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Implant for Upper Front Teeth

I would like to present another case of a single implant for upper front teeth that I did recently. The patient was suffering from advanced gum disease with generalized excessive bone loss. His teeth were generally mobile and sensitive to cold. He was unhappy with the status quo of his oral health and wanted to improve his oral wellness.

Upon examination, I noticed a few cavities. The upper left incisor was hopelessly loose and decayed. The patient was missing his molars on his upper right side, and two of his lower molars had post-treatment endodontic disease. The two endodontically treated molars were hopeless in their prognoses. After a couple of excellent and thorough cleaning by my hygienist, his gum disease has improved tremendously. He was also educated on the causes of gum disease, ways to combat the illness, and preventions.

A comprehensive treatment plan was drafted, presented, and discussed with the patient. I like to treat patients holistically, so I modified the plan after considering his inputs like wants, priorities, fears, and finance. With this holistic approach, he accepted the final treatment plan involving fillings, extractions, and implant-supported crowns.

Fortunately, the patient was motivated to keep his mouth healthy, so his periodontal health improved significantly. The cavities were first treated with white composite resin fillings that contained no bisphenol A (BPA). Before I added an implant for upper front teeth, the original upper front tooth had to be extracted. A Straumann implant was then inserted surgically in the same appointment. Bone graft and guided tissue regeneration techniques were also employed to generate more bone around the implant as it was healing, similar to the previous case I presented in my other blogs.

Affinity Dental Care | Implant for Upper Front Teeth

Affinity Dental Care | Implant for Upper Front Teeth

Affinity Dental Care | Implant for Upper Front Teeth

Fig 1 – X-ray, front, and occlusal view of the tooth.

The missing front tooth was temporarily replaced with a bonded resin tooth for the first four months. A new temporary tooth was made chairside using the machined titanium base covered by composite resin by me at four months to replace the bonded tooth. To improve the visual harmony of the front teeth, I filled the chip of the central front incisor beside it and modified the shape to reduce the diastema.

Affinity Dental Care | Implant for Upper Front Teeth

Fig 2 – X-ray of the BLX Straumann implant in place.

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Fig 3 – A bonded temporary tooth to replace the missing.

Affinity Dental Care | Implant for Upper Front Teeth

Fig 4 – A temporary tooth attached to the implant.

The gums were allowed to reform and model around the temporary resin crown for about two months before a “permanent” crown was made to replace the resin crown. The permanent crown was made with esthetic lithium disilicate that is strong and life-like.

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Fig 5 – A permanent crown supported by an implant integrated into the bone.

The patient was happy with the esthetic result and functionality of the implant-supported front tooth. Since then, I have placed two more implants in his upper right side where he has missing molars, and I will share the progress with you in my future blog.

Contact us with any questions or to book your next appointment.

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Botox in Dentistry

 

Affinity Dental Care – Botox in Dentistry

Botox was first approved in 1989 to treat two eye-muscle disorders, blepharospasm (uncontrollable blinking) and strabismus (crossed eyes). Botox is a Botulinum neurotoxin protein produced by the bacterium Clostridium botulinum. The same toxin can cause a life-threatening type of food poisoning called Botulism. It is most recognized as a wrinkle-reducing treatment. When used in a small amount, it may help treat symptoms of myofascial pain-related temporomandibular joint (TMJ) disorders in the head and neck region. There are several Botulinum neurotoxins in the market: Botox, Dysport, Xeomin, Jeuveau, and Myobloc. Besides Botox’s use for wrinkles removal, it is approved for eleven therapeutic indications, including chronic migraine, overactive bladder, leakage of urine (incontinence) due to overactive bladder caused by a neurologic condition, cervical dystonia, spasticity, and severe underarm sweating (axillary hyperhidrosis). Because of its ability to inhibit the motor neurons and desensitize the nociceptive pathways, Botox in dentistry has been used to treat TMJ disorders in some people effectively. In a few studies, Botox could significantly decrease pain and increase mouth movements for three months following treatment. However, this treatment for TMJ disorders is experimental. The U.S. Food and Drug Administration (FDA) has not approved Botox for use in TMJ disorders.

However TMJ-related myofascial disorders are caused by tensed muscles and can express as:

– Sore cheeks and jaw

– Limited or painful jaw opening

– The bulge in your face

– Pain around your neck and ears

– Headaches or migraines

– Clenching and grinding your teeth (bruxism)

– Ringing in your ears

– Shoulder pain

– Facial pain

Botulinum toxin inhibits the release of the neurotransmitter acetylcholine (ACh) from the neuromuscular junctions in skeletal muscles. Because ACh causes muscle contraction, the inhibition of the release help the muscles to stop sustained contraction and relax.

Before the injection, the myofascial trigger points were located by palpation of the masticatory muscles (usually undergoing spasm with a bulge visually on the face or neck, which is also very tender when touched). The Botox is then injected into the sites identified as the trigger points.

Because it is not officially approved for treating TMJ-related symptoms, I do not recommend Botox in dentistry unless other nonsurgical treatments have failed. The other therapies that should be considered first are:

– medications such as pain relievers and anti-inflammatories

– occlusion adjustment/balance to relieve premature contact of certain teeth

– muscle relaxants

– physical therapy

– oral splints or mouth guards

– relaxation techniques

Botox may help treat the following TMJ disorder symptoms that are caused by muscle spasms and hyperactivity:

– jaw tension

– headaches due to teeth grinding

– lockjaw in cases of severe stress

– severe bruxism

The improvement usually starts on the 3rd day of injection and peaks at three months. The injections should be repeated at three months intervals to decrease the symptoms. Sometimes, the injections must be repeated every three months for a few years.

People who have had Botox treatment for TMJ can expect to return to regular activities as soon as they leave the office. However, you should remain upright and avoid rubbing or massaging the injection sites for several hours after treatment. This helps prevent the toxin from spreading to other muscles.

Botox has a very high safety margin but has possible side effects. The most common side effects of Botox for TMJ treatment are:

– Temporary eyelid droop

– Headache or flu-like symptoms

– Dry or watering eye

– Drooping on one eyelid, eyebrow or side of the mouth

– Drooling

– Nausea

– A “fixed” smile lasting six to eight weeks

After the injection, the patient may experience the following in the first few days:

– Pain

– Redness at the injection site

– Muscle weakness

– Bruising at the injection site

The pain can be eased with a cold pack or numbing cream on the first day of injection. Botulinum should be avoided by pregnant women, nursing mothers, and people with an allergy to proteins in cow’s milk.

In addition to Botox in dentistry, I also utilize adjunctive therapies to treat the underlying causes of the disorder. Some simple, non-invasive treatments like the following can be very effective:

– Mouth splint and night guard

– Head and neck exercise

– Yoga, deep breathing, meditation, or massages

– Eliminate bad posture, slumping or slouching

– Recognize when you are clenching your teeth and work to relax your jaw

– Avoid chewing on gum, biting your nails, or eating too many tough or sticky foods

We provide you with all your treatment options at Affinity Dental Care. You may benefit from a combination of treatments, or you may need to try several treatments before finding one that works. Let’s work together to keep your smile the best it can be.

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Mini Dental Implants

 

Affinity Dental Care – Mini Implants

Where there is periodontitis (infection in the supporting gums and bone around the teeth), the bone disappears and gets smaller. When the teeth are extracted, the jaw bone shrinks and diminishes in dimensions. Both gum disease and extraction can change the shape and size of the jaws. A person with all teeth extracted would eventually display a suck-in look at the lips. This is where mini dental implants come in.

Affinity Dental Care - Mini Implants

Dental implants can help to maintain and stimulate bone growth when embedded in the jaw bone. The primary material used for implants is titanium, a strong but lightweight metal compatible with the human body and therefore would not prompt a reaction from the immune system.

Dental implants need to be wholly embedded within the jaw bone for proper healing and osteointegration, but when the dimensions of the jaw bone become too small and thin after years of shrinkage, the traditional implants can be too big in diameter, too long for the available jaw bone.

What Are Traditional Implants?

Traditional implants have diameters bigger than 3.25 mm and up 5 mm. There are extra-wide implants that are up to 9 mm in diameter. The traditional and extra-wide ones are made of at least two pieces – the implants (the fixtures in the bone) and the pieces attached to the implants (called the caps or abutments). When the jaw bone is not wide enough, a bone graft and guided bone regeneration (GBR) can be performed to gain more bone. However, not all patients and situations are suitable for these procedures before placing an implant. Mini dental implants (MDIs)can be an option for some instances with insufficient bone.

What Are Mini Implants?

They have the same structure as the traditional implants but are smaller than 3 mm in diameter and include a ball-shaped end that protrudes from the jawbone as one structure. Because of their smaller size, mini implants are also called narrow diameter implants or small diameter implants (NDIs and SDIs).

MDIs are smaller and, therefore, can fit in the narrower jaw. The procedure to place the mini implants is much less involved. Since the amount of bone and dimensions are dramatically different at different locations along the jaw, in most cases, I would order a 3-dimensional cone beam tomography X-ray of the jaw first to locate the suitable and safe areas (away from some vital tissues and structures) before the implant placements.

After careful planning and fabrication of a surgical guide for the implant placements, the implant surgical procedure is done without cutting gums as is the traditional way to expose the underlying bone. No suture is needed, and minimal bleeding ensures afterward. Post-surgical pain is usually very minimal.

Affinity Dental Care - Mini Implants

Why Mini-Implants?

Because of the simplicity and quickness of the procedure, the use of mini dental implants can be considered in cases the patients:

  • Have compromised health to undergo invasive surgery
  • Do not have enough bone in the jaw for a full-sized implant
  • Do not have enough time to go to repeat dental visits
  • Wants minimal pain and faster recovery time
  • Do not have enough money for the conventional implants and hybrid dentures or bridges

Who is a Good Candidate for Mini Dental Implants?

Mini-implant is indicated for patients with missing teeth (partial edentulous with some natural teeth), who will have partial dentures (removable plates) or wearing existing dentures. The MDIs with ball attachments can help stabilize and retain the dentures, making the wearer feel comfortable and secure.
Patients with certain health conditions like diabetes, vascular disease, or blood thinner can benefit from mini-implants. Some lifestyle factors like being a smoker but decent oral hygiene can succeed better with mini-implant.

However, mini dental implants are not for everyone. If there is excessive bone loss (the width of the bone is less than 4.5 mm and the length is less than 10 mm), even mini-implants would not have enough bone for them. If the density of the bone is too low, like in patients with osteopenia to osteoporosis, mini-implants would not have good stability. They are unsuitable for patients who grind and clench their teeth excessively. They are not indicative of supporting crowns or bridges. Straumann makes the mini-Implant I use in patients at Affinity Dental Care. Besides being less invasive, the reasons I only use Straumann mini-implants are because:

They are made with Roxolid, which has higher mechanical strength than titanium. Roxolid is a proprietary alloy with ~85% titanium and ~15% zirconium. The combination of the properties of these two metals leads to higher tensile and fatigue strength than comparable titanium implants. The higher a material’s tensile strength, the lower the risk for forced rupture. Higher fatigue strength is more critical in small implants, meaning the implants have a lower chance of fracture. Sandblasted, large grit, acid-etched implant surface, (SLA) is a type of surface treatment that creates surface roughness intending to enhance osseointegration through more significant bone-to-implant contact (BIC). This specially treated surface enhances osteointegration rate and high consistent survival rates.

Affinity Dental Care - Mini Implants

Other Benefits Include:

  • They can be made to fit your existing dentures
  • Easy cleaning
  • Firmer denture fit
  • High success rate
  • Good long-term results

Care and Maintenance

Mini dental implants just need the same care as natural teeth. If you have mini dental implants, brush your teeth twice daily, floss once a day, and visit your dentist regularly.

Past Results

Affinity Dental Care - Mini Implants

The photo shows a Straumann Roxolid mini-implant right after it was placed by Dr. Wong recently.

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The second photo shows the healing of the same implant after a week.

To make an informed decision, talk to a dentist experienced in both mini and standard implants.

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686 Walkers Line, Burlington ON L7N 2E9
Phone: (289)-861-5111
Email: info@affinitydentalcare.ca

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Vitamins for Oral Health

Affinity Dental Care – Oral Health

I have previously discussed nutrients and vitamins for oral health that can affect your wellness in several blogs. This time I would like to focus on oral and dental health. We all know that healthy eating will provide different nutrients for your wellness. A healthy balanced diet should contain a variety of vegetables, fruits, whole grains, fat-free dairy, and protein.

Vitamins A, B, C, D and minerals have significant oral health implications. Other nutrient intakes can also impact our oral and dental health. Let us look at them individually to see their impact on our oral health.

Vitamins for Oral Health:

Vitamins B, C, D, K & A

Vitamin B:

There are eight types of Vitamin B. Among them, Vitamin B2 (Riboflavin), B3 (Niacin), B6 (Pyridoxine), and B12 (Cyanocobalamin) are essential for our oral health. Deficiencies are most common in older adults, alcohol users, people with restricted diets, gastrointestinal issues or recent surgeries. Vitamin B complex deficiencies like Vitamin B2, 3, 6, and 12 can lead to recurrent aphthous stomatitis (canker sore), enamel hypo-mineralization, angular cheilitis (cracked mouth corners), halitosis (bad breath), gingivitis, glossitis (tongue inflammation), atrophy of the papillae, stomatitis (mouth ulcer), rashes around the nose, dysphagia (difficult swallowing), and pallor.

Vitamin C:

is also known as ascorbic acid. It is a water-soluble vitamin and is not stored in our bodies. It must be taken daily through food or supplements.
It controls infections and healing wounds and is a powerful antioxidant that can neutralize harmful free radicals. It is needed to make collagen, a fibrous protein in connective tissue vital for our various body systems in nerve, immune, bone, cartilage, ligament, blood, gums, and skin. A vitamin C deficiency can result in scurvy, resulting in bleeding gums and loose teeth.

A clinical trial conducted by Shimabukuro and colleagues on patients with gingivitis found that using Vitamin C could reduce spontaneous bleeding and redness of the gum. Patients having chronic gingivitis, chronic periodontitis, and type 2 diabetes can benefit from Vitamin C. Vitamin C is an antioxidant capable of inhibiting the initiation of carcinogenesis, including oral cancers, and can help neutralize the transformation of cells. In addition, a high intake of vitamin C from natural sources (i.e., fruits and vegetables) was associated with a significantly lower risk of head and neck cancer. Thus, vitamin C is currently recommended as a therapeutic measure to minimize the initiation and progression of oral cancer.

Vitamin D:

stimulates calcium and phosphorus absorption in the intestines and kidneys. It supports the functions of calcium and phosphorus in remineralizing and strengthening teeth. In children between the ages of six and eleven, several studies in Canada and Sweden have concluded that there is a significant inverse relationship between vitamin D levels in the body and caries development.

The results are probably due to incomplete calcification of teeth and alveolar bone. The incomplete calcification of enamel is called enamel hypoplasia. It is characterized by deficient, pitted, and rough enamel surfaces. These deformities increase the chances of bacteria colonization on teeth and difficulties cleaning the teeth. Deficiency in it will cause a low calcium level in the blood; the bones mobilize calcium to level out the blood calcium, leading to an increased risk for osteoporosis and arthritis (in adults) or rickets (in kids).

Vitamin D also plays a role in activating antimicrobial peptides (AMPs) such as Cathelicidins and Defensins. The increase in those AMPs in the oral epithelial cells, salivary ducts, and saliva lyse (break down) the oral bacteria significantly, reducing caries. Adequate Vitamin D in serum increases calcium content in the saliva. A deficiency of vitamin D can decrease the salivary flow by 65%. Therefore, vitamin D regulates salivary flow rate and quality.

Vitamin K:

The body needs vitamin K to produce prothrombin, a protein and clotting factor important in blood clotting and bone metabolism.
Deficiency is rare, but, in severe cases, it can increase bleeding and predispose a person to oral candidiasis.

Vitamin A:

Apart from its role in healthy vision, it is a critical component required to maintain the mucosal membranes, salivary glands, and teeth.
Saliva helps break down food and also cleans bacteria from in between your teeth. Deficiency will result in xerostomia (dry mouth), taste sensitivity, tooth brittleness, salivary gland degeneration, and caries risk. A lower intake of vitamin A has been associated with decreased oral epithelial development, impaired tooth formation, enamel hypoplasia and periodontitis

Vitamins for Oral Health:

Calcium, Protein, Folic Acid, Zinc, Magnesium & Potassium

Calcium:

is the main components in the mineralization of the protein matrix of bone and teeth. The hardened substance made up of the two minerals is called hydroxyapatite. It gives bones and teeth their compressive strength. Inadequate absorption during pregnancy may result in bone deformities, incomplete tooth calcification, tooth malformation, and increased susceptibility to caries after tooth eruption.
In adolescence, inadequate intake of calcium will lead to osteopenia or osteoporosis.

Protein:

is needed to construct all body tissues and is a fundamental building block for any living organism. Protein deficiency results in the poor structural integrity of the dentition and the supporting periodontal tissues. Delayed wound healing and poor resistance to oral pathogens.

Folic acid:

is the synthetic form of vitamin B9, also known as pteroylmonoglutamic acid. Folate is the naturally occurring form of vitamin B9. It is essential for DNA synthesis. Deficiency in folate during pregnancy can lead to cleft lip or palate. Lack of it can lead to angular cheilitis, stomatitis, sore or burning mouth, inflamed gingiva, and glossitis.

Zinc:

is often found in oral rinses and toothpaste because it helps with common gum diseases, including gingivitis and other common periodontal problems.
Low zinc levels can increase the chance of developing infections and degenerative pathologies. Zinc also plays a vital role in the psychosocial functioning of human behaviour. In the oral cavity, zinc is found in saliva, dental plaque, and enamel. It contributes to healthy teeth formation and the reduction of halitosis in the mouth
Clinical trials have demonstrated that zinc ions decrease the rate of enamel demineralization.

Magnesium:

Magnesium and calcium complement each other to build hard tooth enamel and maintain bone density. Ideally, you should receive a two-to-one ratio of calcium to magnesium daily. Good dietary sources of magnesium include dark green vegetables, legumes, nuts, corn, brown rice, buckwheat, rye, and other whole grains. Too much magnesium all at once can cause digestive side effects such as diarrhea, so you may need to spread your intake out over the day.

Potassium:

A diet rich in Potassium can help your teeth and bones use calcium more efficiently because Potassium is a companion to magnesium in the body’s efforts to regulate blood acidity. When your blood becomes too acidic, the acids can remove calcium from your teeth and jawbone, weakening them.
You can get Potassium from many foods. Bananas, prunes, avocados, potatoes (including sweet potatoes), tomatoes, and Swiss chard are all rich in Potassium.
Potassium nitrate is also found in some toothpaste to help to reduce tooth sensitivity.

Affinity Dental Care is a general dental clinic in Burlington that provides comprehensive treatment for the families in the neighbourhood. If you are looking for an excellent dental clinic near you, please call 289-861-5111 or email us at info@affinitydentalcare.ca for a consultation on your dental health status.

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Implant Progress, Part 4

Earlier this August, I wrote a blog as a second instalment on an anterior implant case. The patient lost her upper left front tooth due to a severe cavity in the root (caused by external resorption). Subsequently, the tooth was extracted, and a Straumann BLX implant was surgically placed in the extraction socket. An exogenous bone graft (freeze-dried bone particles from another human being) was placed around the implant. To keep the bone graft particle intact and to prevent the soft gum tissue from penetrating among the bone particles, a piece of collagen membrane was placed over the particles and sutured in place.

Implant progress 4 missing tooth
A few months have passed for the implant to be integrated into the jaw by the newly formed bone. A temporary crown was made to attach to the stabilized implant.

The last post ended with a photo, see below, of a temporary crown attached to the patient’s implant on her upper left side.

Temporary crown
Since then, a few changes have been made to the patient’s front teeth that dramatically improved the aesthetics.

First, the space between the two upper front teeth was too prominent, resulting in a large black triangle. To address this issue, I bonded composite resin to her natural tooth on her right side (your left when you look at the photo) and modified the temporary crown on the left to make them more symmetrical and pleasing.

The results were much more attractive than in the beginning. However, the length and shade of the temporary crown were not pleasing enough. Improvements were still needed before the final crown could be processed.

The modification process continued for a few months as the patient interacted with me to let me know what she liked. The complications I have to face are that the old bridge has a different shade and translucency than her other teeth, and the lateral incisor of the bridge is a bit too long. It made it harder for me to create a harmonious transition from her natural teeth on the right side to the bridge on her left with my temporary crown in the centre. After many changes and alterations, we finally have a decent appearance.

Decent appearance
After six months of healing the implant and teeth adjustments, the patient and I were happy with the results. Then I made a final crown with titanium, zirconia and lithium disilicate.

Final crown
During the fabrication process of the final crown, it was also modified a few times before the results were deemed satisfactory. The final crown was attached and tightened to the implant with a screw.

The response of her gums to it was excellent. Her smile has not just been restored but improved.

Before image
After implant image 1After image

Before and after composite resin bonding and an implant-supported crown.

The patient is delighted with the results. I will let the gums around the implant crown heal for 2 to 3 months before performing gum augmentation to improve the appearance of the soft tissues further, especially the interdental papilla.

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The Latest Technologies to Make Implant Placement

There are new techniques and technology that Affinity Dental Care uses to make implant placement easier.

  1. The socket shield technique is a “newer” technique used during immediate implant placement (remove a hopeless tooth and replace it with an implant right after the extraction) in the anterior region to preserve the integrity of the periodontium and the thin buccal bone that lies beneath. This technique does not remove the whole root of an upper front tooth. It eliminates two-thirds of the root, leaving a small piece of the front part of the root in the socket as a type of shield. Implant placement then takes place behind the protection of the socket shield with the intention of minimal disruption to the buccal bone and associated gum tissues. The final results are much more aesthetic and natural.
  2. Implant surgical guides can be incredible aids for prosthetically driven implant placement (plan the location of the crown first, then place the implant where the tooth/crown will be). The implant surgical guide can help us to place the implants precisely where we want them to be so that the resulting crowns can be functional and good-looking.
  3. A new technology called a 3D navigation system can help with implant planning and placement. It is essentially an image-guided and robot-assisted surgical system. The dentist gains a live view of the patient’s 3D anatomy and a digital handpiece to guide drill movements during surgery using the technology. I have tried out a 3D navigation system called X-NAV. The results I get from an oral surgeon colleague using these devices are excellent, though. The feedback I have received from the surgeon about this surgical process is that it gives the confidence of guided surgery and precision in placement location while allowing for the freehanded adjustment feel during the procedure.
  4. Another advancement is using a diode laser to uncover implants (after a few months of healing) instead of scalpels to reduce bleeding and eliminate the need for suture removal. CO2 lasers have a similar coagulation style and effect as diode lasers. Nd: YAG and Er, Cr: YSGG lasers effectively manage peri-implantitis (remove infection around implants).
  5. Digital scanning with a 3-D scanner and 3-D printer are the two other new technologies that we can streamline our workflow in implant dentistry. The 3-D scanner can accurately capture the location of the implant, and the 3-D printer can reproduce the implant and the teeth of the mouth so that the dental laboratory technicians can produce the crown for the implant.
  6. CAD/CAM dental milling machine can mill out the crown after receiving the digital information from the 3-D scanner.
  7. Newer ceramic implants are developed to replace implants made with titanium. Zirconium dioxide is not metal like titanium and is white. Its use may be suitable in certain circumstances where the highest esthetic is desirable, or metal-free holistic treatment is wanted. The material has been proven to have good osseointegration and soft tissue adhesion. It also demonstrates lower plaque accumulation and less bacterial adhesion than titanium implants.

We always strive to keep our technologies abreast of the time. If you have any questions about your suitability for dental implants to improve your smile and health, feel free to contact us for answers.

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Implant Therapy Part 2

This blog is a continuation of the last blog on implant therapy. This time I am going to talk about prostheses supported by implants.

The prostheses that implants can support are a crown, a bridge or a denture (hence called overdenture). The fees for implants and prostheses are usually high because of the expensive costs of the many machines, equipment, instruments, parts and accessories, sundries, sterilization wraps (and pouches) and the charges from the dental laboratories making the prostheses.

At Affinity Dental Care, we use three implant systems: Straumann, Conelog and Molaris implants. All three are high-quality implants that cost over $600 per implant. Additional parts are needed to go onto the implants, like healing caps (the cover screw on the implant) and healing abutment (the long conical cylinder that attaches to the implant and sticks out of the gums). When making the prostheses, there are additional costs for the impression, implant to the crown interface, overdenture attachment, and the making of the crown etc. They can cost at least $750. Not to mention the costs of the numerous sundries like sterilized saline, irrigation tubing, syringes, gauze and protective sheets etc.

The cost can be even higher when bone graft and membrane are involved.

Our expenses to place an implant and a crown onto it can easily be $1,500. Not to mention the special machines and instruments specifically for the procedures in the process.

Implant surgery and placement can be unpredictable, complications can arise, and additional surgeries, remakes and repairs may be needed. Usually, we only charge our patients the costs for the extra supplies and lab bills to our patients.

There can be some inadvertent complications to the prostheses:

An implant involves many procedures. Each procedure requires precisions. Pre-surgical examination and treatment planning is essential. Even with careful preparations, complications can happen. They can be:

  1. Breakage/fracture/loosening
    With time, you may inadvertently break/fracture/loosen the prosthesis, the implant(s), or the implant component(s). In particular, your prosthesis is connected to the implants by small internal screws that you can inadvertently loosen or fracture. Usually, these complications can be fixed relatively quickly, and fractured prostheses can be replaced without further complications.

     
  2. Implant failure/infection
    Implants supporting the prostheses can fail or can become infected. The treatment may require surgical intervention(s) and may have significant implications for your prosthesis, appearance, and usability. Occasionally, a new prosthesis may need to be made, or the design of the current prosthesis may be modified significantly as a result. The costs of managing failed, or infected implants and a new prosthesis or repairs/modifications to the existing prosthesis are not usually included in the initial estimate. This cost can be high and higher than the initial treatment’s cost. The time needed to manage such situations can also be significant.
     
  3. Adaptation/acustomization/expectations/realities of your mouth
    Although the prosthesis can come close to the appearance and functionality of your original teeth, it is not a perfect copy or replica of your teeth. However, we seek improvement over your current situation and not perfection. We cannot guarantee the delivery of a “perfect smile” or teeth that feel “just  like your own teeth.”  Expectations can be unrealistic if you expect implant-supported teeth to look and feel just like natural teeth, especially when you have lost the teeth for a long time and the site has severe bone resorption. As a result, the implant-supported teeth will not have the actual gums supporting the implant crown with the natural contour. However, it can appear very naturally with pink gum appearance. Rarely have some patients been unable to become comfortable with their new implant-supported prosthesis.

     
  4. Changes over time
    Your mouth will undergo slow changes with time. Your gums may shrink, and adjacent teeth may drift, be extracted or change colour. Your prosthesis will also undergo slow changes over the years. The surface may wear and change its colour. The gums around may shrink or grow more prominent. Such changes are very slow but may impact the appearance, functionality or longevity of your implant-supported prosthesis and may lead to a need or desire on your part for modification or remake of the prosthesis.

     
  5. Temporary prosthesis
    Frequently, a  temporary crown/bridge/denture/retainer is needed to help you cope with the missing teeth until the completion of treatment. These temporary appliances have limitations of fit, appearance, and durability. In particular, they can be brittle, dislodge easily, and wear/disintegrate quickly. There may be treatment times when you are advised not to wear your temporary prosthesis so that the surgical tissues can heal undisturbed. You will usually be informed of this in advance.
     

    Rarely are some patients unable to wear their temporary prostheses (mainly temporary dentures). There is usually no harm if the patient stops wearing the temporary denture(s). About overdentures

All prosthodontic prostheses require a period of adaptation after their insertion (i.e., when you become accustomed to the new prosthesis), including feel, speech, bite, self-biting etc. The prosthesis may appear foreign, uncomfortable, and annoying during this adaptation period. These issues are typical and will become better with time. Some of the common problems are outlined below.

  • Feel: Your prosthesis may feel big and bulky. You may feel extra fullness in your lips or insufficient space for your tongue.
  • Speech: You may notice that some sounds or speech, in general, are negatively affected. This phenomenon is typically much more noticeable to you than to others. We advise reading out loud to allow for your speech to improve. Some clinical situations are particularly likely to result in temporary (and, occasionally, permanent speech effects). These clinical situations include replacements of upper front teeth and patients who wore upper removable dentures for an extended period before transitioning to a fixed implant-supported bridge.
  • Food impaction: You may notice food annoying getting caught between, around, or under your prosthesis. We will do our best to address this. However, occasionally this problem cannot be eliminated completely.
  • Bite: We will create a bite for your prosthesis that is even, comfortable, and least damaging to your prosthesis and your remaining teeth. However, your implant-supported prosthesis cannot and will not feel exactly like your own natural teeth.
  • Self-biting: Your gums and tongue are not accustomed to the presence of the new prosthesis. You may notice biting your tongue or lip until they become accustomed. This problem can be very uncomfortable. Eating slowly is usually a good strategy until your mouth becomes used to the new prosthesis.
  • Saliva: Excessive salivation is very common after inserting a new prosthesis. Excessive salivation typically resolves quickly as your mouth learns that the new prosthesis in your mouth is not a candy.
  • Denture sores: Patients who receive removable dentures or overdentures should expect that the dentures will cause some temporary gum irritation. This is usually easily improved through adjustments to your denture by the dentist. Several appointments may be needed.

Your overdentures are retained to the implants by clips with plastic inserts. These inserts will wear over time and require yearly (or sooner) replacements.

  • Relines
    Your gums will continue changing their shape as you age. This will likely cause your overdenture to lose its precise fit to the gums. As a result, it may start feeling loose, and you may notice food collecting underneath after several years. Your removable dentures/overdentures will need regular relines every few years as the need arises. 
  • Retention
    An overdenture is a removable prosthesis. You may discover at your treatment’s conclusion that you wish your removable prosthesis to be even more retentive than possible with the current design. This can often be accomplished where appropriate by placing additional implants and fabricating a brand new prosthesis. 

About crown(s)/bridge(s)

  • Crowns and bridges are held to the implants by small internal screws. These screws fit through small channels in your crown(s)/bridge(s). The very top of the channel(s) is covered with small filling(s) after the treatment. This small filling may occasionally dislodge, leaving the channel open. This represents no danger or risk for anything other than the possible annoyance of food getting stuck inside the hole. The hole can be easily resealed with a new filling.
  • Cleaning
    Your teeth and new prosthesis must be kept impeccably clean by you at home and professionally cleaned regularly at a dentist’s office. Failure to do so may cause the development of an infection and may cause the loss of your implant(s) or the prosthesis. 
  • Monitoring
    You must return for regular recall assessments. These assessments include a clinical exam and radiograph(s) (Xrays). Many problems that may occur with implant treatment will not be noticeable to you at first until it is too late. It is your responsibility to bring to our immediate attention any complications that you may encounter. Failure to do so may cause a simple-to-fix problem to become more extensive and expensive.

This second blog, together with the first one, is the information we at Affinity Dental Care provide to our patients to help them understand the implant therapy and make the right decision on the treatment. Our goal is to give the patients the proper treatments suitable for their conditions and help them achieve healthiness and confidence that will last.

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Implant progress continues

In October 2020, I wrote a blog on a patient whose upper front central incisor (tooth #21) had external resorption. The resorption was extensive and rendered the tooth hopeless in prognosis. Different options were presented and discussed – endodontic treatment and extraction with a fixed bridge, a removable denture, or an implant-supported crown as the final prosthesis. Another factor we debated on the challenge in her case besides the time and surgical procedures going to involve – is her oral lichen planus.

Oral lichen planus can present in six types clinically: Reticular (fine white striae cross each other in the lesion), Atrophic (areas of erythematous lesion surrounded by reticular components), papular type, bullous type, plaque-type, erosive or ulcerative type. This disease occurs more frequently in females and is a T-cell mediated autoimmune disease. The ramification is the delayed healing of the gum tissues, leading to a higher chance of infection after surgery.

Despite the higher chance of failure, she elected to have the tooth removed and replaced with an implant-support tooth.

Therefore, the patient had to take a high dosage of antibiotics and rinse her mouth with antiseptic with meticulous oral hygiene before and after the surgery.

The first appointment in October 2020 was to extract tooth #21 and bone graft the socket with mineralized freeze-dried bone allografts (FDBA). The purpose of the bone graft is to create more bone dimensions for the future implant.

Implant progress on incisor Before and after dental implantX-ray of the upper central incisor before extraction, after extraction with the bone graft, and with the implant.

Bone graft particlesBone graft particles

Right after the tooth was extracted, a simple cantilever bridge was fabricated and bonded to the other central incisor to provide a temporary tooth to replace the extracted tooth. The bone was allowed to remodel inside the extraction sockets for over eight months. The healing was non-eventful overall. In August 2021, another course of antibiotic and mouth rinse regimes were initiated for a week before placing a Straumann bone level taper implant (Roxolid SLA) in the grafted site. I attached an immediate temporary crown made of polyether ether ketone (PEEK).

Incisor before extractionThe upper left central incisor before extraction.

Temporary bridge after the extractionA temporary bridge after the extraction

The upper left central incisor replaced with an immediate temporary crown attached to an implantThe upper left central incisor replaced with an immediate temporary crown attached to an implant

A temporary PEEK crown attached to the implant lets the surrounding gums remodel to provide a natural appearance. During the remodelling period, the temporary crown was removed a few times during the six-month healing period to recontour the shape of the temporary crown – 1) to allow the gums to form a natural appearance and 2) to achieve an aesthetically balanced tooth shape that the future permanent crown can model on. Meanwhile, the other upper central incisor (tooth #11) was modified to remove the black triangle (the excessive space between the two front teeth at the gums) and to make the tooth less ovoid in shape. The results are far more natural and harmonious.

After both the upper central incisors were modifiedAfter both the upper central incisors were modified

At this stage, after the implant has been placed in the bone for over six months, the implant was tested for stability using a resonance device to make sure it has good bone ingrowth into the implant. The result was excellent, with a reading of over 80, which indicates that the implant has pretty good stability.

Trios scannerKnowing that the implant is ready for a definitive “permanent” crown, an impression was obtained using our latest 3-D scanner to make the digital topographic impression. It is a technique to measure the sizes, locations, orientations, depth, morphologies, and angulations of all the teeth and other tissues in the mouth. The scanner can also select the shade and chroma of the teeth that match the standard Vita shade guide. A 3-D printer can print out the digital impression if needed.

A digital impression of upper teeth taken by a Trios scannerA digital impression of upper teeth taken by a Trios scanner

The “permanent” crown for the implant is being fabricated during the writing of this blog. The crown will have three components – the base made with machined titanium, the white zirconia bonded onto the titanium base and a layer of live-like material made with lithium disilicate baked on top of the whiter zirconia.

The “permanent” crown for the implant
Once I have the crown attached to the implant, I will continue to blog on the progress of the final stage of this exciting journey.

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Implant therapy, Part 1

There are a few reasons implant therapy is wanted by a patient or recommended by the patient’s dentist. The reasons for having an implant procedure are:

1) To replace a missing tooth

2) To improve the ability to chew

3) To prevent adjacent teeth from drifting

4) To make the removable denture more stable

If you are missing your tooth/teeth and have no concerns about aesthetics, your ability to eat and your dentist have advised you that the likelihood of the teeth drifting is low. A reasonable option is No Treatment and not to replace your missing tooth/teeth.

Besides implants, you should be advised that other options exist to replace their missing tooth/teeth. Among all the options listed below, each has pros and cons. What is suitable depends on an individual’s situation. The possible options are:

1) Removable denture

2) Dental bridge

3) Dental implant therapy

Dental Implant Therapy

Dental Implant therapy consists of two parts

  • Dental implant

The first part is the surgical placement of the dental implant in the jaw bone. The dental implant is made with titanium and looks similar to the tooth’s root. The implant is made with titanium which is a bone-friendly material. When the dental implant is surgically placed into the jaw bone, the bone heals around the implant. Once the bone heals around the implant, this provides a stable foundation for the prosthesis.

  • Dental crown, bridge or overdenture

The second part is the parts above the jaw bone and visible. It could be a crown, which looks like a natural tooth, a bridge and an overdenture. Collectively, they are called a prosthesis which is the component that sits on top of the dental implant.

The prosthesis may be:

  1. Fixed on top of an implant such as a crown or a dental bridge
  2. Removable like a denture sitting on top of the clips of the dental implants. The clips on top of the implants help improve the denture’s stability. Hence it is called overdenture.

Advantages and disadvantages of dental implant therapy

The advantages of having dental implants are:

  • If a prosthesis is fixed on the implant, the prosthesis functions like your natural teeth.
  • If you have a removable prosthesis, the implants provide better stability to your denture.
  • Dental implant therapy often does not negatively affect your adjacent teeth, whereas other non-implant options such as the dental bridge require reduction/shaving of your adjacent teeth.

Disadvantages of dental implants

The disadvantages to having dental implants are:

  • Implant therapy does require one or more surgeries.
  • Compared to the other non-implant options, the treatment time for dental implant therapy is significantly longer because time is needed to allow the bone and soft tissue to heal around the implant.
  • After placement of the dental implant, although the possibility is low, there is always a risk that the bone does not heal properly around the implant. If this occurs, the implant has failed and must be removed. Future placement of a new implant is possible but may require additional procedures such as bone grafting.
  • Some patients may develop inflammation, infection or complication around the functional implant. These do not occur often, but when it happens, you will need additional treatment to eliminate the problem. The worst-case scenario may involve the removal of the implant.
  • The prosthesis is subject to normal wear and tear. As a result, technical complications may arise, such as loosening the screws, cement washout, and fracturing of the porcelain. These technical complications may be fixed, but the entire prosthesis may need replacement.
  • Factors that may be associated with increased risk of implant complications and failure include:
    • smoking
    • diabetes
    • poor care of the mouth
    • not following the dentist’s recommendations
    • not visiting the dentist for regular monitoring and care

Implant surgical procedure

Regarding any risks from the implant surgery, generally, the procedures are minimally invasive and therefore carry little risk. However, there are possible complications that include:

  1. Infection following surgery. This is unlikely if you use the prescribed medications before the surgery.
  2. Implant failure. There is less than a 10% chance that the implant(s) will become unsuccessfully attached to your jawbone.
  3. Nerve damage. If there is minimal bone height in the lower posterior jaw, implants may be placed close to the central nerve of this jaw. This nerve will be identified at the surgery, and all precautions will be taken to protect it from damage. However, occasionally because of post-surgical swelling, the nerve may give altered (generally reduced) sensation for a period of days to months before returning to normal. In rare instances, the change in sensation may be permanent. If nerve function is altered, it could result in tingling, pins and needles, and/or burning sensations. Most commonly, it is a numb feeling on the surface tissue overlying the implants, inside the lip and on the surface of the lip. There would be no effect on muscle movement or facial appearance. In other words, damage to this nerve will not cause any paralysis.
  4. Damage to the roots of adjacent teeth. In infrequent instances, implants placed adjacent to natural teeth may damage the adjacent tooth/teeth during the implant site preparation. If this occurs, further treatment may be necessary to deal with the tooth damage.
  5. Encroachment into the nasal cavity or the maxillary sinus. Although there may be some initial discomfort and minor nasal bleeding, implants that penetrate the spaces typically heal well. In some instances where the pain persists, additional medical treatment may be required later. Rarely it may be necessary to remove an implant.
  6. Failure of the bone graft. In some instances, bone grafting procedures may not provide adequate bone for the subsequent placement of dental implants due to complete or partial failure of the bone graft because of poor healing and graft infection.

Should any implant not properly attach, it will be removed. If the conditions are still favourable for an implant, another attempt to place an implant will be performed; otherwise, other options like a bridge or a denture can be considered.

It is anticipated that the implant(s), if successful, will function for many years if you take care of them. However, the longevity of the implant(s) depends on many factors, including:

  • good general health, excellent oral hygiene,
  • complicating oral habits such as night grinding,
  • regular dental care for your remaining teeth,
  • regular check-ups for the implant(s) and the attached the crown(s),
  • and a smoke-free lifestyle.

Bone grafts and membrane

For successful implant therapy, there must be enough bone. If there is not enough bone, the patient may need surgery to increase the amount of bone. Using bone grafts and membranes is the key to improving bone quantity and quality.

There are potential sources of the bone and membrane:

  • Bone harvest from other areas of your mouth.
  • Bone purchased from a bone bank- The source of the bone may be from human or bovine. These bone tissues are regulated by the strict organ donation criteria, where donors are screened and tested for transmissible diseases. The harvested bone undergoes intense processing and retests.
  • Membranes used are of bovine or porcine origin.
  • The bone grafts and membrane used are safe to use. Specifically with the materials that we use, to date, there has been no documented case of disease transmission (hepatitis, syphilis, blood and tissue infections, and the AIDS virus).

Dental implant therapyThe clips on the implant can hold the denture down

Dental implant therapyA molar crown attached to an implant

This blog is part of the information we at Affinity Dental Care provide to our patients to help them understand the implant therapy and make the right decision on the treatment. Our goal is to give the patients the proper treatments suitable for their conditions and help them achieve healthiness and confidence that will last.

Blog

White filling resin with no Bisphenol-A

Like Affinity Dental Care, most dentists nowadays do not use silver amalgam fillings anymore because of the mercury content in this material.

We only use composite resin for the fillings in both anterior and molar teeth to avoid mercury alloy. We like composite resin because of other advantages as well – tooth coloured, translucency that makes it more life-like, less drilling and removal of sound tooth structure before filling with this material, and ease of repair.

However, there are many different brands of composite resin by several manufacturers. They are not all the same in terms of chemistry and their properties.

Unfortunately, many different brands use BPA (bisphenol-A) or Bis-GMA (Bisphenol-A-Glycidyl-Methacrylate). BPA is an endocrine-disrupting chemical that affects your health in a large quantity. Considerable exposure can cause problems in the brain and prostate of fetuses and children. It can also cause behavioural issues in children. Other studies also link this chemical to early puberty, metabolic disorders such as obesity and diabetes, heart disease, high blood pressure, infertility, thyroid dysfunction, and some cancers.

Spermatogenesis impairment and male reproductive abnormalities are related to excessive exposure to this chemical.

Bisphenol-A is a commonly used chemical for plastic materials such as polycarbonate bottles, containers, or coatings of cans. Bis-GMA is not the same as BPA; it comprises only the BPA structure in a tightly bonded ether form. There are traces of BPA in those composites, however.

Suffice it to say. It is a good idea to minimize the amount we are exposed to. In Affinity Dental Care, we use a non-BPA or GMA-containing composite resin made by Kulzer Dental called Venus Pearl. Venus Pearl does not contain any of the two chemicals.

Besides this advantage, there are other benefits of this composite material as it is:

  • easy to be used to fill the cavities – it is not sticky and has a creamy consistency that makes the material easy to be applied to the cleaned cavities,
  • durable – the material’s matrix is a nano-hybrid complex (the filler is from 5 nanometres to 5 micrometres) that resists wear, erosion and crack propagation,
  • strong – It combines high flexural strength with minimal shrinkage stress. The results are long-lasting, and
  • good looking – it offers a wide range of shades and can be applied in single- and multi-shade layering techniques. The material adapts perfectly to the colour of the surrounding teeth, creating an outstandingly natural look.

We do not introduce chemicals that are known to cause harm to our patients at Affinity Dental Care cause we like to consider wellness and health for our patients.

Non-BPA Fillings

Non-BPA Fillings

Top – a molar with a silver amalgam filling. Bottom – the same molar with a white composite resin filling. Dr. Wong at Affinity Dental Care did the filling.

AFFINITY DENTAL CARE IS TAKING YOUR SAFETY SERIOUSLY DURING YOUR VISITS

  • We will not see patients who have assessed positive for COVID-19.
  • Physical barriers are In place to maintain patient safety like a plexiglass shield around the reception desk.
  • All the doorknobs, countertops, waiting room chairs and other areas where previous patient has been in contact are wiped down with disinfectant soon after the patient leaves and before the next patient arrives.
  • An extra 15 minutes will be given between patients to provide adequate time to get equipment like chairs, lights, counter tops, handles and any open surfaces in the treatment area clean and disinfected.
  • Our instruments are wrapped or bagged before sterilization in our new autoclave machine to maintain sterility before being used on our patients.
  • We keep the door to the treatment area closed at all times to keep the air inside for the air management system to filter and disinfect the air. HEPA filtering and UV disinfectant light are used in the process.
  • We wear fit tested N95 masks, gloves, eye protection, head coverings and protective gowns when we are treating patients.
  • We diligently wash hands and use alcohol-based hand sanitizer between patients.
  • We provide alcohol-based hand sanitizer throughout the clinic for our patients.
  • Staff monitor themselves twice daily to make sure we have no symptoms.

At Affinity Dental Care, rest assured that we take your safety seriously.