Complex Case Example–Tilted Dental Implant Used To Bypass Impacted Tooth and Bone Expansion for Missing Front Teeth

Complex Case Example–Tilted Dental Implant Used To Bypass Impacted Tooth and Bone Expansion for Missing Front Teeth

Complex Case Example–Tilted Dental Implant Used To Bypass Impacted Tooth and Bone Expansion for Missing Front Teeth

This patient presented to my office in Burbank by referral for dental implants from another patient. She had two dental problems. One was her 6 tooth front upper bridge was loose and had come out a few times and the second problem was her lower molar in the #19 position.

After examining her, it was noted that the 6 unit anterior bridge was only anchored by the two canine teeth. Both of those teeth had root canals and had broken off to the gumline. They are too weak to use for a new bridge. In this space where she had been missing the four center upper teeth (7-10) her bone had atrophied (shrunk) because the teeth have been missing for so long.

On the bottom jaw, her existing molar was cut in half by her previous dentist and a root canal was done through a very old procedure called a hemisection. She was walking around with basically half a tooth that wasn’t even re-crowned because of its poor prognosis. The complicating factor on the lower jaw was that she had an impacted premolar tooth stuck deeply in her jawbone. She was told an implant could not be done here because the impacted tooth was in the way. Generally speaking impacted teeth can be removed like wisdom teeth are impacted. This tooth is special because it is completely encased in bone and has a very high risk of nerve damage and jaw fracture to remove it.

In order to treat her in both the upper front and lower left #19 area several procedures in sequence were necessary. Her treatment took about 11 months to complete.

5 Steps to Successful Treatment

1. Extract the canine teeth #6 and 11 with simultaneous socket bone grafting and ridge splitting bone widening expansion.

Tooth #19 molar would be extracted at the same time as this procedure under IV sedation anesthesia.

I made her a temporary removable partial denture stayplate (some people call this a “flipper”) to be used as a temporary that was inserted on the same day of extraction and bone grafting.

2. After waiting 4 months for the bone graft for the upper front teeth to become strong bone , 3 implants were placed into the newly widened bone in the upper front area. At the same time, under sedation, a purposely tilted implant was angulated around the impacted premolar tooth.

The tip of the implant would be placed at an angle so that it would not hit the impacted tooth but the head of the implant would come out in a more ideal location for the molar.

3. The implants were allowed to heal for 4 months after placement.

4. A custom abutment was made for the angulated tilted implant in the #19 molar position. Custom abutments were also made for the 3 front implants so that their angle could be corrected and to be tall enough to support a bridge.

Custom abutments are able to correct angulation when implants are purposely placed in tilted positions such as the all on 4 procedure

5. The molar was replaced with a monolithic zirconia crown while the front bridge was custom fabricated from porcelain fused to metal with gum colored ceramic. Pink tissue porcelain was used so that the teeth would not look too long.

The pink porcelain edge does not show when she smiles, so no one can tell that both white and pink porcelain was used to make her smile looks much more natural. Both of these bridges are held by cement rather than by screws.

Keep in mind that her situation is compromised to begin with so a perfect result is not possible. She has an overbite from her upper jaw being too big which will always compromise the cosmetics of the front teeth. She is a very sweet woman in her 60s that just needed a healthy, confident smile that she would not have to worry about any more.

Every Dental Implant Case is Different

I think it is important to show cases to you that are real in every day dental practice. Nature made us all very unique and that is beautiful thing. If you have a unique case, and would like a second opinion, please contact our office and schedule your appointment.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry


  1. Terry

    Good afternoon doc. I just read a post on the net and it really did informed me alot. I’m on warafin and I want to do a extraction on my tooth that hurts so bad. I went to the hospital and they be telling me that I will have to be admitted in the hospital for them them to monitor it. I’m my inr for last month is 2.47 n I’m taking 7.5 now every night. How can I Good afternoon doc. I just read a post on the net and it really did informed me alot. I’m on warafin and I want to do a extraction on my tooth that hurts so bad. I went to the hospital and they be telling me that I will have to be admitted in the hospital for them them to monitor it. I’m my inr for last month is 2.47 n I’m taking 7.5 now every night. How can I go along and do the procedure?


    April 13, 2015 at 6:34 pm Reply
    1. Ramsey Amin DDS

      Hello Terry,

      Thank you for contacting me. I’m happy to help. The more appropriate post for your question is this one:
      Blood Thinners and Dental Implants

      Warfarin is also known as Coumadin and is a blood thinner that prevents your blood from coagulating normally. So in essence, your dentist is worried that you will bleed to death from the extraction. Your INR which is called international normalized ratio seems to be in range. The INR is typically between 2 and 3 to be effective. Unless you have some very serious medical issues in addition to being on Coumadin, there isn’t a lot of reason to have this tooth extracted in the hospital! My guess is you have atrial fibrillation. Your dental implant specialist who will do the extraction may need to consult with you physician on possibly taking you off of Coumadin a couple days beforehand and then restarting it again about 24 hours later.

      In my own practice, I rarely takes somebody off of their blood thinner to remove just a single tooth. There are ways to manage bleeding without having to modify her medication. Sometimes the risk of coming off of Coumadin is higher than the risk of bleeding. Some patients can have a stroke, heart attack or pulmonary embolism during that 2-3 day period that there blood thickens.

      You need to find a dentist who is very comfortable dealing with patients on Coumadin. This would be my best advice. They need to understand your unique situation and medical history. You may want to consider having a same-day dental implant in order to avoid multiple surgeries and multiple bleeding episodes. Just a thought.

      Bleeding can also be managed using platelet rich fibrin which can be made from drawing blood from your arm. Good luck

      PRF can be usedto help blood clotting and enhance healing

      Ramsey Amin DDS

      April 14, 2015 at 4:48 am Reply
  2. sussan norris

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    May 31, 2014 at 2:05 pm Reply

Write a Comment

Monica D.
Monica D.
December 29, 2020.
There aren't enough words (and I have a lot of words) to tell you how grateful I am to have found Dr. Ramsey Amin and his wonderful staff. I had an enormous amount of bone loss and I was hopeless after being treated by a different doctor for two years. I had multiple procedures such as gum graft, extractions, and a sinus lift. After all of that, the doctor released me and told me he could not help me any longer. He sent me to a large teaching hospital - who also had no idea how to help me. I was terrified and embarrassed. I had been missing teeth due to those procedures since 2017. That sent me out on a journey of meeting with no less than five different dentist/oral surgeons. Most of them shamed me for the bone loss and wondered what I had done to cause this. In reality, I had done nothing. The bone loss is my body's immune system fighting me, as well as hereditary traits. In fact not only was I having difficulty being able to have implants, I also had so much bone loss that I was also not a candidate for dentures. I researched "what to do when you have bone loss and can't get implants" and I found Dr. Amin's website. Then I researched him, read his reviews, watched every one of his You Tube videos. I called and got an appointment, and kept going to consultations with other providers. I had long since stopped smiling and being social. Missing teeth and the shaming was affecting my life so adversely. When I met with Dr. Amin for my consultation he was ready. He had all of my records and had already reviewed my scans. But more than that, he genuinely wanted to get to know about my life. He was/is authentic, kind and extremely professional with so much success and experience in difficult cases like mine. He worked up a treatment plan & I came back two weeks later to discuss my options...and the journey began. I have had three procedures under IV sedation, no pain, no narcotics needed for aftercare. Dr. Amin is a consumate, experienced oral surgeon who cares about your health & understands your fears. He communicates every step of the way and will provide you with all the information you need to make a decision to improve your health. I am still working toward my end goal, and we had to zig from traditional implants and zag to zygomatic implants instead...which is the reason I chose him in the first place. If there was nothing else that could be done to get me healthy & smiling again, I knew he would have that option to help me. And of course 2020, the year of CV-19. Don't worry, Dr. Amin & his staff follow all health & safety protocols. This review is long, because it is important you know my journey, so you might understand how fortunate I feel to be healing. I'm torn, because this place is like a great restaurant, I want to shout from the rooftops how great it is, how great he is. And at the same time, I want to keep this all to myself. I come 75 miles each way to see him. I know people travel from all over the world for his expertise. Do yourself a favor, have a consultation. You won't regret it. Dr. Amin is amazing and so is his staff.
Jennifer B.
Jennifer B.
December 18, 2020.
I cannot speak highly enough of Dr. Amin and his professional staff. I have to start off and say that I am absolutely TERRIFIED of the dentist due to several past experiences. I found myself putting this off for YEARS until I was referred over to Dr. Amin. I was petrified on my first visit... but he along with his WONDERFUL staff made me feel so calm and at ease. I had quite a bit of work that needed to be done, but we found the perfect plan that worked out for me, and I couldn't be happier. Words cannot express my gratitude to each and every staff member that made me feel safe and comfortable. Dr. Amin was always so attentive in asking if I was ever in pain... and I never was. These are truly remarkable individuals, and I'm so lucky to have a dentist that I can trust. I ABSOLUTELY LOVE each and every one of you! Thank you,
D M.
D M.
December 17, 2020.
I cannot say enough positive things about Dr. Amin and his staff. I originally found them on Yelp about two years ago. I needed an implant, front tooth of all places, and was extremely nervous not only about surgery but about how it would turn out. Let me just say I just adore the staff. Everyone is crazy friendly and the whole office has a very positive vibe. The staff is adorable and always has me smiling by the time I leave. They are all thorough and on-point about what they do, and I truly appreciate it. They are quick to respond to my emails no matter the question, and their appointment reminders are great too. Dr. Amin is very thorough and reassuring, and answered any questions my husband or I had. My regular dentist had questions about the procedure and Dr. Amin's office even reached out to them at my request (my dentist said they never received a call, but Dr. Amin's staff had date, time and notes - love the thoroughness!). After surgery the Dr. called to leave me a message about how it went. Very minimal pain during healing, never any pain during any visits. It took a few tries to get everything just right for the permanent crown (color, etc), but the end result is beyond fantastic! At one point during healing I thought I was experiencing some looseness or wiggling but unfortunately couldn't make it to the office. When I was finally able to make it in the Dr. was so relieved, bless his heart. Luckily it was just a false alarm and everything checked out ok. They're a bit further out from me, but I wanted the best. I sure found it! I wish they were my regular dentist, and I'm looking forward to seeing them again for my check-up which was delayed due to COVID.
Melissa E.
Melissa E.
December 9, 2020.
I found Dr. Amin a few years back after I hadn't been to a dentist in a decade. Many traumatic dental experiences in childhood have made me so phobic that even getting a cleaning was a knee-knocking, heart-pounding trial. But finally I couldn't put off some things any longer. During my first anesthesia session, Dr. Amin replaced five old metal fillings, and during the second he did three more plus a crown. I was completely comfortable, and never felt a thing. Because they were extra-long sessions, I did sleep for about 12 hours after, but the next day I felt just fine. This past week, my back top tooth cracked in half and fell out of my mouth, and a couple days later the crown on the remainder of the tooth fell out too! Despite being nervous about Covid 19, I had to get it taken care of, so I called and quizzed the staff about precautions, which turned out to be even above and beyond what I would have expected. So yesterday I went for the tooth extraction and plug. After they put on the blood pressure cuff and put in the IV, I gradually got a little tired and closed my eyes. I sat there for about 10 minutes and thought Gee, I wonder if they're going to get started any time soon, and a minute later Dr. Amin said "Wake up, you're all done!" That was a short session, and I didn't have the kind of fatigue I did my first time. I stayed up most of the evening. Today, everything is good! I'm taking my antibiotic and eating soft foods, and there is surprisingly little pain now that the numbness has worn off. The tooth site and my cheek are a little sore, and the corner of my mouth, and I have a very slight headache, but nothing to any great level--I'm not even taking the acetaminophen. I feel good, and wide awake. Thanks to everyone at the office for a comfortable and professional job! I really REALLY appreciate you for giving me painless dental experiences!
Tanya S.
Tanya S.
December 3, 2020.
What can I say about Dr. Amin he is the best! I'm so grateful for him. He has literally changed my life and given me the confidence to smile more. I had major restorative dental work done and everything went smoothly. Dr. Amin is very compassionate and he really cares about his patients he made me feel comfortable and cared for. He is very knowledgeable and has a great sense of humor. His office is very clean and they take the patients health and safety very serious. His staff is also amazing they made me feel very welcomed and important. I'm so happy I did my research and found Dr. Amin.  Thank you Dr. Amin and team.
Sheila S.
Sheila S.
November 6, 2020.
Two implants done! Finished all procedures and I couldn't be happier. It's the first time in years I looked forward to going to the dentist. Even during Covid life the staff and Dr. Amin took care of me. There is a possibility I may move to Long Beach but I would still travel to keep Dr. Amin as my dentist.
Allison S.
Allison S.
November 4, 2020.
I could not ask for a more caring, exceptionally knowledgeable dental care provider. He's not just a dentist, but someone who looks after your immediate dental needs and helps you plan and prepare for the future.
Julia R.
Julia R.
October 8, 2020.
I've been going to Dr. Amin since I turned 16 and have been going since. Before going to Dr. Amin's dental office, I had 4 crowns that I was not happy with and dealt with it until finally I asked Dr. Amin and because I  feel comfortable and because I trust him with his work I recently had my crowns fixed and worked on by  Dr. Amin and have never loved my smile the way I do now, I can actually enjoy my pictures, I can enjoy my smile from either angle and that really mattered to me. Thank you so much Dr. Amin still and will be in love with MY smile
Aaron D.
Aaron D.
October 6, 2020.
I've been coming to Dr. Ramsey for about five years and I have to say, he is by far the best dentist I've had - ever. The staff is professional and kind, the office is exceptionally well maintained, and Dr. Ramsey is careful and extremely knowledgeable about current developments and research in dentistry. I recently had a dental implant which was a long process but well worth it. I required a sinus lift as well as a bone graft. The surgery went off without a hitch, I was comfortable and the healing process was quick and without complication. Highly recommend!!
Flo O.
Flo O.
September 21, 2020.
This is my 1st review of Dr. Amin, and in my over 17 years of being with him, my experiences with Dr. Amin and his staff have always been positive.  I don't recall a bad experience with the several implant procedures i have had.  They run an efficient office.  I like that they are proactive and reach out to their patients to remind us of routine care needed.  Dr. Amin's bedside care is impeccable.  They are also technologically up to date in terms of sending out texts as reminders, ability to incorporate any appointment into your mobile phone.  That is certainly a plus.  Keep up the great care!!!