed in the right side of upper lip could have been used to regain symmetry of those lips. I can not attest to how long it "stays" in the gingiva for me when treating lips and nasolabial folds with it I advise patients to expect about a year before it is completely resolved. That is interesting that it would stay 3X's longer in the gingiva.
Really nice save of this case.
I have never heard of using Juvederm for this, very interesting.
Your standards for a 10 are off the charts as this case isn't a 7! You may have been the only dentist in FLA that could have done this well given the situation. No doubt the FGTP concepts were key.
On 5/1/2019 at 6:09 am, Andrew Hall said...Excellent case as always - great plan and execution.
If you had any of the Juvederm left over a bit placed in the right side of upper lip could have been used to regain symmetry of those lips. I can not attest to how long it "stays" in the gingiva for me when treating lips and nasolabial folds with it I advise patients to expect about a year before it is completely resolved. That is interesting that it would stay 3X's longer in the gingiva.
My understanding is that the duration of the material is somewhat dependent on the mobility of the area you're injecting. Lips last the shortest at around 6-12 months, nasiolabial folds and lower face augmentations are about 12-18 months, midface areas like cheeks and tear troughs last 18-24 months, and non-mobile sites such as gingiva can last 2-3 years.
On 5/1/2019 at 3:25 am, Bob Conte said...That's a pretty hot "7"!
Great case.
Easy, Bob, she's married. 
If you haven't seen it...you need to watch. If you have, just laugh knowing the content included. Enjoy.
Not to throw more numbers out there, but handling those #6 and 11s would give most of us plenty of fits, let alone that entire case. Amazing work Ross.
