Friday, November 27, 2009

Immediate Implant Placement and Immediate Implant Loading

Immediate Loading is a hot topic in implant dentistry.

This means you will have a tooth placed on your dental implant within 24 -48 hours of surgery.

Here is an example of the entire lower jaw replaced with nine implants and an immediate bridge:

Every patient that I treat has always wants his or her teeth right away. You really need weigh the risks versus benefits of this particular procedure.

Immediate teeth work best for teeth in the front of the mouth. It also works very well if you are missing all your teeth and is most successful if you are having several implants placed for your whole  jaw. When the dental implants are put in,  a temporary tooth or whole set of teeth are made right on the spot or have been made prior to surgery by a lab technician. You would walk out of the office with teeth not gaps. The temporary teeth  look, feel and work like your regular teeth.

You have an important role in the success of this amazing procedure. I will tell you, that you have to be committed to a soft diet for about 3 months. Even though a tooth is made on the immediate, same day implant, it still has to fuse to your bone. This is called "osseointegration." If you can’t commit yourself to this, immediate loading or immediate temporaries are not for you. It has a high risk of failure if you chew harder foods too early. All of the implants can fail.

If it were just one tooth, like your front and center upper tooth,  the immediate temporary is made so it doesn’t touch the bottom teeth. This further prevents the chance of using the tooth too early.

Some of the important factors in determining if immediate loading can be done are:

•Bone density

•Amount of bone

•Initial stability of the implants

•Shape and type of gum

•Implant design and type

•Your bite

What's the race to get a tooth today? I am all for immediate dental implants when it does not pose a significant risk of failure to you. If the procedure will be just as successful to have the immediate implant, as it is the traditional "delayed" approach, then you should strongly consider it. It may even reduce the total cost, too and saves time.

I have a wealth of experience in this procedure and let me tell you this is not for the novice implant surgeon or dentist. One tiny error can yield disastrous results.

The next level up is an immediate implant with a temporary on the same day the tooth is extracted! This is an extremely common procedure I have been performing  in my office for several years. I most commonly do this for front or side teeth. If there is infection, it may not be an option for you. Sometimes the infection dissolves the really thin bone on the outside surface. If this is the case, an immediate dental implant is not recommended.

A bone graft is sometimes necessary with immediate load dental implants and can be done at the same appointment. Every situation is very different.

With any situation you should have a back up plan. In my opinion, this procedure is a bit "over-marketed" as a solution for everyone, but it really only accounts for about 5-15% of situations. There are times that immediate implants are planned, but during the surgery I find that the bone or implant is not strong enough and I have to abort and not put the implants in that day.

The bottom line.... immediate dental implants are great in the perfect situation. Pre-surgical planning and expert execution of the procedure makes all the difference

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Monday, November 23, 2009

Immediate Front Tooth Immediate Dental Implant *(Difficult Case)*

A female patient of mine from Scottsdale AZ presented with a discolored upper front tooth. The tooth had been traumatized in the past and is now "dead."

The radiograph "x-ray" shows the root is resorbing or "dissolving". A Bridge is a poor choice in this case because it would mean cutting down the otherwise healthy adjacent teeth to "stumps" to fit a bridge

The tooth was extracted and on the same day an immediate implant was placed. These photos are from the day of surgery. *Note: ALMOST NO BLEEDING*

This is the temporary tooth made for her on the day of surgery. She wore this for 3 months during the implant healing phase. She was told she could not chew with this tooth for the entire 3 months.

Notice how well the gums have healed after 3 months. The "scalloping" of the gumline is perfect and we have avoided a long crown and any risk of "black triangles" between the teeth

Here is the final tooth. This is close to perfect. The gums have healed ideally and the final result is exceptional. Ideally she should have had orthodontics to align her teeth, but she just wanted a straight front tooth. She was extremely happy with the result!

The final x-ray shows great bone levels! She should have this tooth for the rest of her life!

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Thursday, November 5, 2009

Wisdom Teeth...To Keep or Not to Keep?

Wisdom teeth also known as third molars are the last teeth to erupt. Wisdom teeth may become a problem for you as they grow and develop in each corner of your mouth. Problems often develop gradually since development normally spans several years. Nevertheless, these gradual changes can cause sudden and severe pain. Understanding why such things can happen may help you to deal with these problems, or better still, to encourage you to take preventive measures before they occur.
The jawbone grows to approximately its adult size by your late teens. Unfortunately, that size is often too small to hold developing wisdom teeth. This happens because our jaws are smaller than those of early humans who needed large jaws and more teeth for their tougher diet.
When there is not enough room for your wisdom teeth, they may become impacted, or partially trapped in the jawbone and gums. The crown, or top of the tooth, may erupt, or just break through the gum, or it may remain completely within the bone. The roots can grow in unusual directions and may cause a variety of problems in your mouth and with your sinus cavity or the nerve in your lower jaw. The primary preventive measure for wisdom teeth is removal, preferably at an early stage.

Impacted Wisdom Teeth
A tooth becomes impacted due to lack of space in the dental arch and its eruption is therefore prevented by gum, bone, another tooth or all three. Lack of space occurs because our jaws have become smaller through evolution. We do not lose teeth through decay as frequently as in the past and our diet does not wear down our teeth as much.
Impacted wisdom teeth can grow in a variety of directions. This is illustrated below.

A wisdom tooth may grow toward your other teeth, away from them, or even in horizontal or vertical positions. When such conditions occur, it's far simpler and less painful to have them removed early before they have a chance to firmly anchor in your jaw as the teeth grow and the roots lengthen.

Wisdom Tooth Assessment
Not everyone has problems with their wisdom teeth. Factors that determine whether you will have problems include the size of your jaw and how your wisdom teeth grow in. There may be pain and swelling, or you may have no symptoms at all even though the other teeth in your mouth may be at risk of damage. In addition to actual pain, common problems caused by wisdom teeth can include gum disease, crowding, decay, poor position, and cysts.
Since it is not practical for most people to evaluate how their wisdom teeth are developing, the best approach is to visit Dr. Dorfman or another Board Certified Oral & Maxillofacial Surgeon for an evaluation. Dr. Dorfman will review your dental history, take dental X-rays, and perform an examination to determine the general health of your mouth and the condition of your wisdom teeth. If a problem with your wisdom teeth is detected, our participating dentist may recommend surgery to remove them and eliminate or avoid any unpleasant symptoms. Early removal is best for most patients as it usually helps to avoid more serious problems later on.
It is very important to talk to Dr. Dorfman about extraction procedure, risks, possible complications and outcomes of the removal of these teeth.

Why Remove Wisdom Teeth?
Wisdom teeth generally cause problems when they erupt partially through the gum.
Below are the most common reasons for removing wisdom teeth.
1. Tooth decay
Saliva, bacteria and food particles can collect around an impacted wisdom tooth, causing it, or the next tooth to decay. It is very difficult to remove such decay. Pain and infection will usually follow.

2. Gum infection
When a wisdom tooth is partially erupted, food and bacteria collect under the gum causing a local infection. This may result in bad breath, pain, swelling and the inability to open your mouth fully. The infection can spread to involve the cheek and neck. Once the initial episode occurs, each subsequent attack becomes more frequent and more severe.
3. Pressure pain
Pain may also come from the pressure of the erupting wisdom tooth against other teeth. In some cases this pressure may cause the erosion of these teeth.
4. Orthodontic reasons
Many younger patients have had prolonged orthodontic treatment to straighten teeth. Wisdom teeth may cause movement of teeth particularly the front teeth when they try to erupt. This will compromise the orthodontic result.
5. Prosthetic reasons
Patients who are to have dentures constructed should have any wisdom tooth removed. If a wisdom tooth erupts beneath a denture it will cause severe irritation and if removed, the patient will need to have a new denture constructed as the shape of the gum will have changed.
6. Cyst formation
A cyst (fluid filled sac) can develop from the soft tissue around an impacted wisdom tooth. Cysts cause bone destruction, jaw expansion and displacement or damage to nearby teeth. The removal of the tooth and cyst is necessary to prevent further bone loss. Tumors may develop within these cysts or the jaw may fracture spontaneously if the cyst grows very large.
Why remove an impacted wisdom tooth if it hasn’t caused any trouble?
Impacted wisdom teeth are almost certain to cause problems if left in place. This is particularly true of the lower wisdom teeth. Such problems may occur suddenly and often at the most inconvenient times.

When is the best time to have my wisdom teeth removed?
It is now recommended by dentists that impacted wisdom teeth be removed between the ages of 14 and 22 years whether they are causing problems or not. Surgery is technically easier and patients recover much more quickly when they are younger. What is a relatively minor operation at 20 can become quiet difficult in patients over 40. Also the risk of complications increases with age and the healing process is slower.

Traveling to foreign places
It may be advisable to have them removed before traveling if you are going to an area where specialist dental services are not readily available and your wisdom teeth are impacted.

The ‘Pros & Cons’ of wisdom tooth removal

1. Some ‘Pros’ of removing a wisdom tooth.
Wisdom teeth may be hard to access with your toothbrush or floss. Over time, the accumulation of bacteria, sugars and acids may cause a cavity to form in the tooth. If it is not restored with a filling, the cavity may spread and destroy more tooth structure causing severe consequences to the tooth and surrounding supportive structures.
Due to the difficulty of keeping these teeth clean with your daily brushing and flossing, bacteria and food debris remaining on the wisdom teeth may present a foul smell causing bad breath.
A wisdom tooth that is still under the gums in a horizontal position rather than a vertical position may exert pressure on surrounding teeth causing crowding and crooked teeth. This also may occur if there is not enough space in the mouth for the wisdom tooth. This may warrant braces to repair the damage.
A wisdom tooth that is still under the gums may become irritated. The gum tissue that lay over the tooth may harbour food debris and bacteria that gets trapped under the gum resulting in an infection in the gums.
There is the potential for more problems to occur the longer you wait and the older you get. This is because as you get older, the bone surrounding the tooth becomes increasingly dense making the tooth more difficult to remove. The healing process may also be slower.

2. Some ‘Cons’ of removing a wisdom tooth.
Depending on the size shape and position of the tooth, removal can vary from a simple extraction to a more complex extraction. With a simple extraction, there is usually little swelling, bruising and bleeding. More complex extraction will require special treatment which may result in more bruising, swelling and bleeding. However, our participating dentists will provide you with post treatment instructions to minimise these side effects.
Following an extraction, a condition called "dry socket" may occur. If the blood clot that formed in the extraction area becomes dislodged, it exposes the underlying bone. This condition is very painful but resolves after a few days. It is preventable by following the post treatment instructions provided by your oral surgeon.

The Operation
Surgery is often done at Dr. Dorfman's rather than in a hospital in most circumstances. Dr. Dorfman will review the recommended procedure with you so that you will fully understand and be comfortable with the procedure before it is done. You will also be given information about eating, medication, rest, driving, and other considerations before surgery as well as after.
Very few people have their wisdom teeth removed under local anesthesia by their dentist. This means that they are awake but the area around the wisdom teeth is completely numb. Dr Dorfman performs the surgery with IV Sedation or General Anesthesia along with local anesthesia to allow people to sleep during the procedure and keep vital signs stable.
The operation will not start until the anesthetic has taken effect. It is often necessary to make a small cut in the gum over the wisdom tooth, and to remove some bone so that the tooth can be lifted out. Stitches are usually put in to help the gum heal.

Post operative healing
The healing process begins immediately after surgery as your body sends blood to nourish the tooth socket. Simple pressure from a piece of gause is usually all that is needed to control the bleeding and to help a blood clot to form in the socket, which promotes healing. Within a day or two, soft tissue begins to fill in the socket, aided by the blood clot. Eventually, the bone surrounding the socket begins to grow, filling in the socket completely. This is illustrated below.

As your mouth heals, you can promote faster healing and avoid complications by simply following the care instructions that our particiapting dentists will give you. While you may experience some discomfort as your mouth heals, following simple instructions will normally be all that is needed. However, you should call our participating dentists if you experience excessive bleeding or swelling, persistent and severe pain, fever, or any reaction to medications. A follow-up examination will also be scheduled to make sure that the socket is healing properly and that your mouth is returning to a normal, healthy state.

Post operative care
Following the removal of your wisdom teeth it is important that you call our participating dentists if any unusual bleeding, swelling or pain occurs. The first 6-8 hours after the extraction are typically the worst but are manageable.
At first, it may be possible to feel small fragments of bone with your tongue. These are the edges of the tooth socket and will soon disappear as the gum heals. Depending on the type of stitches used, they may need to be removed. Arrangements will be made for this to be done. If dissolvable stitches have been used, they will disappear 7 to 10 days after the operation.

Below are some tips to assist you after the operation.
1. Do not disturb the wound.
Disturbing the wound may invite irritation, infection and bleeding. Chew on the opposite side for the first 24 hours.
2. Do not smoke for 12 hours.
Smoking will promote bleeding and interfere with healing.
3. Do not spit or suck through a straw.
This will promote bleeding and may dislodge the blood clot which could result in a dry socket.
4. Control of bleeding.
If the area is not closed with stitches, a pressure pack made of folded sterile gauze pads will be placed over the socket. It is important that this pack stay in place to control bleeding and to encourage clot formation. The gauze is usually kept in place for 30 minutes. If the bleeding has not stopped once the original pack is removed, place a new gauze pad over the extraction site.
5. Control of swelling
After surgery, some swelling is to be expected. This can be controlled through the use of cold packs which slow the circulation. A cold pack is usually placed at the site of swelling during the first 24 hours in a cycle of 20 minutes on and 20 minutes off. After the first 24 hours, it is advisable to rinse with warm saltwater every two hours to promote healing (one teaspoon of salt to a glass of warm water). Do not rinse your mouth out during the first 24 hours because this disturbs the blood clots that are part of the healing process.
6. Medication for pain control
Anti-inflammatory medication such as Ibuprofen is used to control minor discomfort following oral surgery. Stronger analgesics are ususally prescribed by Dr. Dorfman for discomfort as well.
7. Diet and nutrition
A soft diet may be prescribed for the patient for a few days following surgery. You can gradually return to a normal diet once any jaw stiffness has settled. Very hot drinks and spicy food can increase pain and bleeding and should be avoided until the gum has healed. Also avoid alcohol as alcohol can increase bleeding and delay healing.
Most people do not experience any complications after having their wisdom teeth removed. Nonetheless, you should plan to see Dr. Dorfman approximately one week later to ensure everything is healing well.