GBR in a front tooth for incoming dental implant

Guided bone regeneration (GBR) is one of the most exciting topics of mine in dentistry. Istvan Urban is a Hungarian dentist who is the most famous in this field. I wonder if he can hold his seminar in Budapest now. Because of corona virus, Hungary seems to be shutting down people from other countries. My friends went to go there in Japanese dentist’s tour 2 years ago. I missed the chance.  His papers The amount of new bone by the surgery of Dr. Urban looks so huge. The key point to succeed is release incision, especially in back side of upper lip. Ordinary release incision cannot make good primary closure of gum. Horizontal and vertical ridge augmentation in upper front teeth area is the most challenging surgery. Some videos in YouTube are uploaded showing introduction the Urban institution, short lectures, and European osteointegration congress. The time of each congress video is 1 to 2 hours, which makes me have a little expectation of getting useful information for free. I could watch a few seconds of release incision in an upper frontal vertical and horizontal defect. However, I could not get a real key point of  the procedure in detail, which only dentists who attend his seminar can learn. The case above is my single tooth implant case which required GBR before inserting an implant. The membrane which covered bone graft was exposed after the GBR, which didn’t affect the result at all.

Helped by system 2

According to the international bestseller “Thinking, Fast and Slow” by Daniel Kshneman, psychologists have been interested in the two modes of thinking evoked by multiplication problem. The two systems in the mind are referred to System 1 and System 2. System 1 operates automatically and quickly, with little or no effort and no sense of voluntary control. System 2 allocates attention to effortful mental activities that demand it, including complex computations. The operations of System 2 are often associated with the subjective experience of agency, choice, and concentration.

When I have a new patient, I sometimes am trapped by the first impression to him or her. And I judge character of the patient and decide if I will treat only the part he pointed, ignore other problems, and finish ASAP, or make a treatment plan of whole mouth after solving his initial chief complaint.

A guy, aging nearly 70, came to my clinic, showing a grimace with pain. He said he went to a dental college hospital because of an acute pain in his lower front tooth. The pain didn’t subside after the hospital’s treatment. By his wife’s introduction, he decided to come here. After all, the problematic tooth causing his pain was not one treated in the hospital. I treated a neighboring tooth which had pus at the edge of root. After the root canal treatment, eventually the pain subsided. He looked like a fastidious guy and my intuition, namely my system 1, worked dominantly in my mind, made me think I should finish and will not do further treatment to avoid emotional trouble.

But, a dental hygienist who is experienced and competent looked at his memo pad filled with lots of schedules, when she made his next appointment after the first visit. She told me that he must be a household name and I should research Wikipedia. She was right. My system 2 began to work and found that he worked in Ministry of Foreign Affairs, engaged in Scandinavian, became a professor of a private university, is an author of international relationship books, and is working as a commentator in TV news program.

After the root canal treatment and subsequent erase of the pain, he showed trust and asked full mouth treatment, and accepted my treatment plan which includes sinus lift, implants, and prosthesis for natural teeth, as you can see photos and X-ray. He was impressed and satisfied to see the before and after photos.

If I had not had the dental hygienist’s attentiveness, I would have missed a chance of full mouth reconstruction which inspires my imagination and creativity. Without her precious advice, I couldn’t have got the successful case.

The problem is when I must activate my system 2 in decision making, avoiding bias caused by system 1. I’m going to study psychology more to solve the problem, to make a better decision.

Passion to save my friend

In a national bestseller book “Awaken the giant within”, Tony Robbins said “I had a hard time giving credence to a doctor who was counseling patients about health but he, himself, was forty pounds overweight” and came across as a caricature where a fat doctor says “You need more exercise. Go and get me a cheeseburger with onions” to his patient. “Physician, heal thyself.” “It is a good doctor who follows his own prognosis.”

From a dentist view, I suppose many doctors, except for dentists, don’t care about their teeth. I wonder if it can be said for only Japanese medical doctors. My high school era’s friend was one of them. He is a handsome and smart guy who was a surgeon and now is working as an adviser dealing with medical law suits in an insurance company. He lost lower molars when he was late thirties. He came to my clinic for the first time 5 years ago. However, he did’t want an implant, but a removable denture which was not used in the end. Probably, he doubted the reliability of dental implant through some dental law suits. Then, he came once again last year. His chief complaint was smell caused by the fracture of upper front teeth. He wanted another removable denture after extraction of troubled teeth. Several days later, he said “This denture is awful, unbearable, I can’t talk clearly when giving lectures. Carry out implant treatment in the upper front teeth”.

I made Power Point slides explaining it’s necessary to have implants in the lower molars to save the upper front teeth implants and other natural teeth, showing force mechanism. I didn’t use any psychological persuasion skill described in a book “Influence: Science and Practice” by Cialdini, R.B. I just used my passion to save his dental condition. He looked impressed by my explanation and accepted my treatment plan.

He smiled and said, “I’m so happy to be able to enjoy eating” after the treatment. I was also happy to contribute to the quality of his life. Maintenance and periodical check-ups are necessary. However, I haven’t seen him since then, probably, because of the new coronavirus predicament. I must pull myself together and face up to the threat.

Challenging case

Recently, I had a patient who had trouble with dental implants which his former dentist had embedded. At first, I rejected to treat him. Because, the implants were different from ones which our clinic dealt with. I use implants produced by Straumman co. which has been used worldwide. I did not know the product maker of the patients’ implants through the appearance and X ray images of them. It is said that there are over 50 implant makers in the world. Some new companies aim niche in the market, struggling to keep up with the technology of the companies already having big share. Sometimes, some companies’ implants have kinks though they say their product are fool proof. I wanted to pull out the patient’s implants with counter clockwise strength, because they were poorly positioned. Of course, considering patient’s agony, I can’t carry out it. He asked me to treat many times, and finally, I gave in. Now, I am enjoying the process of reconstruction of his occlusion.



(It’s like night and day, isn’t it?)


 X-ray at the first visit

10 years after sinus floor augmentation


I sometimes encounter patients who don’t have enough bone in upper molar teeth missing area for placing dental implants. I learned skills of sinus floor augmentation, surgery of growing new bone in sinus for upcoming dental implants surgery, at University of Michigan in 2002. The reason for going abroad was that I could practice the skills using cadavers in US, which has been prohibited in Japan. Since then, I have overcome the difficulties in placing implants in upper molar. This is one of such cases, CT scan images after 10 years showing stable condition. The more I learn, the more I can contribute.

Combination of skills, it’s fun!

Collapsed bite cases, which require wide varieties of skill to fix, are challenging for dentists. However, I am excited whenever I face them. In such cases, thinking process for treatments is really fun for me. The case below is the combination of techniques such as diagnosis of occlusion, implant, orthodontic treatment, gum surgery, and crown restoration. The treatment took 2 years. I want to thank the patient for his understanding and cooperation. Without them, I couldn’t have reached the goal. I will describe the prosess, step by step later.



before(lower jaw)


after(fixed by implants, bracing, crowns)

Dental implants: 10 years after sinus floor elevation

 My friend’s back teeth were lost due to decay. (He is a brain surgeon.) To carry out dental implants for him, I had to learn the way to generate bone in his sinus. An egg is a good material for practicing sinus floor elevation. I learned the technique in Michigan 10 years ago. Dentists who had the skill in Japan were rare in those days. Whenever I have patients who need the surgery, I make it a rule to practice with eggs before actual performance.

partially cut the shell without damage membrane inside
peel membrane from the shell without breaking


bone grafting


partially cut the bone without damage membrane inside


peel membrane without breaking


bone grafting and implant




10 years after