1. Facial
Appearance and Restorative Dental Treatment
2. Cracked
Tooth Syndrome
3. Dental
Implants Placement with Computed Tomography (CT) Scan
4.
Restoring Congenitally Missing Teeth with Dental Implants
5. The
Goal of Modern Implant Dentistry
6.
Advantages of Implant Supported Teeth
7. Cracked
Tooth Syndrome/ CERAMIC or GOLD Inlay/Onlay
8.
Creating Smiles with Complete Dentures
9. Implant
Dentistry/Bone Expansion (long)
10.
Replacing a Failed Resin-Bonded Bridge with a Single Tooth Implant
11.
Implant-Supported Prostheses (Teeth) for Cleft Palate Patients
12.
Cosmetic Dentistry/Ceramic/Inlay/Onlay
13. Your
Bite - Why It's So Important to Your Dental Health
14. Tooth
Extraction with Immediate Implant Replacement
15.
Cosmetic Dentistry/Improving Color & Strength of Teeth
16.
Dental Implant/Dentures and Natural Appearance
17.
Dental Implants/Sinus Lift
18.
Dental Implants/Bone Regeneration/Nerve Repositioning
19.
Dental Implants/How Many?
20.
Dental Implants and Facial Appearance
21.
Cosmetic Dentistry/Ceramic VS PFM Crowns
22.
Comprehensive Implant Dentistry with Fixed Bridgework
23.
Dental Implants Provide Similar Function, Appearance, and Feel of Natural
Teeth.
24.
Implant Dentistry/One Appointment Subperiosteal Implant
25.
Dental Implants/Types of Subperiosteal Implants
26.
Dental Implants/ Bone Grafting/ The Healing Phase
27.Implant Dentistry/Types of Implants
28.
Implant dentistry with Cosmetic Improvement of Facial Appearance
29.
The Process of
Alveolar Distraction Osteogenesis
for improved implant placement
30.
Understanding How Your
Body’s Natural
Growth Factors, Platlet Rich
Plasma (PRP) can Help Accelerate
the Healing Process
31. Understanding Combination Syndrome and How to Correct This
Dental Problem
32.
Benefits of Conservative
and Cosmetic Periodontal & Restorative Dentistry
Article
#1
Facial Appearance and Restorative Dental Treatment
Q:
I have never been happy with the shape and
color of my teeth. What are my options?
A:
A prosthodontist treating a patient can do
much to improve the appearance and natural beauty of the face. The entire
lower half of the face depends on the where the teeth are positioned, as
well as their shape, form, surface texture and color. It is usually not
difficult on casual meeting to detect a person who has artificially
constructed crowns. A dark line at the gum tissue or bulky thick teeth
detracts from realism. The upper lip often appears lengthened and tense or
wrinkled in an attempt to conceal the anterior teeth. The result is the
appearance of premature aging which is caused not by age itself but by the
change of facial appearance from the soft tissue compensating for lack of an
aesthetic dental smile.
An approach to improved facial and tooth
appearance is with thin porcelain cosmetic veneers. This would be indicated
in cases where extensive wear or existing tooth position and/or fillings
would not be improved by home bleaching. Many times there might be
rotations that create shadows and these can be corrected by veneering the
teeth with porcelain to create a more symmetrical arrangement.
Whenever veneering is done, designing the final shapes of the teeth prior to
treatment is important.
Correcting tooth appearance with traditional
crowns involves more tooth reduction. These may be all porcelain that are
bonded to the teeth or porcelain that is fused to a metal substructure.
Since these crowns are often in the aesthetic zone, appearance is important.
The type of porcelain used can determine how real the color and appearance
is. The more sophisticated porcelain crowns use a multi-layering technique
and the color is built in. The simpler crowns might have only three layers
of color while the more cosmetic ones may have eight or more layers. The
margins or junction of the crowned teeth also might be made totally out of
porcelain and blend into the root without a dark line. Finally the artistic
skill of the dentist and technician determines the end result.
Since the laboratory plays such an important
roll in the treatment result, the closer the laboratory, such as an in
office dental laboratory, the better. The type of material used in building
the teeth as well as the skill of the technician are the final determinants
for the result.
Dr. Edward M. Amet, an American Board
Certified Prosthodontist and American Board Certified Implant Dentist,
provides comprehensive dental treatment. He founded the Reconstructive &
Implant Dental Center in 1988 and has been in practice for 30 years. He has
extensive training and experience in both the surgical and the prosthodontic
phases of implant therapy, with skilled and talented on site dental
technicians. These on staff dental technicians can make the prosthodontics
personalized for each patient. "Our goal, states Dr. Amet, is to provide our
patients with the finest quality of care, as comfortably and pain-free as
possible."
[Top]
Article
#2 Cracked
Tooth Syndrome
Q: I have many
posterior teeth that have existing large amalgam or plastic composite
fillings. Several of these teeth are now sensitive to biting pressure and
cold food or drinks, but there is no apparent decay. What could be the
problem and the solution to the discomfort?
A. Discomfort in
chewing is the most frequent symptom of a cracked tooth, with unexplained
sensitivity to cold experienced by the patient. The chief complaint is that
it hurts to bite on one or both sides of the mouth, but it may not be
apparent which tooth is involved or whether the pain is in the upper or
lower jaw. A cracked tooth should be suspected when pain is experienced when
chewing hard foods.
The dentist should be suspicious that a tooth
is cracked if no caries or sensitive cementum is found and the tooth
structure appears normal on the x-ray examination. These cracks occur in any
of the posterior teeth.
Unfortunately, most cracked posterior teeth
have been restored, often with silver amalgam or plastic composite
restorations. These obscure the cracks and necessitate the use of other
diagnostic procedures, including localized biting pressure,
transillumenation or stained with dye to locate the cracks.
The frequency with which mandibular molars
crack is an indication of the "nutcracked" effect of the jaws. The upper
molars wedge the lower molars apart, either by excessive force or biting
pressure such as ice chewing.
Treatment to prevent further cracking and
root canal therapy is a must. Cast gold inlay/onlay restorations are a
conservative way to treat teeth that have vertical fractures that may not
have had previously an amalgam filling in place. Gold inlay/onlay has been
available for more than one hundred and fifty years and restore teeth
without having to cut the entire tooth down for a full crown. Another
important feature is the cement used to secure the gold inlay/onlay to the
tooth. The use of resin modified glassionomer cement releases fluoride and
bonds to the tooth, is extremely strong, and helps prevent recurrent decay.
Another conservative treatment for cracked
teeth is with a very durable and esthetic restorative material, is a Leucite
reinforce pressed glass ceramic This is a type of ceramic material that not
only exhibits similar hardness to natural tooth structure, but also closely
resembles it's color. Another important feature is the method of cementation
of these restorations. They are actually bonded to the remaining tooth
structure. This results in the saving of existing tooth structure and can
also re-establish it's original strength and decrease tooth sensitivity.
[Top]
Article#3
Dental Implants/Placement with Computed
Tomography (CT)Scan
Q:
What type of radiographic (X-ray) evaluation is needed before dental implant
placement?
A:
The success of osseointegrated implants is
making implant dentistry a part of everyday dental practice. The increased
demand for dental implants has resulted in technology by the dental product
industry to improve and expand the currently available implant placement
planning options. This new technology has provided the capability for the
most accurate presurgical evaluation, easier surgical care, and more
aesthetic final restorations.
Traditionally, the clinical evaluation of the
implant patient is based on visual examination, manual palpation, gauging
tissue thickness, mounted diagnostic casts and traditional dental panoramic
x-rays. The analysis provides a tremendous amount of preoperative diagnostic
information on the available bone, it's location and the potential
prosthetic outcome. However, it was not uncommon to discover conditions at
the time of surgery that differed from what was anticipated based on the
diagnostic information obtained. For example, the bone may have been too
thin for implant placement or may not have been where it was necessary for
placement of usable prosthetic abutments and crown placement. The proper
alignment of abutments may not have been possible due to implant angulation.
When these situations occurred, it became necessary for the surgeon and the
restorative dentist to decide mid-surgery, where to place the implants. If
the restorative dentist was not present, this decision had to be made by the
surgeon who might or might not have been capable of deciding if the implant
could be restored.
Advanced computer technology has enabled this
type of decision making a problem of the past. Computed Tomography
(CT scans), aided by specially designed software has made it possible
to download the information from the optical disk of the CT scan, processed
at an imaging center, and then e-mailed to the PC (personal computer)
of the dentist surgically planning and placing them. With this capability, a
three dimensional view can be made instead of the normal two dimensional
dental x-ray. This allows better visualization and implant placement
planning prior to surgery. Using the special computer program, implants can
be placed, the bone height, thickness and density evaluated. This can be
done in the implant dentist's office without the patient needing to be
present and provides the capability for more accurate presurgical
evaluation, easier surgical care and more esthetic final restorations.
[Top]
Article
#4
Restoring congenitally missing teeth with
dental implants.
Q:
My daughter will be completing orthodontic
treatment soon and she has a congenitally missing permanent upper lateral
incisor. What are her options for replacing that missing tooth?
A:
The single edentulous space in a dental arch
allows for several restorative options. Conventional techniques include a
removable partial denture, a cemented fixed bridge and a resin-bonded fixed
bridge. Each of these options can be successfully used. However none of
these alternatives can actually replace the original tooth and the way it
emerges from the gingival tissue and it's ability to maintain the bone
height. A prosthetic tooth, supported by an endosteal implant, may be the
closest match to the natural tooth.
For a single missing tooth, the conventional
removable partial denture would be an option of last resort. It is bulky,
unesthetic, and can be difficult to wear. The three-unit fixed cemented
bridge is certainly a time-tested prosthetic treatment option. However, it
requires that adjacent teeth, often intact, be prepared as terminal
abutments. The acid-etched resin bonded bridge was first introduced as a
conservative approach to tooth replacement. Most resin-bonded bridges
involve nonrestored teeth, with minimal tooth preparations, to serve as
retention. This bridge often results in overcontoured attachments on the
lingual resulting in plaque traps. In a 10 year retrospective study, an
overall debonding rate of 31% occurred.
The implant-supported fixed prosthesis is an
excellent alternative to replace a missing tooth if there is adequate width
and height of remaining alveolar bone. Therefore, treatment planning for an
endosteal root form implant requires accurate planning, but can result in a
very realistic natural appearance that aides in maintaining bone height. The
ability to restore the fully edentulous mandible and maxilla through the use
of endosteal implants has expanded to include the partially edentate
population. Conventional dental treatment options such as the removable
partial denture, the three-unit fixed bridge and the resin-bonded retainer
may need to be reconsidered now that endosteal root form implants have been
proven effective. The prosthetic tooth, supported by an endosteal implant
emerges from the tissue attached to a "root" (the implant), in a manner
which more closely resembles the natural tooth it replaces than any other
treatment option available. In a clinical situation where there is adequate
bone and adjacent virgin teeth, the single tooth implant restoration can
certainly be considered as the primary treatment alternative.
[Top]
Article
#5
The Goal of Modern Implant Dentistry
Q:
What is the goal of modern implant dentistry?
A:
The goal of modern implant dentistry is to
return patients to oral health in a predictable fashion. The partially and
completely edentulous patient may be unable to recover normal function,
aesthetics, comfort or speech with traditional removable prosthesis.
The patient's function when wearing a
complete denture may be reduced to 25-40% of that formerly experienced with
the natural dentition. An implant prosthesis however, may return the
function to near normal limits. The esthetics of the edentulous patient are
also affected as a result of bone atrophy. The continued bone resorption
leads to irreversible facial changes. Endosteal implants stimulate bone in a
manner similar to healthy natural teeth to maintain bone size. As a result
of this bone maintenance, the facial features are not compromised by lack of
support. In addition, implant-supported restorations as compared to complete
dentures are positioned in relation to aesthetics, function, and speech, not
in the "neutral zones" of soft tissue support.
The soft tissues of the edentulous patients
are often tender from the effects of thinning mucosa, decreased saliva flow
and unstable or unretentive prostheses. The implant-retained restoration
does not require soft tissue support and improves oral comfort. Finally,
speech and function are compromised with removable prostheses, as it may
move as much as 10mm from the supporting lower jaw structure during use. The
tongue and perioral musculature are used to limit the movement of the
mandibular prosthesis thus interfering with mastication and speech. The
implant abutment prosthesis is stable and retentive without the efforts of
the musculature and therefore, offer more predictable function in
mastication and speech. Thus implant supported teeth offer a more
predictable treatment course than removable dentures. The dental profession
and public are becoming increasingly aware of this. Between 1983 and 1987
there was a four-fold increase in the number of implants placed. Since that
time or every four years, there has been a four-fold increase in the number
of implants placed
[Top]
Article
#6
Advantages of Implant Supported Teeth
Q:
If dental implants are used to provide
support for replacement teeth, what are the advantages compared to the use
of traditional removable complete dentures?
A:
The goal of modern implant dentistry is to
return patients to oral health in a predictable fashion. The partial and
completely edentulous patient may be unable to recover normal function,
aesthetics, or speech with traditional removable dentures.
The patient's function when wearing a denture
may be reduced to 25-40% of that formerly experienced with natural teeth.
Implant supported teeth may return the function to near normal limits. The
aesthetics of the edentulous patient are also affected as a result of bone
loss and atrophy. This continued resorption leads to irreversible facial
changes. An implant stimulates the bone and maintains its dimension in a
manner similar to healthy natural teeth. As a result, the facial features
are not compromised by lack of support. In addition, implant supported
restorations are positioned in relation to aesthetics, function, and speech,
not in the "neutral zones" of soft tissue support.
The soft tissues of the edentulous patients
are tender from the effects of thinning mucosa, decreased salivary flow, and
unstable or unretentive dentures. The implant-retained restoration does not
require soft tissue support, and improves oral comfort. Speech and function
are compromised with lower dentures, which may move l0mm from the supporting
structure during use. The tongue and perioral musculature may be compromised
to limit the movement of the mandibular denture. The implant abutment teeth
are stable and retentive without the efforts of the musculature.
Implant supported teeth offer a more
predictable treatment course than removable dentures. The dental profession
and public are becoming increasingly aware of this. Among 1983 and 1987
there was a four-fold increase in the number of implants placed.
[Top]
Article
#7
Cracked Tooth Syndrome/CERAMIC or GOLD Inlay/Onlay
Q: I have many
posterior teeth that have existing large silver amalgam fillings. Several of
these teeth are now sensitive to biting pressure and cold food or drinks,
but there was no apparent decay at my last dental examination. What could be
the problem and the solution to the discomfort?
A:
Discomfort in chewing is the most frequent
symptom of a cracked tooth, with unexplained sensitivity to cold experienced
by the patient. The chief complaint is that it hurts to bite on one side of
the mouth, but it may not be apparent which tooth is involved or whether the
pain is in the upper or lower teeth. A cracked tooth should be suspected
when pain is experienced when chewing tough foods.
The dentist should be suspicious that a tooth
is cracked if no caries or sensitive cementum is found and the tooth
structure appears normal on the x-ray examination. Cracks occur most
frequently in lower molar teeth, but may occur in any of the posterior
teeth.
Most posterior teeth that develop vertical
fractures or cracks, have been restored, with silver amalgam. This material
often obscures the underlying vertical fracture, necessitating the use of
other diagnostic procedures for detection, including localized biting
pressure and transillumenation. The teeth can also be stained with a dye to
locate cracks.
The frequency with which mandibular molars crack
is an indication of the "nutcracker" effect of the jaws. The upper molars wedge
the cusps of the lower molars apart, either from excessive clenching forces or
constant trauma from bruxing and ice chewing.
There is a direct relationship between the
size of an amalgam restoration and the number of teeth cracked. The more
extensive and deeper the restoration, the less tooth remaining to support
the load.
Treatment to prevent further cracking is a
must. Today very durable and aesthetic restorative materials are
available as well traditional cast gold restorations. The types of
ceramic materials available not only exhibit similar hardness as natural
tooth structure, but also closely resembles its color. Another
important feature is the method of cementation of these restorations.
They are bonded to the remaining tooth structure. This results in
reestablish of the original tooth strength with less removal of existing
tooth structure and also with decreased tooth sensitivity.
Traditional cast gold restoration if well done will often last 35-40 years.
[Top]
Article
#8
Creating Smiles with Complete Dentures
Q: I have never
been happy with my complete dentures for eating or my facial appearance.
What are my options?
A: The success of
facial appearance and prosthetic dental treatment is directly related
to good treatment planning. The prosthodontist treating a patient can
do much to improve the appearance and natural beauty of the face as well as
the ability of the patient to eat.
The entire lower half of the face depends on
where the teeth are positioned, as well as their shape, form, surface
texture and color. It is usually not difficult on casual meeting to detect a
person who has artificially constructed teeth or completed dentures.
Small evenly set denture teeth detract from realism. The upper lip
often appears lengthened and tense or wrinkled in an attempt to conceal the
anterior teeth which may be set too far posterior in the mouth. The result
is the appearance of premature aging which is caused not by age itself but
by the change of facial appearance from the chin and nose seemingly so close
together and the soft tissue compensating for this incorrect distance
between these parts of the face. The result is the lack of an aesthetic
dental smile with premature aging.
The goal of modern dentistry is to achieve
integration of dental implants and restorative treatment which replaces a
missing tooth or teeth and lost supporting structures, as well as to restore
proper aesthetics and function. In order to achieve this goal, it is
necessary for the patient and dentist to be able to visualize the final
prosthetic results, prior to surgical treatment. Therefore it is essential
for the dentist to have a thorough understanding of all phases of treatment
in order to diagnose, treatment plan and restore natural appearance.
Since the dental laboratory plays such an
important roll in treatment, having an in office laboratory is desirable to
achieve the final aesthetic and functional result. Finally the artistic
skill of the dentist and technician determines the end result.
Dr. Edward M. Amet, an American Board
Certified Prosthodontist and American Board Certified Implant Dentist,
provides comprehensive dental treatment. He founded the Reconstructive &
Implant Dental Center in 1988 and the Reconstructive & Implant Dental
Laboratory in 1994 and has been in practice for 33 years. He has extensive
training and experience in both the surgical and prosthodontic phases of
prosthodontic and implant therapy, with skilled and talented on site dental
technicians. The selection of the most ideal tooth shape and size as well
as the arrangement for the patient is done by Dr. Amet.
This can make the prosthetics personalized for each patient. "Our goal,
states Dr. Amet, is to provide our patients with the finest quality of care
as comfortably and pain-free as possible."
[Top]
Article
#9
Bone Grafting for Dental Implant Placement
Q: I have been
advised that I need extensive bone grafting for dental
implant placement. Are there alternatives to this procedure that would allow
implant placement and not compromise the result?
A:
The standard method of preparing a bone site
(the osteotomy) to receive an endosteal
dental implant involves the removal of bone with a
graded series of drills of increasing sizes. The largest drill in the series
approximates the length and diameter of the implant to be inserted. In areas
where there is adequate bone of good quality, a careful surgical technique
with a drill can produce consistent results.
In the lower jaw (mandible), Branemark
classification type I and II bone predominates. In this area, drilling is
the practical and convenient means of placing implants. A dense outer layer
of bone is generally available for the initial fixation of the implant.
Often the implant can be placed to take advantage of one or both the inner
and outer cortical bone plates. Placing implants in the upper jaw (maxilla)
presents a different set of surgical problems compared to the mandible. In
the maxilla, the bone is generally type III or IV. The hard outer layer of
bone is thin or entirely absent. Resorption and prominent sinuses often
limit the number of good sites available for a routine placement. Spiny
ridge areas, too narrow in width for drilling, are common.
The quality of maxillary bone can be
extremely variable in a single location. It is likely that a maxilla will
contain voids, fatty marrow and fibrous inclusions. The resorbed maxilla is
generally undercut in shape so that the surgeon is forced to place implants
with a flared inclination toward the lip. The arch form results in more
steep emergence angulations and complex abutment needs. Because of the
problems of drilling in the maxilla, this author prefers a means of
osteotomy preparation in which the bone is not removed. This method is
called the "bone expansion technique". The objective of this technique is to
maintain, if possible, all of the existing maxillary bone by pushing the
bone aside with minimal trauma while developing an accurately shaped
osteotomy. The bone expansion technique attempts to retain all of the bone
that is present and to take advantage of the softer bone quality by
relocating the bone to suit the needs of the surgery. This potential
compacting of bone helps to maintain fixation of the newly placed implants.
In contrast to drilling, the bone expansion
technique improves maxillary anatomy by widening the ridge as the
instruments are inserted. The instruments, developed by the author, are
shaped so that the next larger instrument tip fits into the opening created
by the previous instrument. The inner and outer bone is pushed or expanded
laterally from the opening of the implant site development with successive
penetrations of the larger instruments. In a narrow ridge, expansion of the
bone at the site is an inherent beneficial characteristic of this technique.
The author has used the bone expansion technique in the maxilla or upper
jaw, since 1992, with consistently excellent results. Drilling does not
improve local anatomy or bone quality. This technique allows a simple means
to expand the ridge, deepen sites, create more usable sites and improve bone
quality. The bone expansion technique is heatless and offers excellent
tactile sensitivity, control and visibility. Torque from the handpiece is
nonexistent and access is as good or better than drills, in the posterior
maxilla.
The bone expansion technique is a useful and
predictable procedure for implant placement in soft maxillary bone. This
technique improves the chances of placing implants throughout the maxilla,
especially around the sinus and in the tuberosity as a routine office
procedure. The bone expansion technique is gentle, does not generate heat
and takes advantage of available bone by relocating it in a variety of
surgical applications. For many patients, the bone expansion technique can
help simplify implant surgery by reducing the need for more traumatic,
time-consuming and costly grafting procedures.
[Top]
Article
#10
Replacing a Failed Resin-Bonded bridge with a
Single Tooth Implant.
Q:
I have a resin-bonded or "Maryland" bridge
that periodically needs to be recemented. I am concerned with developing
decay under it. I do not want my teeth next to the space ground down for
bridge work, would a dental implant be possible?
A: The single
edentulous space in a dental arch allows for several restorative options.
Conventional techniques include a removable partial denture, a cemented
fixed bridge and a resin-bonded fixed bridge. Each of these options can be
successfully used. However, none of these alternatives can actually replace
the original tooth, the way it emerges from the gingival tissue and its
ability to maintain the bone height. A prosthetic tooth, supported by an
endosteal implant, may be the closest match to the natural tooth.
For a single missing tooth, the conventional
removable partial denture would be an option of last resort. It is bulky,
unesthetic and can be difficult to wear. The three-unit fixed cemented
bridge is certainly a time-tested prosthetic treatment option. However, it
requires that adjacent teeth, often intact, be prepared as terminal
abutments. The acid-etched resin bonded bridge was first introduced as a
conservative approach to tooth replacement. Most resin-bonded bridges
involve nonrestored teeth, with minimal tooth preparations, to serve as
retention. This bridge often results in overcontoured attachments on the
lingual resulting in plaque traps. In a 10-year retrospective study, an
overall debonding ( falling-off ) rate of 31% occurred.
The implant-supported crown is an excellent
alternative to replace a missing tooth if there is adequate width and height
of remaining alveolar bone. Therefore, treatment planning for an endosteal
root form implant requires accurate planning, but can result in a very
realistic natural appearing result that aides in maintaining bone height.
The ability to restore the fully edentulous
mandible and maxilla through the use of endosteal implants has expanded to
include the partially edentulous population. Conventional dental treatment
options such as the removable partial denture, the three-unit fixed bridge
and the resin-bonded retainer may need to be reconsidered now that endosteal
root form implants have been proven effective. The prosthetic tooth,
supported by an endosteal implant emerges from the tissue attached to a
"root" (the implant), in a manner which closely resembles the natural tooth
it replaces. In a clinical situation where there is adequate bone and
adjacent virgin teeth, the single tooth implant restoration can certainly be
considered as the primary treatment alternative.
[Top]
Article
#11
Implant-supported Prosthesis (Teeth) for
Cleft Palate Patients
Q:
I have difficulty with my complete upper
denture staying in position as I have a cleft palate. Can dental implants be
used to help make this more secure?
A: Adult patients
with cleft palates often have an upper jaw with deficient bone and soft
tissue irregularities. Surgically altered cleft palates are often associated
with deformities of the upper jaw or maxilla. The dental and periodontal
status in these adult patients are commonly in a compromised state from
providing long-term support and retention for prostheses (teeth) that aid in
speech. Oropharyngeal rehabilitation of adult patients with cleft palate can
be a perplexing clinical situation.
Most adult patients with cleft palates who
have undergone numerous surgical procedures for closure of alveolar palatal,
or pharyngeal defects, have large areas of scar tissue present. Scar tissue
is less resilient and more difficult to border mold and this inhibits
formation of an acceptable denture border seal. The palatal vault often
contains numerous scar bands, is flat and extends no higher than the back of
the residual alveolus with little underlying bone. These tissue
characteristics and anatomic irregularities make fabrication of an
acceptably stable and retentive prosthesis difficult.
Prosthetic evaluation involves an analysis to
determine, the type of restoration that is required, which may be a fixed or
removable partial or complete denture with or without a pharyngeal
extension. The aim of this prosthesis is to improve speech, deglutition,
mastication and esthetics. To achieve these goals, the prosthesis must have
adequate retention and stability, provide appropriate functions and be
hygienically maintainable by the patient.
Titanium self-tapping implants can
successfully achieve osseointegration in the maxillary alveolus and
pterygoid plates of the patient with a cleft palate. The use of implants can
provide adequate retention and stability for the prosthetic restoration of
oropharyngeal structures, thus improving speech, deglutition, mastication
and esthetics.
[Top]
Article
#12
Cosmetic Dentistry/Ceramic or Gold /Inlay/Onlay
Q:
I have many posterior teeth that need
existing silver amalgam fillings replaced and would like to have my teeth
restored with natural appearing fillings without them being completely cut
down for porcelain type crowns. What are my options for cosmetic dentistry?
A. For many years
dentistry has tried to create restorative materials which resemble natural
tooth structure both in color and hardness. Many materials have been
developed and tried over the past one hundred years yet few, if any, have
met all the requirements needed for filling type restorations in the
posterior region of the mouth. Gold restorations are long lasting and silver
restorations are less expensive, yet neither meet the esthetic
considerations requested by many patients. Composite or plastic restorations
are very esthetic but tend to wear down. Previous porcelain inlays were
esthetic and wear resistant but are prone to fracturing.
Today, a very durable and esthetic ceramic
reinforced leucite restorative material, is now available. This is a type of
ceramic material that not only exhibits similar hardness to natural tooth
structure but also closely resembles its color. Another important feature is
the method of cementation of these restorations. They are actually bonded to
the remaining tooth structure. This results in the saving of existing tooth
structure and can also re-establish its original strength and decrease tooth
sensitivity.
Today, conventional impressions, temporary
filings and multiple appointment visits can be a thing of the past. The
CEREC system by the Siemen's Corporation allows us to provide the highest
quality esthetic restorations in a single appointment visit. A revolutionary
CAD/CAM, computer aided design/computer aided milling, procedure replaces
the conventional laboratory fabrications of the restoration. Through an
optical scanning procedure, which takes a few minutes, the computer provides
all the information necessary for the CAD/CAM machine to make the CEREC
restoration from a block of high quality ceramic material. The result is an
esthetic high quality ceramic restoration with no conventional impressions
or multiple appointment visits. It also allows more of the tooth to remain
intact by bonding the restoration which also strengthens the tooth. Finally,
this restoration usually has less cost to the patient than traditional
crowns.
[Top]
Article
#13
Your Bite--Why It’s Important to your
Dental Health
Q:
Since I have had crown and bridge work
completed on my upper front eight teeth, my bite feels strange. My dentist
has adjusted my bite but that has not made a difference. There is no pain
when I bite and none of the teeth have a problem. My jaw muscles feel tight
and a space has been created between two of my back teeth. What should be
done?
A:
Like your blood pressure, your bite can
change as you grow older or as a result of wear disease or extensive dental
restorative treatment. The way your teeth come together, your occlusion or
bite, is one of the most important aspects of your oral health. Improper
occlusion, which may include excessive tooth forces, damaging sliding
contacts or contacts which interfere with your ideal bite, can result in
serious dental problems, such as open contacts, 1ike you have developed
between your back teeth. Dentists have always been aware of the dangers that
poor occlusion can have:
* Early failure or discomfort in fillings,
crowns, bridges, implants, or dentures.
* Aggravation of periodontal conditions which
lead to tooth loss.
* TMD syndrome - a painful joint or muscular
disorder of the face and neck.
* Excessive tooth wear.
Identifying and measuring bite problems can
be difficult. Your occlusion is dynamic. It changes because of wear, stress,
fatigue and other factors. Some changes in your bite may be symptoms of
problems that are much better treated sooner rather than later.
Evaluating the occlusion or bite is done by
analyzing diagnostic casts made from dental impressions that have been
mounted on an articulating instrument, with traditional marking paper that
leaves a spot on the teeth where they bite into it, and now, with a computed
diagnostic instrument. Through the use of this new computed diagnostic
instrument, the T-Scan, your dentist can evaluate your bite more easily and
more precisely, and make occlusal corrections and establish harmony. The
T-Scan works with a thin plastic sensor that you bite on. The sensor sends a
movie of your occlusion to a color video screen. Both you and your dentist
can view the movie and discuss your bite.
[Top]
Article
#14 Tooth
Extraction with Implant Replacement
Q.
I am a young woman in my early 30's and am thinking about having a front tooth
that has a failing root canal replaced with a dental implant. Since it is in
front I am very concerned with the appearance. Can you help me with the type of
implant procedure to be used?
A.
The type of implant procedure with an
endosteal root form implant is important along with the newer tapered implant
shapes. The surgical procedure can vary from a one stage one appointment
with the healing abutment placed through the soft tissue at the time of
placement, to considerations for infection and need for bone grafting. There is
also a simple procedure to expand bone with instruments called osteotomes,
and eliminate the time and cost needed for grafting if done as a separate
procedure. The amount and height of the bone is essential for good aesthetics
with the final restoration or crown.
The
implant is allowed to heal in the bone for a period of 0-6 months and
become integrated, or securely attached to the bone. The newer generation of
implants are more secure at time of placement and can be restored more rapidly
that the older generation implant of straight design.
Since the front tooth is failing from an old root canal, when it is removed a
bone graft may be needed to rebuild the ridge and restore the "gum tissue" or
soft tissue for correct contour of the prosthetic tooth or crown. This bone
grafting procedure is called a ridge augmentation. When there has been acute or
chronic infection, such as a failing root canal, there may be bone loss that
needs to be regenerated before the implant is placed. If possible the graft is
completed at the time of implant placement. If a graft is completed, the
position of the implant and the resulting soft tissue will create a natural
appearance for the crown. Careful planning is necessary for the best result
along with the prosthetics or laboratory support. It is the prosthetics or
laboratory work, which is finally seen by the patient, and although the crown or
teeth are really separate from the surgical implant work they are very related
to the health of the tissue and the final aesthetics.
Since the laboratory plays such an important roll in the final result the closer
the laboratory is, such as an in office dental laboratory, the better. The type
of material used in building the teeth as well as the skill of the technician is
the final determinants for the result. The appearance of the crown or realism
will be greatly influenced by the type of porcelain that it is made with. An in
office laboratory can work with the more sophisticated and esthetic porcelains
and the quality can be excellent.
[Top]
Article #15
Cosmetic Dentistry/Improving Color &
Strength of Teeth
Q.
I am approaching middle age and have never been
happy with the color of my teeth. What are my options?
A.
The most conservative approach is the home
bleaching systems provided by a dental offices. These usually consist of custom
trays that have been designed to hold the home bleaching gel, a 10-20% carbamine
peroxide, in intimate contact with the teeth for an hour or more at a time. This
procedure is often done at night, while sleeping, for 5-10nights. The amount of
lightening of the teeth is dependent on the length of time the bleaching agent
is used, its concentration and the repeated daily application. The safety of the
system has been reported to have no damage to the teeth and only an occasional
tooth sensitivity that is very transient. The lighter color of the teeth tends
to remain but some return to original color after a number of months. This can
be reversed by a reapplication of the bleaching solution. Another approach is to
have a one visit power bleaching at the office.
Another approach to improved tooth appearance is
with thin porcelain cosmetic veneers. This would be indicated in cases where
extensive wear or existing tooth position and/or fillings would not be improved
by home bleaching. Many times there might be rotations that create shadows and
these can be corrected also by veneering the teeth with porcelain to create a
more symmetrical arrangement. Whenever veneering is done, designing the final
shapes of the teeth for treatment is important. This is usually done by a
diagnostic wax-up and/or with cosmetic imaging. The wax-up helps the technician
who is going to make the veneers and the cosmetic imaging allows the patient to
visualize the results at chairside in color on a T.V. screen prior to their
fabrication. The wax-up also helps the doctor as the teeth need to be reduced on
the front surface about the thickness of a fingernail to allow room for the
porcelain veneers. These then are bonded on to the teeth and are very strong.
The final approach to lightening and correcting
tooth appearance would be with traditional crowns which involves more tooth
reduction. These may be all porcelain that are bonded onto the teeth or
porcelain that is fused to a metal substructure Since these crowns are often in
the aesthetic zone, appearance is important. The type of porcelain used can
determine how real the color is. The more sophisticated porcelain crowns use a
multi-layering technique and the color is built in. The simpler crowns might
have only three layers of color while the more cosmetic ones may have eight or
more layers. The margins or junction of the crowned teeth also might be made
totally out of porcelain and blend into the root without a dark line. Finally
the artistic skill of the dentist and technician determines the end result.
Usually these cases are preplanned with a wax-up and imagery before being
started when the highest cosmetic result is desired. These are then either
bonded or cemented on and are very strong.
The type of material used in building the teeth
as well as the skill of the technician are the final determinants for the
result. The appearance of the crown or realism will be greatly influenced by the
type of porcelain that it is made with. An in-office laboratory can work with
the more sophisticated and aesthetic porcelains and the quality can be
excellent.
[Top]
Article
#16
Dental Implant/Dentures and Natural
Appearance
Q.
Why do dentures often look like false teeth?
A. The
prosthodontist treating a patient with missing teeth has much to do with
natural appearance and facial expression. The appearance of the entire lower
half of the face depends on the teeth and their supporting structures. It is
usually not difficult on casual meeting to detect a person who is wearing
poorly constructed dentures. The characteristic thin drooping upper lip that
appears lengthened and has a reduced red vermilion border is typical of
malposition anterior teeth as well as reduced vertical dimension between the
chin and nose. Tense wrinkled lips often reveal the persons efforts to hold
the dentures in place. The drooping corners of the mouth tell the story of
the misshape and misplaced dental arch form of the anterior teeth, the thin
denture borders and often reduced vertical facial dimension.
The result is the appearance of premature
aging which is caused not by age itself but by the lack of support for the
lips and cheeks due to the loss or improper placement of teeth. The apparent
extra fullness of the lower lip may be the result of too broad a lower
dental arch or the elimination of the natural groove below the lower lip,
the mentolabial sulcus. This may indicate that the lower anterior teeth have
been placed too far toward the tongue or that the lower denture flange is
over extended or too thick.
It is also not uncommon for the treating
prosthodontist to find that the laboratory denture set-up has resulted in
very small perfectly set teeth that have been placed to far above or below
the lips thus giving the patient a false unnatural appearance. By the
Prosthodontist arranging the denture set-up him self, this can be prevented.
An implant stimulates the bone and maintains
its dimension and density in a manner similar to healthy natural teeth. As a
result, the patient's facial features are not compromised by lack of
proper support. In addition, implant-supported prostheses are
positioned in relation to aesthetics, function, and speech, not in "neutral
zones" of soft tissue support.
If you have dentures and feel that your
appearance could be improved, many times by stabilizing the denture base
with dental implants and focusing on individualized tooth setups, a more
natural appearance can be achieved. Having on staff dental technicians aids
in personalized care.
[Top]
Article #17
Dental Implants and Maxillary Sinus Lift
Q:
I have been wearing a removable partial denture to replace my upper molar teeth
for many years. Can I have implants placed in that area?
A:
One of dentistry’s goals is to make implant treatment available to all patients
who may benefit from it. Unfortunately, the advanced bone loss that accompanies
long term wearing of upper complete denture or upper removable partial denture
renders these same patients poor candidates for dental implant treatment.
The
patient with advanced bone loss in the posterior upper jaw poses serious
challenges for implant therapy. Generally, the type of bone available in the
upper jaw is spongy bone with its large spaces and non-dense, soft nature. This
is not the quality of bone suited for dental implant therapy. Another factor
influencing dental implant treatment in the upper jaw is with the lost of upper
posterior teeth, enlargement of the sinuses occurs with encroaches on what
little bone that remains. Successful implant therapy in the maxillary jaw is
dramatically reduced if poor bone quality is combined with a lack of sufficient
bone height and density. Management of these conditions is accomplished with the
use of larger or wider and longer implants with a boiactive coating and sinus
grafting.
Subantral augmentation or sinus grafting is a way to improve results in the
severely resorbed posterior upper jaw. By increasing bone in the sinus region,
the subantral augmentation enables the practitioner to use larger and longer
implants that are indicated in the posterior region to replace molars to
withstand the biting forces exerted there. Sinus augmentation should be
considered whenever a lack of alveolar bone height prevents the use of implants
of 10mm in length. Ridge augmentation and/or bone expansion is also advisable if
the alveolar bone width is less than 4mm.
[Top]
Article #18
Dental Implants/Bone Regeneration/Nerve
Repositioning
Q:
If inadequate bone is present to support dental
implants, what are the available options for patients needing dental
implants?
A:
Many times patients will be missing teeth in
the posterior region of the jaws and because they have been missing for a
number of years, the bone has resorbed and there is inadequate support for
dental implants. In the posterior region of the upper jaw, the bone resorbs
and the maxillary sinus enlarges eliminating the bone needed to hold the
dental implants. This has been managed for many years by performing a
procedure called a sinus lift with subantral augmentation. A window is made
into the maxillary sinus and the area is bone grafted. Dental implants may
be placed at the same time. The bone can be taken from the patient's hip,
however, the results from using bone from bone banks has proven as effective
and easier for the patient. This bone has been sterilized and is very safe.
When
there is inadequate bone in the front or anterior of either jaw, then the area
is grafted again using banked bone and a technique with a "barrier" that helps
the body regenerate bone. This has been done for more than 20 years and is very
predictable as well as very safe. If the area is extremely deficient in bone
volume, then bone from the patient may need to be transferred from one part of
the mouth or head and secured to the area with bone screws.
In
the posterior region of the lower jaw, it may be possible to use any of the
grafting procedures used in the anterior region of the jaws, but there still may
be insufficient room to place dental implants. If the root form type are used,
then the nerve is repositioned to allow the full thickness of the jaw bone for
the implant. There is always a risk of numbness if this is done, but this
procedure has been documented in literature since the late sixty's and has been
very effective.
[Top]
Article #19
Dental Implants/How Many for a Lower Jaw?
Q.
After wearing complete dentures for many years, I find that my lower jaw no
longer has an adequate ridge to support a complete lower denture. I have been
told that two root form implants could be used but four or five would be better.
Would you please explain the difference? I also have a fear of dental
procedures.
A.
Most people that have been wearing
complete dentures for 10 to 15 years will have a greatly reduced foundation for
the lower denture. Usually for these people, implants can only be placed in the
anterior region of the lower jaw. If only two implants are placed, then the
lower teeth will only be supported in the front and not in the rear where most
of the normal chewing takes place. This results in movement of the lower
denture, food collecting under the teeth with discomfort, as when a raspberry or
tomato seed is lodge under a lower denture.
However, when four or five implants are placed in the anterior lower jaw region,
then the total weight of the biting forced can be directed down through the
implants to the bone and the teeth will feel solid like natural teeth. This
physiological bone loading promotes spontaneous bone regeneration in the areas
of advanced bone loss of the mandible resulting in greater bone strength. An
implant-connecting bar is used to support the teeth and connects the implants
together, which strengthens the system. The teeth resting on the
implant-connecting bar will have total support and stability, which prevents
them from moving and the teeth from pressing into the gun tissue when eating.
Food cannot get under the teeth and cause discomfort. The comfort and
satisfaction in having stable lower teeth is extremely rewarding to the receipt.
Another major implant benefit is that
now the prosthodontist can set the teeth and positioned them where they belong
and thus the appearance becomes very natural.
For
any patient having a surgical procedure done, the comfort in having monitored
I.V. sedation with medications to eliminate post-operative swelling and
resulting pain is the standard of care. Patients are always surprised at how
little post-operative swelling and discomfort they have and how little they
remember of the procedure.
[Top]
.
Article #20
Dental Implants and Facial
(Aesthetics) Appearance
Q.
At age 79, I find that my lower denture makes eating difficult and none of the
five sets of dentures that have been made over the years, seem to make my face
appear natural. Will having dental implants placed help in restoring a more
normal facial appearance?
A.
The prosthodontist treating a
patient with dental implants has much to do with the beauty of the face as any
other medical specialist. The appearance of the entire lower half of the face
depends on where the teeth are positioned. It is usually not difficult on casual
meeting to detect a person who is wearing poorly constructed dentures. The
characteristic thin drooping upper lip that appears lengthened and has a reduced
red vermilion border is typical of malposition anterior teeth and a reduced
vertical facial height. Tense wrinkled lips often reveal the person’s efforts to
hold the dentures in place. The drooping corners of the mouth tell the story of
the misshaped and misplaced dental arch form of the anterior teeth, the thin
denture borders and often reduced vertical facial height. The result is the
appearance of premature aging which is caused not by age itself but by the lack
of support for the lips and cheeks due to the loss or improper placement of
teeth. The apparent extra fullness of the lower lip may be the result of too
broad a lower dental arch or the elimination of the natural groove below the
lower lip, the mentolabial sulcus. This may indicate that the lower anterior
teeth have been placed too far toward the tongue or that the lower denture
flange is over extended or too thick.
One
must study normal facial landmarks before attempting to achieve the goal of
natural and pleasing facial expressions with implant teeth. The facial landmarks
of the lower third of the face have a direct relationship to the presence of the
natural teeth. The contours of the lips depend on their intrinsic structure and
support for them provided by the teeth and soft tissue or denture bases behind
them. When the natural teeth are lost, these landmarks and surrounding facial
tissues become distorted. To reestablish normal appearance and function, implant
teeth must be replaced in the same position as the natural teeth that were lost.
You may have dentures and feel that your appearance needs be improved.
This can be done by stabilizing the denture base
with dental implants and the prosthodontist focusing on a personalized denture
setup resulting in a natural appearance.
Since the laboratory plays such an important roll in the final result, having
the laboratory in office and the prosthodontist complete the set-up, results are
a natural appearance. The type of material used in the teeth as well as the
skills of the prosthodontist are the final determinants for success.
[Top]
Article
#21
Cosmetic Dentistry/Ceramic vs PFM Crowns
Q: Currently, I
have porcelain-fused-to-metal crowns that have dark areas around them at the
gum line. Will the new crowns being placed in the front of my mouth have
this same result long term or can this be eliminated?
A:
Porcelain-fused-to-metal crowns have become the most popular crowns in
dentistry. Their acceptance began in the late 1950’s, culminating in their
current widespread use. Practitioners also know that gold crowns provide
greater longevity with less wear of opposing teeth than PFM crowns. Today,
all-ceramic crowns have higher esthetic possibilities without metal to
stimulate metal allergies.
PFM crowns may have a chalky, opaque and/or
gray appearance. Because of previous experience with soft tissue recession
and display of metal, patients may ask if their new crowns will have a gray
black portion at the gumline. But this negative appearance is not necessary
if dentists have prepared teeth properly and if PFM crowns are constructed
properly by technicians. In my opinion, after 33 years as a dentist and from
observing tens of thousands of crowns, most PFM crowns can be discerned
easily from natural teeth by an untrained observer.
The primary reasons for unacceptable
esthetics include:
*an inadequate amount of tooth reduction by dentists, which lets opaque
porcelain and metal show;
*technicians' use of external coloration
techniques instead of internal pigmentation, which allows crown colors
to change after a few years of exposure to mouth conditions and
dissolution of the external coloration.
If practitioners plan to provide PFM crowns
that look like real teeth, they will be willing to pay higher than average
laboratory fees and provide excellent well-reduced tooth preparations for
technicians. Do ceramic (non-metal containing) crowns have better appearance
than PFM crowns? Well-controlled, documented research is not available, but
surveys and studies have reported on the relative esthetic acceptability of
porcelain veneers to PFM crowns. Porcelain veneers are overwhelmingly
considered to have better esthetic acceptability than PFM crowns. Several
conservative types of ceramic crowns are really large versions of porcelain
veneers.
It's easy to see that their esthetic
characteristics are better than typical PFM crowns, without regard to
practitioner or technician. Although both PFM and all-ceramic crowns can
have excellent esthetics, all-ceramic crowns, as placed in the United States
today, are usually better in appearance.
[Top]
Article #22
Comprehensive Implant Dentistry with Fixed
Bridgework
Q: I have worn an
upper denture with a lower removable partial for 5 years and would like to
have implants with teeth that are not removable. Would this be possible?
Presently I have five lower front teeth.
A. If the five
lower teeth have good bone support and good tooth position, then this would
be an advantage as they would help determine where the remaining teeth
should be positioned for appearance, speech and function. The first step
would be a screening panoramic x-ray and mounted diagnostic casts or models,
on a dental articulator. This helps determine the present and final tooth
position when the treatment is completed as well as visualizing the amount
of gum tissue change or bone loss that has occurred from having the teeth
removed and wearing the complete denture and lower removable partial
denture. The more the gum tissue has changed or bone loss has occurred over
the years, the larger the upper teeth need to be. If fixed bridgework is to
be made, a grafting procedure would be needed to augment or rebuild the
upper ridge in order to replace normal size teeth. Often the posterior upper
jaw will have little bone as the maxillary sinuses enlarge over the years
and a procedure known as a sinus lift would be needed to recreate the
necessary bone support for the implants that hold the teeth.
Whenever there is a question about the amount
of bone present or position of the implant to be placed or a vital structure
is in close proximity, a CAT scan or CT x-ray (Computed Tomography) should
be taken to aid in the determination of the bone thickness, height and
length. These are done at an imaging center or a hospital and by
reformatting the x-ray slices the computer is able to show the thickness and
height of bone present. This aids in the positioning of the implant prior to
surgery as well as determining if grafting is needed.
When patients have worn an upper complete
denture for many years with a few remaining lower anterior teeth and a lower
removable partial denture, they often develop "combination syndrome." This
means that the upper jaw bone tends to lose bone in the anterior region
making the complete denture unstable. They also have bone loss in the lower
posterior jaw. This type of loss usually requires some bone grafting to
compensate for these changes. A good diagnostic workup is important to
determine the length of treatment time, the cost and treatment options that
could include fixed bridgework or teeth that are not removable. Finally the
teeth then could be made out of porcelain fused to metal that are cemented
or screwed onto the implants. The screw retained bridge allows it to be
removed by the dentist. If bruxism is a problem, then the teeth might be
made of a material that allows some wear so the lower five teeth would not
have a wear problem as would occur if porcelain were used in the upper
teeth.
[Top]
Article #23
Dental Implants Provide Similar Function,
Appearance and Feel of Natural Teeth.
Q:
Would you like to eat out with your friends
at a restaurant but feel apprehensive? Would you like to go dancing, but
just can’t face meeting new people? Are you daring enough to talk or laugh
in public although your loose fitting dentures limit your sense of
expression due to the fullness in the roof of your mouth which may cause
them to dislodge or fall out?
A: These feelings
may be familiar to anyone who wears removable partials or dentures. Even
people with well-made removable dental appliances may experience some or all
of these problems, but now there is an answer.
Modern advances in dental implant technology
and surgical techniques mean that more and more people who have lost some or
all of their natural teeth can live fuller, richer, happier lives. Dental
implants may take the form of a single substitute tooth root that provides a
stable foundation for the missing tooth or it may take the form of a
framework and support many teeth. The implant is anchored firmly into or
onto the jawbone through a natural process where the bone and the implant
become integrated, providing the same stability as natural teeth. This means
that replacement teeth can look, feel and function just like real teeth.
Since dental implants, like teeth, are
embedded in or on the jaw bone, the painful chewing associated with
removable teeth is eliminated, as implants put no chewing pressure directly
on the gums. While implants have been available for many years, new advances
make them available to more people. Bone can be regrown or regenerated to
provide support for implants where they could not have been placed before.
With dental implants, you can enjoy a greater
variety of foods. Your mouth is restored as closely as possible to its
original state, with increased comfort and preservation of the facial
structure, with a good possibility that jaw deterioration will be
eliminated. Best of all, you will be able to smile more naturally and you
can be confident in normal activities such as talking and laughing.
Dr. Edward M. Amet, American Board Certified
Prosthodontist, founded the Reconstructive & Implant Dental Center in 1988
and has been in practice for 33 years. He has extensive training and
experience in both the surgical and the prosthodontic phases of implant
therapy, with skilled and talented on site dental technicians. These on
staff dental technicians make the prosthetics personalized for each patient.
"Our goal," states Dr. Amet, "is to provide our patients with the finest
quality of care, as comfortably and pain-free as possible."
[Top]
Article
#24
Implant Dentistry/One Appointment Subperiosteal
Implant
Q. I am interested
in knowing more about dental implants that would be indicated in cases where
advanced bone loss has occurred. I have been told that bone grafting would
be needed that might be obtained from the hip or some other location inside
the mouth. What other type of dental implant procedure can be done in these
cases?
A.
The full and partial subperisoteal implant
has been used successfully for more that 40 years as a viable treatment
method in oral implantology and is ADA approved. This implant is placed with
no drilling in the jaw bone and it strengthens the remaining jaw by resting
on top of the bone under the gum tissue and supports the front and back to
increase the strength of the thin jaw. During the 1978 Harvard Consensus
Conference and the 1988 Consensus Development Conference on dental implants,
a panel of experts determined that the subperiosteal implant compared
favorably with the success averages for other more standard dental
treatments such as fixed multiple unit crown and bridge. However, placement
of the implant has required two surgeries; one for a more difficult bone
impressions and another easier one for implant placement. The necessity of
the two stage procedure has often discouraged both patient and dentist from
consideration of this treatment modality.
Through advanced computer and x-ray
technology it is now possible to create an exact replica of the bone of the
mandible or maxilla, thus eliminating the need for the bone impression
surgery. A computed tomography (CT) scan x-ray is taken, the image is
transferred to a magnetic tape and entered into a computer. An exact 3D
image of the bone is generated. From this image, via CAM (computer assisted
manufacturing) methods, a precise model of the bone is created on which the
custom implant can be constructed.
In the early 80's it was discovered and
pioneered that a naturally occurring substance in the body called
Hydroxylapatite (H.A.) could be placed on the outer surface of dental
implants. This H.A. coating when placed on the outer surface of the
subperiosteal implant has resulted in success rates of 97.7% as reported by
Dr. Robert James. The CT- scan-generated, H.A. coated subperiosteal implant
technology has been available since March 29, 1984. Today the one surgery
can be done with only three small incisions as opposed to the original
extensive incision and this decreases the healing time. The implant also can
be put into function from the first day so the patient is never without
teeth.
[Top]
Article #25
Dental Implants/Types of Subperiosteal
Implants
Q.
I am interested in knowing more about a type of
dental implant called the subperiosteal implant.
A.
The mandibular subperiosteal implant has played a
successful role in selected cases in the past, and with current
technology, eliminates the necessity for two surgeries. This does not mean that
it is the implant of choice for the mandible with advanced resorption: it has
limitations. Currently it does not fit the description of contemporary implant
dentistry.
Limitations of subperiosteal implants are:
-
The one piece
design, implant and connecting bar.
-
The added
cost of this type of procedure, especially when only one surgery is
performed.
-
The need to
custom make this device and the limited availability
of laboratory technical support.
-
The limited
number of patients that may be treated with the device. Advanced bone
loss or excess alveolar bone will create problems, compromise medical
status, controlled diabetic etc,
-
The limitations
of retreatment.
-
And finally
only the mandibular dental arch can be considered for successful long
term therapy.
Current Contemporary Implant Dentistry
uses a definition of individual implant
components, or the implant is separate from the abutment(s) and/or implant
connecting bar and the overlaying prosthesis. Currently any case being treated
with a mandibular subperiosteal implant can be more easily treated with
endosteal implants to obtain a totally implant supported and stabilized
prosthesis.
Threaded endosteal implants may be used in the mandible with advanced bone loss.
In 1994 David Hockwald and Michael Marshall published an article in Oral and
Maxillofacial Surgery Clinics Nov 1994; 765-779. Marshall again reported at
the March 1998 AO meeting on "Spontaneous Ridge Growth with Dental Implants".
Hans Bosker also reported this in Oral
Surg Oral Diagn, Pub Freo r.,y. Kuopio, Finland 2:1991
Using the symphysis for bone anchorage implants and only loading the mandible
through these for a totally implant supported prosthesis, brings Wolf’s
law into action and there is "Spontaneous Ridge Growth with Dental Implants".
This only occurs with advanced bone loss in a thin mandible and is a normal
physiological phenomena. This does not occur with the mandibular subperiosteal
implant with advanced bone loss. This also eliminates the need for bone grafting
in most patients.
Prior to the surgical procedure, it is necessary to obtain a computed tomography
scan or (CT) scan for bone density and dimension determination. The type
of implant, its width and length can then be determined. Most patients with
advanced bone loss and only a portion of the basal bone remaining at 7-10mm, are
easily converted, with bone anchored implants and a connecting bar prosthesis,
to an implant supported and stabilized prosthesis. There can be immediate
loading of these short implants the day of surgery. The patient’s existing
mandibular denture is converted into a treatment overdenture.
Two
variations of bone regeneration that I have found very successful in very thin
mandibles with minimal basal bone remaining are:
One
final point to remember is that as the patient becomes geriatric, the ability to
maintain hygiene may be compromised. An infection of the subperiosteal implant
could result in the need for implant resection or removal with loss of the
entire implant and prosthesis. The patient may have to undergo this procedure at
a time when replacement may not be possible and related lack of eating problems
may occur. When threaded none H.A. coated endosteal implants have been well
placed in the mandible, these same types of complications do not seem to occur
even with decreased hygiene.
[Top]
Article #26
Dental Implants/Bone Grafting/ the
Healing Phase
Q.
I am interested in knowing more about dental
implants as I have been told that I have advanced bone loss from wearing a
complete upper denture and a lower removable partial denture with six
lower anterior teeth for the last 30 years with resulting "Combination
Syndrome"..
A. When teeth are
lost, the bone in the jaws begins to resorb or shrink because it is no
longer needed to support the teeth. This is accelerated by the wearing of
complete dentures or removable partials as they rest on the gum tissue. This
shrinking of the jawbone may make it impossible to wear a denture
satisfactorily or to place root form dental implants without grafting.
In such a situation, careful planning is necessary.
Many times using another type of implant
called a "blade implant", which also osseointegrate and has the American
Dental Association approval, the need for complex grafting can be
eliminated. The type of grafting that must be undertaken if root form or
cylinder type implants are placed can be from bone take from another area of
the jaw or regenerated with a membrane. Blade implants, however, are
designed to be placed in areas where the bone is thin or lower in height
such as the lower posterior jaw thus eliminating complex grafting. Since you
have a complete upper denture, you would continue to wear this after the
lower blade implants have been placed. You will never be without teeth. The
upper jaw can have a sinus elevation with subantral augmentation while the
lower jaw is healing for eventual implant placement with fixed bridgework.
The sinus grafting material used would be
irradiated bone from a tissue bank. Since this material has become
available, the results are equal for simultaneous or delayed implant
placement. This has become the material of choice for my patients. The
upper complete denture would be able to be used during the entire healing
time. Once your lower implants are restored with fixed bridgework, the upper
denture would be much more stable. The implants placed into the sinus
elevation would support the upper denture so that the last grafting
procedure could be done for the pre-maxilla. This is the hardest area to
graft under a denture and could only be done once the denture is stabilized.
Bone would be taken from the chin or ramus and the bone material placed into
that area that allows the body to regenerate the missing bone. The section
of bone from the chin or ramus would be attached to the upper anterior jaw
(pre-maxilla) with tiny small screws and then dental implants placed. After
the upper implants and graft have all integrated, either fixed bridgework or
a secure bar over-denture could be made to satisfy the missing teeth, gum
tissue and appearance.
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Article #27
Implant
dentistry/Types of Implants
Q.
I am 59 years old and have worn complete
dentures for 30 years. I have been told a lower complete denture will not
fit my jaw well because of little remaining bone. I have also been told that
in order to have bone anchored implants placed I would need to go through a
lengthy bone grafting procedure and it might take a year or more for the
implants to take. Are there any other implants that are American Dental
Association approved that might work and not be as difficult to perform or
take as long to heal or be as expensive?
A.
There are several types of dental implants that have ADA approval and the
most common one used is the root form or screw implant.
These are placed into the lower anterior jawbone. Often, as in your case,
after wearing a lower complete denture for many years the bone has resorbed
and little is left for a denture foundation The bone graft is to build up
the lower jaw to have room as well as strength to accept this type of
implant.. The bone grafting usually takes six months to heal then three to
six months additionally for the implants to heal. However even in cases
of advanced bone loss, I have not found the necessity for bone grafting
after using a CT scan. Usually the implants are placed with one stage
surgery with healing abutments in place through the soft tissue the day of
surgery. This then allows the patient’s existing lower teeth to be place on
top of the implants that day, eliminates second stage surgery, and the
treatment for the new teeth can be started after 4 weeks .
Another type of ADA approved implant that is only placed in the anterior
portion of the lower jaw is the transosseous implant and but often involves
general anesthesia because of it's extensive nature. An incision is made
directly underneath the chin and results in very little appearance change
from it. The implant is primarily in the anterior portion of the lower jaw
as it passes through the bone in order to be anterior to the jaw nerve. The
prosthesis or teeth for this type of implant then is not routinely supported
in the posterior of the jaw and the teeth must then rest on the gum tissue
in addition to the implant.
Another type of dental implant that has been in use since the late 1940's is
the subperiosteal implant. It has approval by the ADA and with the advent of
the CT scan x-ray, only one surgical appointment is needed to place it. This
implant is indicated in cases where there is advanced bone loss and the
implant is put into function the day it is placed. No drilling is done in
the jaw bone to place this type of implant rather it rests on top of the
bone under the gum tissue. The implant can also be put into function the day
of surgery and there is not a waiting period before the prosthesis or teeth
can be used on top of the implant.
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Article #28
Implant dentistry
with Cosmetic Improvement of Facial Appearance
Q.
Currently I have a
removable partial denture replacing my upper six front teeth with some bone
loss and facial cosmetic changes apparent. Can dental implants be used to
restore this area and will bone grafting be needed.
A.
The cosmetic restoration of facial appearance and improved dental function
with implant prosthodontic is directly related to restoring missing
intraoral hard and soft tissues and the aesthetics and technical abilities
of the dentist and dental technician. The use of dental implants for oral
rehabilitation has revolutionized prosthodontics over the past 3 decades.
Multiple studies have proven the efficacy and excellent long-term prognosis
with dental implants.
While initial research and clinical use were directed primarily toward the
edentulous patient, more recent studies have focused on the aesthetic and
functional use of implants in the partially edentulous patient. The most
challenging area of modern implant dentistry remains the "aesthetic zone" in
the anterior maxilla and mandible. Replacing multiple anterior teeth in the
otherwise dentate patient requires careful consideration of the location and
volume of residual bone, soft tissue aesthetics, and room for the implants
and prosthesis.
Most dental implants are placed in a delayed manner, after tooth extraction
allowing for both hard and soft tissues to heal prior to implantation.
Unfortunately, this allows for resorption of the alveolar ridge in both the
buccolingual and coronoapical directions. Studies have shown that as much as
3 to 4 mm of resorption can occur during the first 6 months post extraction
without the intervention of tissue grafting or regeneration techniques.
Since facial appearance depends on where the teeth are positioned, as well
as their shape, form, surface texture and color, it is often not difficult
on casual meeting to detect a person who has complete dentures or an
implant fixed partial denture. Small evenly set teeth in complete dentures
can detract from realism. The lips will often appear lengthened and tense or
thin in an attempt to conceal the anterior teeth, which may be set too far
posterior in the mouth. The result is the appearance of premature aging
which is caused not by age itself but by the change of facial appearance
from the chin and nose to close together with the soft tissue compensating
for this decreased distance between these parts of the face. The result is
the lack of an aesthetic dental smile with premature aging. Dental implants
if placed with a delayed surgical technique, for an implant ceramometal
reconstruction with only residual native bone, may develop teeth of
unnatural length with spaces between the root structures.
If
a delayed placement protocol is used or if grafting procedures are
ineffective, the prosthetic phase of implant dentistry must restore the
missing structures artistically and functionally to integrate with the
existing dental structures. The implant supported removable partial denture
provides for restoration of soft and hard tissues while enhancing the
aesthetic results of the replaced dentition through a unique removable
implant prosthesis design.
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Article #29
The Process of
Alveolar Distraction
Osteogenesis
for Improved Implant Placement
Q.
Currently I have a removable
partial denture replacing my upper six front teeth with some bone loss and
facial cosmetic changes apparent. Can dental implants be used to restore this
area. Will bone grafting be needed and if so what types are indicated.
A. Dental
implants can be used to restore this area and the type of bone improvement or
grafting could be with distraction
osteogenesis. This is a surgical process for reconstruction of skeletal
deformities. It involves gradual, controlled displacement of surgically
created fractures which results in simultaneous expansion of soft and hard
tissues with increase in bone volume. It is the ability to reconstruct
combined deficiencies in bone and soft tissue that makes this process unique and
invaluable to all types of reconstructive surgeons. Gavriel Ilizarov, a Russian
orthopedic surgeon, is credited with developing the armamentarium and describing
the biologic basis of this process for the management of orthopedic limb
deformities. The concepts described by Ilizarov have been adapted and modified
for use in maxillofacial surgery. Although the majority of surgical experience
with distraction technology has been in orthopedics, early results indicate the
process to be equally effective in facial skeletal reconstruction. It is now
possible to apply distraction technology to deformities of the jaws and
dentoalveolar process. Development of miniature, internal distraction
devices have made this clinically feasible and practical.
The process of alveolar
distraction osteogenesis involves mobilization, transport, and fixation of a
healthy segment of bone adjacent the deficient site. A mechanical device, the
alveolar distraction device, is used to provide gradual, controlled
transport of a mobilized alveolar segment. When the desired repositioning
of the bone segment is achieved, the distraction device is left in a static mode
to act as a fixation device. Displacement of the osseous segment results in
positioning of a healthy portion of bone into a previously deficient site.
Because the soft tissue is left attached to the transport segment, the movement
of the bone also results in expansion of the soft tissue adjacent the bone
segment. At the original location of the segment is left a regeneration chamber
which has a natural capacity to heal by filling with bone. This propensity of
the regeneration chamber to heal by filling with bone instead of fibrous tissue
is a function of the surrounding, healthy cancellous bone walls and location
within the skeletal functional matrix. As a result of the gradual distraction,
the alveolar housing, including the osseous and soft tissue components are
enlarged in a single, simultaneous process and implants of normal size maybe
placed.
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