Knowledge Library

Anterior Implants
Changes in implant design and new laboratory materials are offering dentists tremendous new opportunities to create highly esthetic anterior appearances and beautiful smiles. At the same time, these new anterior implant designs and materials are solving some of the traditional problems of dentures and complex crown and bridge procedures.

For many patients, missing anterior teeth creates a lack of confidence and less than acceptable esthetics. Today, this can all be changed due to the variety of implant options available. Not only do we have an entire array of new surgical procedures that allow for better esthetic results, we have a number of implant components with various shapes and sizes that allow for excellent restoration.

Most dental laboratories who work with implant surgeons today are developing extensive expertise in the best materials to use for anterior implant restoration. No longer must patients settle for unsightly metal collars. New developments in porcelain technology are creating a more natural look with the shade, light reflection, and marginal design of the final implant restorations far superior to those of just a few years ago.

One of the first issues in anterior implant placement is that of occlusion. Each case is analyzed for the relationship of the maxillary and mandibular arch, as well as the bone quality, density, and ridge height of the anterior area to receive implants. This analysis includes an overview of the best implant placement in order to achieve the proper occlusion. We always keep in mind that we are trying to restore either the natural occlusion or an improved version of the patient’s original occlusion.

In some cases, we will even create mockups of the final case. This allows us to examine the available bone, understand the best angle for the implant, properly select the right size and shape implant, and analyze the overall esthetics of the case.

Once we have established the best implant to be used and its proper position, the final case results will be much more predictable.

As always, we are committed to a high-quality, successful result for all of our mutual patients.

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Dental Implants and Overall Health
In the dental field, treatment planning decisions are made daily. The best course of treatment is determined using three typical criteria: oral health, longevity and cost.  A recent article* in Tufts University’s Health & Nutrition Letter, highlights an aspect often excluded from treatment decisions: overall health.

McGill University conducted a study on the nutritional effects of implant-supported dentures compared to traditional, adhesive-retained dentures with very exciting results! After six months, the group with the implant-retained dentures had higher levels of vitamin B12, hemoglobin and albumin, a body protein considered a reliable indicator for good overall nutrition status. There were no such improvements with the traditional denture group.

The improvements in nutrition levels were attributed to an improved ability to chew and an expansion of dietary options, such as raw fruits and vegetables.

The article stated that “Implant dentures like those used in the study should be the first choice of treatment of someone who has lost his or her teeth, according to a statement issued last year by a panel of dental experts from 10 countries.” As you know, implants are not unequivocally the panacea in every case, yet their advantages and remarkable success rates make them an outstanding treatment option.

Dental Implants have proved themselves the longest-lasting dental restoration available today and for having a host of other advantages over traditional treatments in many cases. The remarkable dietary advantage they provide to denture wearers leads to measurably healthier people.

Please remember the potential you have to improve the lives of your patients and let them take advantage of our complementary consults for dental implant treatment.

*Source: Tufts University Health & Nutrition Letter

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Immediate Implant Placement
Did you know that in many cases a dental implant can be placed at the time of tooth extraction?  If adequate bone volumes exist after careful and meticulous tooth extraction, implants can be placed and integrate successfully from second premolar through second premolar in both maxilla and mandible.    Many times it is most advantageous to the patient to have the dental implant placed at the same procedure, thus avoiding an additional procedure and ensuing recovery period.  While very thorough apical curettage as well as attention to the bony walls must be addressed and firm implant stability must be ensured, many times this is a predictable procedure. 

This does not necessarily hold true in the molar positions.  Due to the large size of the molar “footprint,” a delay of approximately eight weeks is typically more appropriate prior to placement.  While in some cases a tooth can be placed into one of the roots of a molar extraction site (distal root of a lower first molar), it is often more prudent to allow some healing time.  One must keep in mind that the restoration is planned to last over twenty years, so a few extra weeks of healing is usually warranted.

Previous studies showed some decrease in success with simultaneous implant placement.  Those studies are now being overshadowed by those showing it to be a much more predictable procedure. In our experience, patients benefit remarkably by saving time, money and avoiding another healing period, all with a high chance of success in their implant therapy. 

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Guidelines for Splinting Implant Restorations
I am often asked when particular implant restorations should be splinted together during the prosthetic planning phase of treatment.  While each patient and each restoration process needs to be considered individually, there are several helpful guidelines that are used to make sound clinical judgments.  

Although there are exceptions, the following are often considered indicators for splinting:

  • Patients with a reduced number of natural occlusal stops
  • Steep anterior guidance
  • Off-axis angled implants
  • Parafunctional oral habits
  • Implants arranged around an arch
  • The implant restoration includes the canine
  • Edentulous maxilla

Implant restorations with the following characteristics may not need to be splinted:

  • Patients that have multiple natural occlusal stops
  • Shallow anterior guidance
  • Normal occlusal forces
  • Well-oriented implants
  • Implant restorations that do not include the canine
  • Edentulous mandible with implants in bilateral posterior regions

An additional concept that deserves consideration is the “cost of re-entry.” If an individually restored implant should have a problem down the line it can be treated individually since the prosthetic components are not splinted together.  This may not affect final decision in general, yet is worth considering with patients presenting with higher likelihood of failure (immuno-compromised, poor hygiene history and/or smoking habit). 

Another very important consideration is whether the patient desires to floss and clean the teeth on an individual basis or whether they are diligent enough to use floss-threading devices.
I appreciate your questions and it is my pleasure being a resource for you and your practice.  Please do not hesitate to contact my office for resources and support pertaining to your implant and third-molar patients.

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What if George Washington had Dental Implants?
We have all probably heard the story about George Washington’s wooden teeth.  It turns out that the story is actually not true:  The truth is that our first commander-in-chief had dentures made of carved hippopotamus tusks, elephant ivory, cow, elk and human (including his own) teeth.  
Our president suffered from severe dental problems throughout his life.  By the time he was twenty-two he had already lost two teeth and the others were black and decayed. His diet was restricted to soft foods, and he suffered from chronic and acute dental complications throughout his life that eventually contributed to his death.

Some of his dentures were fitted with powerful springs that required constant and high occlusal forces to keep them in his mouth.  If you look at his later portraits, he appears to be upset, yet he is actually straining to keep his jaws together and his dentures from springing out of place. 

If George Washington had dental implants to support his dentures, he would have been able to eat whatever his heart desired, look better in his portraits, and save on dental expenses (his financial records show that he spent 10 times more on his personal dental needs than on his entire estate of more than 200 people).  Also, the crossing of the Delaware would have been much more pleasant and the taste of victory much sweeter.

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Implant Therapy for the Severely Resorbed Edentulous Mandible
It’s important for any patient who suffers with an edentulous mandible to understand the benefits of combined implant therapy with removable mandibular denture, partially supported by two O-rings. Patient education is important for this particular problem because it is assumed that dentures are the only solution for these cases. This “bar and clip” supported prostheses provides as not only a functional, but also as an esthetic solution.

According to Gordon J. Christensen, D.D.S., M.S.D., Ph.D., implants should be placed no more that 15 degrees from parallelism and perpendicular to the planned occlusal plane. Temporarily lining the old mandibular denture is necessary, as there should be no stress on the healing implants.

Mandibular implants require about four months of healing and stabilization. When this is complete, the healing caps should be extended at least 2 mm above the apparent soft tissue healing level and should be at the same diameter as the implants. The required healing time is a minimum of two weeks, but six weeks allows the tissue to mature faster.

Following implant exposure, clinicians should measure with a periodontal probe to determine the placement of the abutments for O-ring attachment. This should be about 1 mm longer than that measurement. Impressions and analogs are then made from state-of-the-art materials.

This procedure includes custom trays made from Dentsply Triad and Permadyne impression materials. These impression materials are hydrophilic, allowing the bonding of a second “wash,” and can be adjusted with a laboratory bur. Spheres that simulate those on the abutments are placed on the impression.

After cast pouring and denture construction, the denture is then tried into the mouth without the O-rings for adjustment. A l mm deep hole is cut into the denture resin. This, along with the flexible rubber-like O-ring in the denture, creates enough room for the denture to move in all directions. The implants receive no vertical or horizontal stress.

Until patients learn how to correctly remove the O-rings, patients may go through two or three recall appointments. This combination of implant therapy and partial dentures has proven to be the more preferable option, considering the alternative of traditional full dentures.

If you have any questions about this implant procedure or any other procedure, please don’t hesitate to call our office.

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Dental Implants’ Most Valuable Application
Because of the numerous situations in which implants are a viable treatment modality, many clinicians are confused about the clinical situations in which implants are most needed.  According to an article by Gordon J. Christensen, DDS, MSD, PhD: Traditional oral treatment can solve most needs, but some clinical conditions are not well served through traditional therapy.  Clinical situations served poorly with traditional dentistry are clearly identified:

  • most edentulous mandibles
  • some edentulous maxillas
  • bilateral distal extension, partially edentulous cases (Kennedy Class I)
  • unilateral distal extension, partially edentulous cases (Kennedy Class I)
  • anterior partially edentulous cases (Kennedy Class IV)
  • cleft palates, accidents and others

Dr. Christensen highlights the value of implant therapy in most edentulous mandibles:
After personally accomplishing hundreds of implant cases, I contend that the severely resorbed edentulous mandible demands dental implants more than any other clinical situation.
He believes that dental implants are a valuable modality for these patients because many have severely resorbed alveolar ridges, which make traditional removable dentures unsatisfactory.  Mandibles that are resorbed significantly have very little trabecular bone and consist of primarily dense cortical plate. Cylinder or screw implants can be placed relatively easily in various locations under these circumstances.

Dr. Christensen concludes this article by stating: Most people with edentulous mandibles are dissatisfied dental cripples.  They are the people who most need dental implants.  Two implants in the nos. 22 and 27 areas, followed by relatively simple denture construction, provide much more satisfactory service than traditional complete dentures.  This relatively inexpensive concept should be considered standard care for most edentulous patients.

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Update on Single-Tooth Replacements
As implant dentistry continues to advance, single-tooth implant replacements are becoming a new standard.  Many dentists are realizing that it is often easier to restore a single-tooth implant than a natural tooth.  They can easily take impressions, labs can manufacture a crown that precisely matches the patient’s oral anatomy and restorations can be achieved with excellent results.

In a recent study, one-hundred general dentists who had made over 20 single-tooth replacements were surveyed.  “Ninety-nine per cent of the dentists polled indicated that they were extremely satisfied with the single-tooth implant and final restorations.” The study further stated that “if I had to place a three-unit bridge versus a single-tooth implant for someone in my family, I would choose the single-tooth implant replacement, unless the abutment teeth for the bridge were already extremely overfilled.”

Our findings parallel those of this study.  Dentists making single-tooth replacements appear to be extremely satisfied, as are their patients.

In the quest to make dentistry and the team approach easier, the single-tooth replacement can create not only happy patients, but a more successful practice.

Studies of single-tooth implant replacements show a 92% or higher success rate and these results have remained consistent.  Today, single-tooth implants can be used either to restore space in the mouth or can be placed immediately at the time of extraction.  The healing period is shorter than ever before and final results are excellent.

Single-tooth implants are also decreasing the need for heroic dentistry, procedures that attempt to save a tooth but which have lower success rates.  Patients no longer have to suffer through numerous procedures, nor do they have to look forward to a lifetime of potential follow-up appointments.  The single-tooth implant is proving to be highly predictable and allows for the normal restorative course of action to be taken.

If you would like any additional information in regard to single-tooth implant placement, please feel free to call our office.  As always, we are delighted to see your patients for consultation and will offer them objective information in a caring manner.

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Smoking and Implant Failures
As if there weren’t enough reasons to recommend smoking cessation, two more now exist. The first emanates from a study published in The International Journal of Oral and Maxillofacial Implants which compared implant failure rates in smokers and non-smokers. The study concluded that smokers were nearly three times as likely to suffer implant failure as non-smokers. The findings indicate an implant failure rate of 11.28 percent in the smoking group, compared with a 4.76 percent failure rate experienced by the non-smoking group.

Overall, failure rates were highest in the posterior maxilla and lowest in the anterior mandible, but smokers had higher failure rates in all regions. Only in the posterior mandible was no significant difference between smokers and non-smokers documented.

Yet another smoking cessation incentive is highlighted by a recent study which indicates that smoking causes complications during wound healing. The study by A.G. Christen, D.D.S, M.S.D., M.A., reveals that tobacco can delay the healing process in patients who have gingival or mucosal infections and oral ulcerations, or who have recently undergone tooth extractions, periodontal surgery or maxillofacial surgery.

Approximately 1 to 3 percent of patients who have had recent tooth extractions suffer from “dry socket.” This disorder is directly correlated to several physiological conditions, such as reduced blood supply to involved areas and hormonal changes. In addition, drawing smoke can disrupt the blood clots present in open sockets.

Tobacco smoke not only irritates and causes infections, but it also decreases the survival rate of skin cells. Because smoking prevents skin cells from regenerating at a normal pace, healing is significantly delayed as the healing tissue’s regenerative potential is damaged.

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Successful Osseointegration
Accurate diagnosis and treatment planning are the keys to a high-quality single-tooth implant prosthesis.  According to a recent study by Dr. Thomas Balshi, several procedures must be considered for osseointegration to occur.

Elimination of Pathosis: If chronic periapical abscess conditions are present, debridement is required intraoperatively.  Extensive debridement can delay immediate implant placement.
Ideal Fixture Alignment and Stability: Fixture stability will improve when the fixture placement engages the cortical plate.

Adjacent Teeth Protection:  In order to protect adjacent teeth, 1.5 mm of bone must remain between fixture threads and periodontal ligaments.  Five to 8mm of intercoronal distance is sufficient; anything less would require orthodontic treatment.

Preserving or Augmenting the Alveolar Ridge: Labial plate resorption is the result of anterior tooth loss.  In such a case, ridge augmentation procedures may be required.  If the resorbed ridges are not augmented, then palatal/lingual fixture placement and anteriorly cantilevered cervical extension of prostheses may be required.

Mucosal Pressure: Avoiding this pressure is attained by using soft liners under removable appliances.  It can also be avoided through bonding of pontics to the adjacent dentition.
With these objectives in mind, successful osseointegration can be achieved.

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Wisdom Teeth and the Rule of Two-Thirds
When do most oral surgeons have their own children’s wisdom teeth removed? They invariably take them out when the mandibular roots are two-thirds formed.

The reasons for this are simple:

1. The mandibular molar roots are two-thirds formed usually between the ages of 14 and 20.  The human capacity to regenerate bone in the extraction site and on the distal surface of the second molar is at its highest potential during this age range. Beautiful bone develops within six weeks following surgery.

2. The small risk of injury to the mandibular nerve is nearly “zero” when the roots are incompletely developed.  Most nerve injuries occur when the fully developed roots of lower wisdom teeth brush against the nerve when the tooth is eased out of the extraction socket.

Does this mean we take out wisdom teeth only during this ideal time?  Unfortunately not.
Consider the following patients that have been seen in our office recently:

  • An 83-year-old man who wanted an immediate upper denture but had tooth #16 partially impacted
  • A 29-year-old woman whose wisdom teeth had fully erupted but which neither she nor her dentist could clean properly
  • A 47-year-old man with a cyst that extended from tooth #28 to his mid mandibular ramus around fully impacted tooth #32
  • A 14-year-old girl whose wisdom teeth roots were one-half developed, has a crowded dentition and whose family insurance benefits were changing

Our team loves taking care of patients who need their wisdom teeth removed. Please call us when we can be of service to your patients.

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Wisdom Teeth and the Adult Patient
Your uncle Henry pulls you aside at Thanksgiving dinner and asks you “How come I never had to get my wisdom teeth out?” What do you tell him? With increased life expectancy and vitality of the adult population, several factors are important to consider regarding erupted third molars:

1. Is your patient prone to dental decay in general? Certainly, patients with a high caries rate will benefit from earlier removal.

2. What is the periodontal status of the second molar? A progression of pocketing in the interproximal region between the second and third molars should raise warning flags.

3. Are there mucogingival problems on the distal of the third molar? Lack of keratinized tissue distally does not bode well for long-term periodontal maintenance.

4. What are the odds of this patient developing heart, liver, lung or kidney problems in the future? A surgical extraction can be severely debilitating, if not life threatening, in a medically compromised or fragile patient.

5. What are the risks associated with extraction? Pain, swelling, bleeding, infection, possibility of numbness and jaw fracture are possible complications and should be discussed with someone educated in their management.

Patients who present with erupted third molars in their adult years do not fit neatly into a nice black and white category. All oral surgery involves an assessment of the balance between potential risks and long-term benefit. If you would like one of your adult patients evaluated, please contact us to set up a consultation appointment. We treat your patients like family.
Uncle Henry included.

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Healthy and Beautiful Smiles At Any Age: Is It Wise to Keep Your Wisdom Teeth?
We’re often asked, “Why are wisdom teeth removed even if they don’t hurt?” Many times there are no symptoms of wisdom tooth trouble.  You may not even know you have wisdom teeth – until pain suddenly strikes because of an infection or pressure on an adjacent tooth.  Since wisdom teeth develop over a period of many years, harmful changes in your mouth may be gradual.

How do you know if you should have your wisdom teeth removed?  An evaluation by your general dentist can answer this question.  X-rays can show potential for a serious problem or that other teeth in your mouth may be at risk for damage.  If your dentist spots a potential problem, he or she may recommend that the wisdom teeth be removed even before they are fully developed.  Wisdom teeth are easier to remove at an early stage because the roots aren’t fully formed or strongly planted in the jaw.  When wisdom teeth are removed during the early stages, the procedures are easier and there is only a small risk of complications.

Many patients choose to have their wisdom teeth removed by an oral and maxillofacial surgeon who specializes in mouth and jaw surgery.  Oral surgeons attend dental school for four years and then go on to obtain specialty training during four years of hospital residency.  Some even go on to obtain their medical degree with another four years of schooling.  General dentists often refer their patients to oral surgeons to have their wisdom teeth removed.  If you are unsure, ask your dentist their opinion if early removal of wisdom teeth is right for you.

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Indications for the Removal of Impacted Third Molars
The controversy regarding indications for the removal of impacted teeth is not surprising. Unfortunately, we live in an environment in which economics too often determine whether or not impacted teeth are removed. This problem is further complicated by the fact that many insurance companies have different coverage rules regarding the removal of impacted teeth. The American Association of Oral and Maxillofacial Surgeons (AAOMS) has done extensive research on this topic and has published a position paper and parameters of care guidelines. We would like to share their findings as well as our thoughts regarding the indications for the removal of impacted third molars.

As a general rule, the AAOMS considers timely removal of impacted and unerupted teeth to be between the ages of 15 and 25, when the usual result of treatment is uncomplicated healing with no morbidity. While the risk of post-operative complications associated with wisdom teeth removal is generally quite low the complication rate increases with the age of the patient. Further research on the removal of impacted teeth from an article by Biglio, et al., appears in The Journal of Oral and Maxillofacial Surgery (Vol. 53, pg. 584- 587). Biglio discusses the “Effect of Removing Impacted Third Molars on Plaque and Gingival Indices,” and reports findings that following the removal of the partially erupted third molars, the mean plaque index scores for symptomatic and asymptomatic groups improved significantly.

Based on the clinical findings of increased complications and pathological conditions in patients over 30, the AAOMS considers wisdom teeth removal an aspect of preventive dentistry. Waiting for impacted and unerupted teeth to cause pain or more serious problems often results in unnecessary complications and more costly treatment. Other indications for the removal of impacted third molars include:

Pericoronitis a condition that usually develops in young patients when third molars are not able to fully erupt due to lack of space. Complaints of pressure and soreness in the area are common.

Bone loss usually observed in older patients, occurs around the impacted third molars and the adjacent second molars. This condition is due to chronic infection or cyst enlargement associated with the third molars and has irreversibly affected the second molars. Early removal of third molars prevents these potential problems from occurring. 

Dental caries occurring in the third molars, as well as caries in the second molars resulting from the malposition of third molars, is a clear indication for third molar removal.
Crowded dental arch If this condition exists, the orthodontist may want third molars removed in conjunction with or following orthodontic therapy.

Cysts or tumors associated with impacted teeth often progress asymptomatically and are an obvious indication for third molar removal. Third molars associated with small cysts and radiolucencies should also be removed to avoid potential growth.

Radiation therapy Impacted teeth in the path of radiation therapy should be removed to avoid the possibility of delayed healing or the development of osteoradionecrosis.

Dental prosthesis Impacted teeth allowed to remain under a dental prosthesis can erode through the mucus and cause irritation.

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Avoiding Complications in the Removal of Wisdom Teeth
When patients with impacted wisdom teeth wait until symptoms appear before having them removed, the risk of complications is significantly increased. These complications include undue discomfort, prolonged recovery periods, damage to the bony support of the adjacent teeth and general health risks, as well as increased treatment costs.

The American Association of Oral and Maxillofacial Surgeons (AAOMS) considers timely removal of impacted and unerupted teeth to occur between the ages of 15 and 25, when the usual result of treatment is uncomplicated healing with no morbidity. While the risk of post-operative complications associated with wisdom teeth removal is quite low, the complication rate increases with the age of the patient. Patients over the age of 30 develop complications and pathological conditions with increasing frequency. Pathology, as a result of retention of impacted teeth, includes:

  • recurring infection
  • resorption of adjacent functional teeth
  • carious lesions of adjacent teeth
  • periodontal abnormalities
  • orthodontic abnormalities
  • weakening of the contiguous bone
  • development of numerous types of cysts and tumors

Based upon these findings, the AAOMS considers timely wisdom tooth removal an aspect of preventive dentistry. Also, most now consider wisdom teeth developmental anomalies, as 20-30 percent of the population are born without one or more wisdom teeth. Waiting for impacted and unerupted teeth to cause pain or complex clinical complications results only in more extensive and costly treatment.

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Increased Risks Associated with Long-Acting Anesthetics When Performing Nerve Blocks
There is an increasing trend where patients who have been treated with long-acting local anesthetics, such as marcaine and articaine, are incurring permanent numbness of the lower lip, chin or tongue.   While profound anesthesia can be obtained in a nerve block fashion, there is a dramatic increase in the probability of permanent numbness.  Remember that these are excellent local anesthetics but are best used in an infiltration type fashion, such as buccal infiltration or PDL type injection.  

Perhaps additional injections of shorter-duration anesthetic are justified considering the permanence of some nerve injuries.

Consider minimizing risk to your patients to include pre-operative administration of antibiotics in the case of teeth that are inflamed or infected or pre-operative oral anxiolytics in the presence of anxiety.   

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Sterilization and Patient Safety
In the last few years, infection control and asepsis have become an issue of public concern. With the discovery of the AIDS (HIV) virus and the continuing problem with the Hepatitis-B virus, it has become necessary for health care facilities to constantly upgrade the sterilization and disinfecting techniques of products.

We are committed to providing you with a safe environment, and frequently attend courses to learn about the latest updates for health care providers.
Your safety is our highest priority in our office; we perform a number of sterilization procedures for your protection throughout the day, including:

  • All treatment surfaces (countertops, chair surfaces, lights, x-ray machines, trays, etc.) are disinfected with the most effective and safest products available before and after each patient appointment.
  • We follow a number of standard sterilization procedures with all instruments. First, all instruments are brought back to our sterilization area and placed in an ultrasonic cleaner. Then the instruments are rinsed thoroughly before being sterilized in a, steam heat autoclave, which runs for various amounts of time and reaches a temperature of 270-275 degrees, thereby destroying any bacteria or viruses. All handpieces are sterilized in a state-of-the-art autoclave.
  • Our autoclaves (steam sterilizers) are monitored regularly to ensure their effectiveness and safety.
  • Team members use safety glasses and new masks and gloves for each patient.
  • All staff members are trained in proper infection control and asepsis and have been vaccinated against the Hepatitis-B virus.

As always, we will do everything possible to provide you with the highest quality of care while maximizing your protection. We want you to be well informed regarding procedures performed in our office and welcome any questions you may have.

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