June 22, 2016
Pulling teeth is a big step, and losing teeth is never an easy thing. Whether one tooth at a time or all at once, this step is physical, financial, AND emotional. The decision is final and often not made in a single day. This decision often takes time. That is ok. That is normal.
There are many reasons to remove teeth. Gum disease can destroy supporting bone. Tooth decay can lead to broken or painful teeth that can’t be restored. Trauma to teeth can lead to irreparable damage. If only one or two teeth are removed, a domino effect can take place that leads to loss of other teeth, sometimes leading to all remaining teeth being removed.
Initially people assume that removing one tooth at a time will save money. A few hundred dollars is less than a few thousand, right? In the grand scheme of things, the opposite is usually true. When a tooth is lost we should replace it. Often this is done with a flipper (a partial denture that replaces a single tooth). If more teeth are removed, teeth must be added to the flipper, creating a partial denture. This process repeats until the only remaining teeth will not support a partial and a complete denture is required. There is a fee for EACH step, and it adds up to a LOT of money.
Each time we are pulling teeth, it involves discomfort to SOME degree. While we can make a person numb (using the Wand and our special compounded topical gel makes this virtually painless) there is still the following days when the area heals. This can be tender and tedious to keep clean. If one has 28 teeth and decides to remove them one at a time, that is 28 “events” to manage. All at once may increase the effort level to clean and maintain, this step is usually brief. And then it is complete.
When we plan in advance to remove teeth, we can have a restoration created before the removal appointment. An immediate denture is used for the healing phase. A healing denture. This is often worn for 3-6 months, 3 months if dentures is the final phase of treatment and 6 months if implants are desired. The initial 3 months often involves relining the healing dentures on more than one occasion. While the tissues heal, they will shrink and the dentures will not fit as well, and a reline can help the fit. If more shrinkage, more reline.
At this point, we consider this “Phase Two”. Final restorations can be:
- Cosmetic Dentures
- Cosmetic Dentures with 2 locator implants for stability
- Cosmetic Dentures with 3 implants and bar and Marius Pin
- Deutsch Removable Bridge on 4+ implants
- All on Four with Hybrid
- All on Four with Prettau Zirconia bridge
- All on 6+ with Zirconia bridge
June 21, 2016
Wait Time to Restore Dental Implants
Must we WAIT to restore dental implants? The biggest challenge with dental implants is the waiting game. In an era of immediate gratification, dental implants do not fit well. Despite all the advances we have, our bodies ability to heal and healing time can not be altered (as of now. Who knows the future?). Even when offices and clinics state that they can do “teeth in a day” they merely mean a provisional, or prototype/temporary, is placed and the final restoration will be delivered later after everything heals.
Variation in Bone Density
Different parts of the jaw have different bone density. This is important because the density will contribute to the immediate AND long term stability. Lower front jaw bone is VERY dense, but upper back jawbone is very SOFT. Implants can be placed, but the methods are different. So is the delay in restoring.
General Rules of Thumb in Wait Time to Restore Dental Implants
Every person is different, but generally speaking, we have some rules of thumb that we follow when restoring implants:
Lower front teeth: 3 months
Lower back teeth: 5 months
Upper front teeth: 5 months
Upper back teeth: 6 months
The fancy term dentists use for “bone fusing to implants” is osseointegration. The root, os, means bone. So what we are saying is we need the bone and implant to integrate before we — USE them. If we disturb the process, then it simply fails and we must start over, but starting over ADDS to the process, so we start over “from behind”. This is another reason that we tell patients that dental implant treatment is a commitment of both money and TIME.
In some cases, we can “load” implants right away. Load means “use”, or load the implant fixture with stress and bite forces. Not ALL cases can do this, but if we CAN, it can save considerable amounts of time.
Types of Bone
Beyond what you WANT to know is the types of bone. You may hear the term cancellous and cortical when referring to bone. Cortical bone is VERY dense, so while sturdy is “good” it is also difficult to drill into for implant placement. The lower front jawbone is almost entirely cortical bone. Most bone is cancelleous or trabecular bone with an outer layer of cortical bone. This means it may be difficult at the start of implant placement but becomes easier to drill during the remainder of treatment. It also means that a sensation of pressure may be felt while the implant is placed due to compaction of bone to make it more like cortical bone (for stability). If the bone can’t be treated in a way to make implants more stable, then we allow more time to pass to get better osseointegration.
Dental Implant Surface Texture
As technology improves, we are learning that the surface of implants speeds things up. The quicker things bond, heal, and become more stable, the sooner we can finish the case. The current thought is to roughen the surface (not smooth, and after milling the thread design) and bathe in acid. This induces the body’s healing factors and leads to long term success.
May 17, 2016
Dental Implant Restoration Phases
Quite often, the BEST treatment is simply not appropriate RIGHT NOW. This can be due to a busy life, limited funds, fear of “lots of work at once”, and even a combination of these factors. Dental implant restoration phases breaks up treatment over time and can make it more affordable. The fee for dental implant treatment should be considered an INVESTMENT. This kind of treatment is not cheap, but since they last longer than most other dental treatment, it is usually considered cheaper in the long run. Nearly every form of implant treatment will exceed contributions from a dental benefit plan, so I do not encourage basing decisions on information from a dental plan. For whatever reason that YOU decide, it is the right decision for YOU.
Knowing the final goal from the beginning is important. Not only is width and length of implants a factor, but also the LOCATION. The location of implants will vary depending on the type of restoration they support, but can be different when planned. Implants to support a lower locator denture (“snap on“ denture) often are placed at the canine position (22 and 27 in the US). But an all-on-four procedure places the two front implants in the lateral/central area (23/24 and the 25/26 spots) since the other implants emerge from the tissues in the premolar region (20/21 or 28/29) or if enough bone exists, even in molar spots (19 or 30).
One important distinction: TYPE of dental implant. Mini implants are those that are narrower than 3.0 mm. Since they are so thin, they are normally solid and traditional abutments cannot be attached. These implants are normally used with a single intention, from a ball shaped top (secure O rings) to locator interface (snap on attachments), and are not currently approved for supporting crowns or bridges, despite many dentists using mini implants “off label”.
Dental Implants Are Hollow
It may be important to know the geometry of dental implants. Originally they were smooth, hollow cylinders with threads inside so things could be screwed in place after “osseointegration” (bone fusing to implant). This is similar to devices used in home improvement when attaching something to walls (hanging a picture or shelf). The device attaches to the wall, the decoration attaches to the device.
Mini implants are like a nail or wood screw; they are not hollow. This means that by design they rise above the bone, but can complicate things. With implants that allow an abutment to attach, the abutment can correct many problems with angulation or length, so if a mini doesn’t go perfectly, the entire thing must be removed/replaced.
(The take home message is that in most offices, mini implants are very limited. In offices that do NOT view them this way, they are legally correct, but acting off label and is outside Dr Timmerman’s current comfort zone).
Dental Implant Restoration Phases Plan for Future Care
If treatment will be in phases, then implants for the first phase CAN be placed in the lateral/central area. The function won’t be the SAME as if they were where they “should” be, but certainly adequate. To play it safe, the implants can be placed but not — USED until part of the final restoration. This would also be a significant savings due to lower lab fees.
Nearly ALL implant cases start out the same way and have dramatically different outcomes, so some decisions don’t need to be made until further down the process.
A “normal” progression may look something like this:
- All, many, or some teeth in a condition needing removal
- Removal of teeth, grafting of sockets
- Healing dentures placed
- Two implants placed for locator denture
- New denture with locator frame
- Two more implants
- New restoration (Hybrid denture that is screwed in place? Deutsch Removable Bridge?)
- More implants as needed/wanted
- Different restoration as needed/wanted
Sometimes we can overlap. An example is that at the time of extractions, implants may be placed. This saves time, but is not always an option. Or instead of two implants, four are placed. This eliminates the middle stages in the progression example above.
Every Case is Unique
Not every case is the same. Not every condition is the same. Each case is custom designed and usually discussed among colleagues to ensure the best possible outcome. This means that a “free consultation” is normally worth every penny, since most details that are of interest to most patients (Am I a candidate for dental implants? Will my case require extra surgery? How much will this cost?) can NOT be determined without a comprehensive and detailed exam. This requires not JUST the normal x-rays, but also CBCT (cone beam computed tomography) to look at the jaws in 3 dimensions, as well as photographs and sometimes impressions for study models. We DO offer free exams, but they usually lead to an exam, so we encourage simply starting with an exam.
March 14, 2016
It appears that there is confusion on what Snap on Smile IS and what it is used for. It should be stated that it is NOT an alternative to porcelain veneers or composite bonding, but it CAN be part of the process. So how does it work?
A prototype is an early mock up or design of something that will be done “correctly” later. A “rough draft” of sorts. In THIS case, it would be a way to preview how a smile could look without doing anything irreversible. However, if material is simply sitting on TOP of the other teeth, it is not a TRUE representation of the final product. It normally feels bulky or the edges can feel rough to the lips or tongue. Final restorations (porcelain veneers or other longer lasting options) do not feel this way and should not be judged on how a snap on smile feels.
This treatment is simply a tooth coloured device that fits over (maybe even snaps) existing teeth, made from a resin that can LOOK like teeth or a new smile, but is NOT durable enough to function (chew) for very long. This is NOT a long term option (unless only used from time to time, not daily).
One popular use is for social events. Since the material is NOT durable, it is only brought out for social events that do not include eating. This allows all the candid photos for Facebook that a person may desire and may afford some self esteem for certain situations. Over time, the material will break down, so investing over and over again may be necessary.
Some use Snap on Smile for a temporary restoration. Dental implant treatment is a common use, as it takes time for dental implants to heal or fuse to the bone (osseointegration). During this time, Snap on Smile can be used to fill in the spaces where teeth are missing, and when the final restoration is placed the Snap on Smile is then discarded.
Perhaps implying deception is a bit harsh. A quick google search will show that many people did not get what they thought they were getting, so clearly a lack of communication is common. The bottom line is that people need to know what they are getting. In the right situations, Snap on Smileis a great option. The investment, when done with a skilled dentist and a skilled lab, will not be small, but often the fee can be applied (all of it or part of it) towards definitive treatment.
March 11, 2016
Despite tooth structure being the hardest substance in the human body, teeth flex microscopically. The flex is so small that we cannot feel it. However, if a part of the tooth is removed, it can flex MORE. Even if the missing tooth structure is replaced with a filling, the flex still increases.
Over time, the flex can lead to cracks. Like Nancy Reagan said, say no to crack. Small cracks become big cracks, and big cracks lead to fractures. In some cases cracks and fractures involve the nerve of the tooth, which can kill it. Normally the pain in earlier stages will lead to treatment before the nerve is involved, but sometimes the first sign of a problem is the fractured and dead tooth.
To treat a tooth with Cracked Tooth Syndrome, the cracked part must be removed. If small, an onlay can be placed that covers a single cusp, but the most comon treatment is a full crown. More than just removing the cracked part, the crown directs the chewing forces inward, so any micro-cracks left behind are less likely to propagate.
We all want to be sure we don’t “cry wolf” when a tooth hurts. Many people try to ignore pain and assume it will just go away or get better. This usually doesn’t work and ends up costing more to fix the longer one waits.