Dental Clinic in Blumenau, Brazil by Dr. Fernando Giovanella: Dental Implants and Oral Surgery

[00:00:00] Look at this interesting clinical experiment that I conducted here at the clinic. I scanned a complete denture to transfer its three-dimensional geometry to the computer.

[00:00:07] Then, I digitally removed half of the flange, printed this modified version using biocompatible 3D resin, and placed it in the patient's mouth.

[00:00:18] The result was impressive. The side of the face where the flange had been removed showed a visible hollowing, making that area look much older.

[00:00:29] Notice in this close-up how the absence of the flange significantly affected the support of the paranasal region.

[00:00:35] This experiment shows that, in some patients, placing a fixed prosthesis without a flange compromises lip support and leads to an aesthetic failure.

[00:00:48] Just imagine the situation. You invest in dental implants to get rid of your dentures, dreaming of a beautiful smile and a younger appearance, only to discover that, in the end, your face looks older and more sunken.

[00:01:01] It feels like a nightmare, but it happens more often than you might imagine, and the culprit has a name: a small, hidden secret that only dentures have.

[00:01:10] You know that little border on your denture that many people consider unattractive? It has a name. It's called a flange, and it's your face's best friend.

[00:01:18] While everyone focuses on the teeth, the flange works quietly in the background. It acts like a facial foundation, supporting the lips.

[00:01:28] Not just the lips, but especially the entire base of the nose. It fills the area between the nose and the mouth and helps maintain the youthful contours of the face.

[00:01:37] Without a flange, the face loses support and can literally appear sunken.

[00:01:44] Now, here's the problem. When you replace your dentures with implants and an implant-supported prosthesis, the flange disappears.

[00:01:50] And do you know what happens in some patients? Their faces literally deflate. Wrinkles become more noticeable, the lips sink inward, and you suddenly look several years older.

[00:02:01] The flange is essential for maintaining facial harmony and preventing premature aging around the mouth in certain patients.

[00:02:13] You might be wondering, why not simply add this flange to the implant-supported prosthesis, right? To the fixed full-arch prosthesis?

[00:02:20] That's an excellent question, and the answer is simple and crucial: hygiene.

[00:02:27] You remove a denture from your mouth to clean it. An implant-supported prosthesis, however, is screwed into place and remains fixed. You clean it while it is in your mouth.

[00:02:37] A fixed, screw-retained implant prosthesis with a flange would become a nightmare to clean because it would overlap the gums, almost like a saddle wrapping around them.

[00:02:47] Imagine trying to brush an area that is impossible to reach every day. This can cause unpleasant breath, recurring gum inflammation, and, in the worst cases, even lead to implant loss.

[00:03:01] A well-designed fixed full-arch prosthesis has a smooth, convex base. However, in some patients, this design reduces lip support.

[00:03:11] So, you might be thinking, "Doctor, how do we solve this problem?" Many people try to address it with facial fillers based on hyaluronic acid or similar substances.

[00:03:20] These are gels injected beneath the skin. They can work in some situations, yes, but not in every case.

[00:03:27] They add volume, but they don't provide structural support. They last only a few months, require touch-ups, and become a recurring expense for the rest of the patient's life.

[00:03:37] If the problem is a lack of support for the lips and the base of the nose, adding filler only masks the underlying cause. The right approach is to restore deep structural support, not simply add volume.

[00:03:48] So, doctor, what is the solution? That's the key question. The good news is that there is a solution, and you're about to understand what it is. I'll explain how it works.

[00:03:58] But first, I want to discuss another problem, which may be even worse and more common.

[00:04:03] This other critical, rarely discussed problem is the position of the implants relative to where the teeth of the implant-supported prosthesis need to be.

[00:04:13] Look, when you lose your teeth, the bone gradually disappears. It shrinks year after year. When it's time to place implants, the dentist needs to find where the remaining bone is.

[00:04:25] Sometimes so much bone has been lost that even a bone graft may not be sufficient. That's why we avoid bone grafting in full-arch cases. But that's a topic for another video.

[00:04:34] For many patients, the remaining bone is located quite far back, away from where the teeth naturally used to be.

[00:04:41] To compensate for this distance, in some cases, the prosthesis needs to be large and bulky, especially behind the front teeth.

[00:04:48] This can make the area near the roof of the mouth, known as the palatal region, very thick. This doesn't happen in every patient.

[00:05:02] In others, however, it can lead to extreme results like this. This makes cleaning more difficult and, guess what, it can also interfere with speech.

[00:05:12] These problems can occur with implant-supported prostheses in general. But in a particularly challenging case like this, adapting to the prosthesis can be even harder.

[00:05:18] Many professionals, including those trained as recently as last year, have been taught to focus on the bone and the implants, but they sometimes forget the most important thing: the final result for the patient.

[00:05:31] I made this mistake many times in the past, too. It literally kept me awake at night. That's when I completely changed my approach.

[00:05:39] Instead of asking where I could place an implant in the bone, I started asking where the prosthesis needed to be for the result to be ideal. We dentists call this reverse planning.

[00:05:49] This approach has been widely studied and implemented for single-tooth implants and even full-mouth rehabilitation cases with good bone availability.

[00:05:57] But when there is severe bone loss in the jaw, this was literally a blind spot.

[00:06:03] The focus was on trying to achieve immediate loading by identifying where the bone was densest, while the final prosthetic result was left for later, with the attitude of "we'll make it work somehow." This is what we know as anchorage techniques.

[00:06:17] Using the tools of digital dentistry, I began running countless simulations for my cases. I believe that everything can be improved.

[00:06:24] I started consistently prioritizing the best implant positioning, with an almost obsessive focus on the aesthetic and functional results of the prosthesis.

[00:06:34] I questioned everything that had been considered standard in the field, including established techniques. One of the main ones was palatal implant placement, a concept that I myself had advocated for more than 15 years.

[00:06:47] With this technique, we place implants farther back, where the remaining bone is still intact. The difference between the implant position and the position where the teeth should be was always compensated for with a prosthesis that was often thick and bulky.

[00:07:04] With the same rigor that I had always applied to securing these implants and finding the best bone site to enable immediate loading and benefit the patient, I also began pursuing superior prosthetic outcomes.

[00:07:19] In some cases, the answer was right there. In others, finding a solution required time and persistence.

[00:07:26] Even in complex cases, I explored different possibilities through simulations in a digital environment. And during one of these experiments, an unexpected possibility emerged.

[00:07:34] If we always follow the same map, we will only discover what has already been discovered. It was a new and unprecedented approach, but one that could be supported by related scientific studies.

[00:07:44] Before applying it clinically, I sought scientific evidence and implemented the concept gradually. It began to show promising results.

[00:07:57] To obtain a more impartial assessment, I shared the idea with fellow dentists who also work with full-arch rehabilitation.

[00:08:05] The consensus was that the surgical modification was consistent with the biological and biomechanical principles described in the scientific literature.

[00:08:12] Even so, I wasn't satisfied. I sought a more rigorous evaluation.

[00:08:17] I submitted the work to the Journal of Prosthetic Dentistry (JPD), one of the most prestigious journals in prosthodontics and full-mouth rehabilitation.

[00:08:25] It is indexed and has a relatively high impact factor. It is also an official publication of several international societies, providing an editorial platform traditionally reserved for innovative contributions with particular clinical relevance.

[00:08:40] After the article underwent a blinded peer-review process, conducted by three international specialists, the manuscript was accepted and published.

[00:08:48] I want to emphasize that this is not the finish line, but the starting point. When a mind opens up to a new possibility, it rarely returns to its original size.

[00:09:02] Today, digital dentistry allows us to plan from the outside of the face inward, from the face to the prosthesis, and from the prosthesis to the implants, bringing together genuine lip support, natural contours, and a thin, easy-to-clean prosthesis.

[00:09:16] Remember the case at the beginning of the video, where I demonstrated the loss of lip support with a prosthesis without a flange?

[00:09:23] Well, here is the result. Here is the before photo alongside the final result using our new approach.

[00:09:30] This patient has a fixed full-arch prosthesis, an implant-supported prosthesis without a flange. The facial support is excellent, with facial fullness even better than what the denture provided.

[00:09:42] This represents a major paradigm shift. Best of all, the prosthesis is thin, delicate, and comfortable.

[00:09:48] With a publication in the Journal of Prosthetic Dentistry, we open the door to rethinking how we can improve our own clinical practice, not only in terms of occlusion, but especially in restoring facial fullness.

[00:10:01] The result is excellent facial support, comparable to what a flange provides, without the bulk that compromises hygiene.

[00:10:08] I emphasize that this approach is still evolving. It represents a paradigm shift that places aesthetic and functional outcomes first.

[00:10:14] We can combine the facial support provided by a flange, which helps prevent premature aging and facial hollowing, with the convenience of a thin, fixed implant-supported prosthesis that is easy to clean.

[00:10:28] This is achieved through a type of internal plane, involving a modification in implant placement. The technical details are beyond the scope of this video.

[00:10:35] If you are a patient and would like to benefit from this approach, contact us to arrange an in-person assessment.

[00:10:41] If you are a dentist and want to implement these advances, stay tuned. We will soon open a specialized training course on digital workflows for severely atrophic jaws.

[00:10:51] Finally, our commitment is to continuous improvement, grounding our practice in distinctive techniques and scientific innovation, whether through treating private patients or providing educational activities.

[00:11:02] A big hug, everyone. See you in the next video.