Blog

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.

Blog

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.

Blog

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.

Blog

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.

Blog

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

An Implant Case

My patient had a tooth in his lower right side, the first molar, that was very mobile due to advanced gum disease with severe bone loss. The tooth was deemed hopeless in prognosis, so I recommended the patient have the tooth extracted. The patient has presented the different options with the would-be space left behind in detail: leaving the space empty, replacing it with a removable partial denture, fixing a three-unit-dental bridge, and placing a crown supporting by an implant. After all the fees, procedures and other questions were answered, the patient elected to have the tooth removed and replaced with an implant-supported crown.

Severe bone loss in the first molar
1. Severe bone loss in the first molar

After having a cone-beam computed tomography taken (CBCT) to determine the adequacy of bone volume and quality for an implant, treatment plans were made to place a tissue level Biohorizons implant immediately after the extraction using a surgical template to guide the placement of the implant.

Treatment planning using 3D imaging
2. Treatment planning using 3D imaging

The patient was instructed to take an antibiotic and rinse his mouth with an antiseptic for a few days before the surgery.

On the day of surgery, a local anesthetic was first administered, and when the numbing was profound enough, the tooth was atraumatically extracted. The inflamed tissues inside the socket were cleaned out carefully and meticulously. Immediately, an implant was placed inside the prepared socket. Due to severe bone loss from his advanced gum disease, ground bone particles from a human donor were grafted and packed around the implant. A special collagen membrane was placed over the bone graft to ensure that the patient’s bone cells migrated among the bone graft particles to form new natural solid bone around the implant.

Immediately implant and bone graft placement after the extraction.
3. Immediately implant and bone graft placement after the extraction.
An implant case
4. The implant with a cover after six months of healing.

After six months of healing, a resonance test, a device that gives out a measurement in number, was done to determine how well the implant had been embedded in the jaw bone. The measurement indicated a well-integrated implant with the bone; therefore, the implant was ready to support a crown. A Trois digital scanner was used to take an impression of the teeth and implant. The digital data were sent to a dental laboratory. A digital model was printed with the implant analogue embedded in it in the same way as the actual implant in the month.

A crown made with Zirconia material was made that fit onto the implant. The crown was then secured to the implant with a screw in the mouth that must be tightened with a torque wrench.

After the crown was securely screwed onto the implant, a composite resin was used to fill in the screw hole. In this case, it is a screw-retained crown. A screw-retained crown is desirable because of its ability to be removed easily from the implant if the crown is chipped and requires removal for repairs. If there is periimplantitis (bone loss around the implant due to infection), the crown must be removed for proper treatments.

The implant without the cover.
5. The implant without the cover.
The crown was made on the digitally printed model.
6. The crown was made on the digitally printed model.
The crown was tightened onto the implant with a special wrench.
7. The crown was tightened onto the implant with a special wrench.
The crown was secured onto the implant and became functional.
8. The crown was secured onto the implant and became functional.
Blog

A Recent Implant Case Requiring Bone Grafting

A few days ago, I was performing extraction of an upper front tooth and bone graft.
The patient has cardiovascular disease and is on a blood thinner. She also has a chronic mucogingival disease called Lichen Planus, which expresses red swollen inflamed gum tissues in her mouth.

After the initial examination, co-diagnosis of the conditions, treatment options, and discussions, the patient elected to extract the tooth and implant-supported crown to replace the tooth.

The case appeared to be an easy extraction and implant placement immediately right after into the socket. However, after a cone-beam tomography (CBCT) was taken on that area, the images show that there is not enough bone in the nasolabial area to accommodate an appropriate implant for the future crown. Besides, the tooth’s root was too close to the bone surface on the labial side that the bone would likely break apart during the extraction, leaving behind a large depression in the alveolar bone. Another discovery is the proximity to the nasopalatine canal, one of the vital organs that an implant should avoid touching.

Due to the above discoveries from the 3-D CBCT, the initial plan was to extract the upper front tooth and preserve the labial (buccal) bone covering the root as much as possible and the bone graft of the entire buccal area to promote bone formation for a future implant in 6 months.

A temporary, provisional tooth will replace the extracted tooth using the teeth beside for attachment.

Those were the plans.

Because of her medical conditions, I contacted her cardiologist for medical consultations and clearance for the proposed extraction and bond graft.
The patient was given oral antibiotics and an antiseptic mouth rinse before the procedure to minimize post-operative infection of the site.

Local anesthetics were given to the patient. The tooth was first cut with a diamond bur vertically from the top to the root, hoping to preserve a sliver of the tooth on the facial (labial, buccal) side to maintain the bone there. However, the bone was so thin that it broke off while removing the rest of the root, so there was no buccal wall for the socket, leaving a defect behind.

Vertical incisions were then made on both sides of the defect on the labial side. The gums were peeled off the defect and raised. A resorbable collagen membrane was trimmed to size and tucked underneath the raised gums (flap). Human feezed dried cortical and cancellous bone chips were mixed with bovine bone particles. After the bone chips and particles were adequately hydrated with sterilized saline solution, they were packed into the defect and underneath the membrane to fill up the defect and beef up the nasolabial area’s volume. The resorbable membrane was then curled over the socket’s cervical opening on the top to cover it. Another membrane made with polytetrafluorethylene (PTFE) was placed over the collagen membrane. The facial flap was sutured to approximate with the palate’s gums (the facial flap was made tension free before the suturing to make sure it covered the membranes’ full surface placidly with the suture stabilization.

A prefabricated temporary tooth was then tried to make sure it was sitting at the same position as the extracted tooth and was not pushing against the flap. Otherwise, the temporary tooth will affect the healing and attachment of the gums together. After some adjustments were made to ensure the false tooth would not pushing against the surgical site, the temporary tooth was then attached to the other teeth besides the extracted tooth using composite resin. Occlusion was checked and adjusted. The surfaces were polished smooth to reduce bacteria and plaque adhesion.

Post-operative instruction sheets were given and discussed with the patient in detail to make sure the healing will be non-eventful.
During the healing phase, the primary goals are for the gum tissues to completely heal over the membranes and fused with the other gum tissues together to disallow any invasion of pathogens into the surgical site. For the gum tissues to stay put and the gums’ epithelial cells to grow together, non-disturbance of the site for at least two weeks is essential. The second goal is to avoid infection taking place before the gums are healed. Systemic antibiotics and topical mouth rinses were prescribed and continued to be taken during the initial healing phase.

In about a week, the patient will come back for the suture removal.

I will continue to update the progress of this case in my future blogs.

Office Is Open

Call Dr. Wong at his dental clinic at (289)-861-5111, Affinity Dental Care, if you want to speak to Dr. Wong about bone grafting. Check out our Burlington Affinity Dental Care location.

     

    Blog

    Biolase Diode Laser and Oral Health

    After implementing laser dentistry in my practice earlier this year, I had the privilege of doing a few procedures that I normally would not do or would not be able to do – mainly for the fear of haemorrhaging during and after the procedures, the complexity of the techniques with conventional methods, less predictable results and severity of post-operative pain level.

    The Biolase Epic X simplifies the procedures by having the preprogramed settings for the different treatments that it can do. Namely: gingivectomy, troughing, curettage, excision, frenectomy, implant recovery, perio pockets, pulpotomy, crown lengthening, infected pockets, endo, haemostasis, aphthous ulcer, and exposure.

    The procedures mentioned above that my laser can be used requires less numbing of the operative area, sometimes only topical aesthetic gel is adequate enough to achieve adequate anesthesia.

    Gingivectomy

    When the gum tissues are inflamed, the tissues overgrow and enlarge in size. The results are both unsightly and unhygienic due to the formation of gum pockets. I can utilize the laser to trim the excessive tissues off precisely to where I want and the healing is quick and noneventful.

    Troughing

    Troughing is a technique that a laser is used to create a space between the gums and the edge of a filling or a crown preparation. With the gums not covering the edge of the preparation, I can place my filling nicely and cleanly onto the tooth right to the margin within interference and contamination. When trough is used in a crown preparation, the margin is fully exposed and clean of other debris for a very precise impression of the preparation to be taken.

    Curettage

    The other term for the procedure is called Laser-Assisted Periodontal Therapy (LAPT). It is a non-surgical periodontal therapy that minimize the generation of aerosol with potential pathogens. It is utilized to remove the inflamed granulation tissues lining inside the gum pockets. The inflamed linings are full of pathogens, toxins and other inflammatory tissues. By removing the granulation tissues and the associated noxious microorganisms and substances, the gums can heal back to their normal healthy state.

    Excision

    The laser tip can be used to excise unwanted tissues or tumours like fibroma, overgrown gingival papillae, papilloma, and frictional keratosis etc. The cut is clean and precise with minimal trauma to the neighbouring healthy tissues. The excised tissues can be used for biopsy as well.

    Frenectomy

    In our mouths, we have a total of 7 frenum in each. They are thin, linear ligamental tissues that connect the lips, tongues or the cheeks to the gums. In severe cases, the attachments are so high and strong that they actually hindering the movements of the tongues or lips. Frenectomy is the procedure that severe the ligaments so that the lips or tongues can move more freely without pulling and damaging to the attached tissues.

    Implant Recovery

    It is an incisional procedure using a laser tip to cut the gum tissues covering the implants in order to expose the implant. The cuts would have minimal bleeding and the healings are fast.

    Perio Pockets

    When the periodontal pockets are deep, laser can be used to reduce the depth of the pockets by trimming the top swollen gums off to reduce the overall pocket depths. In conjunction of laser in non-surgical pocket curettage, the remaining gum tissues can regenerate and heal up nicely.

    Pulpotomy

    In some cases, the infected pulp of a disease tooth can be removed and disinfected simultaneously, leaving the healthy, uninfected live tissues in the roots for healthy healing and regeneration (after the opening is covered with bioactive and compatible materials like Biotene or mineral trioxide aggregate).

    Crown Lengthening

    When a smile is gummy (the upper front teeth appeared to be short and square), the excessive gum tissues can be trimmed off nicely with fine margins that will heal nicely and precisely to improve the smile.

    Infected Pockets

    In other word, it is called laser bacterial reduction (LBR), the bad gum disease causing bacteria found inside the pockets are susceptible to the laser when the right wavelength is used. The laser specifically kills the bacteria but sparse the healthy gum tissues inside the pocket during LBR. It is a very useful tool to reduce bacterial counts inside pockets.

    Endo

    After the root canals are adequately cleaned and shaped with the conventional root canal therapy, laser can be used to target the laser-vulnerable bacteria residing inside the infected canals. The main factor of a successful endo treatment is creating aseptic canals and laser is a very good tool to achieve the goal.

    Haemostasis

    When the laser hit the bleeding vessels/capillaries, several things can happen. If the temperature at the site is kept at about 60 degree Celsius, coagulation of the blood will happen and the bleeding stops.

    Aphthous Ulcer

    Low-level laser therapy (LLLT) has the potential to treat aphthous ulcer and related lesions. In addition to reducing the pain and discomfort, LLLT also stimulates healing of ulcers by activating the mitochondria activities inside the cells.

    Exposure

    Exposure here refers to making a nice clean nonbleeding opening through the soft tissues to expose the impacted tooth (most of the cases are impacted upper canine) so that an orthodontic bracket can be attached to it to guide it down into the proper position.
    Besides the 14 applications delineated above, there are two more applications including teeth whitening and temporal mandibular joint pain control with the Biolase Epic X laser.

    Office Is Open

    Call Dr. Wong at his dental clinic at (289)-861-5111, Affinity Dental Care, if you want to speak to Dr. Wong about your oral health issues that can be related to your overall health. Smile is the key to better total body health. Check out our Burlington Affinity Dental Care location.

       

      Blog

      Teledentistry for Orthodontic Treatments with Aligners

      During this unprecedented time in history, social distancing and non-contact are the norms for our daily lives. The regular visits to your dental clinics are also affected by this new normal. Teledentistry, a concept turned into reality in some aspects of dentistry. For example, dentists can do the initial dental consultation, triage the severity of the problem, and assess the likely reasons for the complaints using computers, mobile phones, or laptops over the internet.
      In this new era, dentists can initiate, process, monitor, and complete orthodontic treatments using aligner trays over the internet. At least for most of the treatments.

      How does teledentistry work?

      Patients interested in having orthodontic treatments using clear aligner trays can contact Dr. Wong at Affinity Dental Care to get initial virtual consultation done. Before the meeting, a team member at Affinity Dental Care will email forms to the patients to complete their medical and dental history ahead of the meeting. During the consultation, I will review the patients’ medical history and conditions that may affect teeth and bone remodeling movement during orthodontic treatments. I will also look at their Dental history for brushing habits, high carbohydrate diets or poor diets, smoking, temporal mandibular dysfunction, and regular dental visit habit. Necessary dental X-rays are required to complete the examination. If the patients have recent X-rays taken in another dental office, my clinic can request the information transfer to us with permission from the patients. Dental X-rays are essential adjuncts for detecting conditions like missing, tilted, rotated, short-rooted, dilacerated, impacted, or over-erupted teeth. They are also crucial for finding out oral pathologies, cavities, bone density, bone loss, temporomandibular dysfunctions, etc.

      If the cases are deemed suitable, and there are no contraindications that need treatments to ratify first, the patients need to take photographs of the teeth and face (front and profile) and impressions of their teeth.

      There is a device that patients can use to help them to take the before mentioned photographs themselves using their cell phones at home. DenToGo developed the device and associated apps. Once the patients decide to move on to the next step with the treatment, Affinity Dental Care will mail the package to the patients with instructions. A team member can travel to their homes to take the teeth’ impressions using a digital scanner. The images taken by the scanner are very accurate, such that the subsequent treatment plannings are more precise and have fewer errors in the measurements.

      If X-rays are missing and needed, the patients can either come to my office to have them taken or go to another clinic to have them taken and have them transferred to my office later.

      I can make a final diagnosis of the malocclusion and treatment plan to address the patients’ wants once I have all the information. Subsequently, the data and my requirements for the aligner treatments will be uploaded to ClearCorrect or other aligner providers to digitally planned out the movements of teeth.
      In my portal, I can virtually see the teeth’ movements at different treatment stages to the final results of the straight and aligned teeth.

      Once I see the virtual movements meet my provided requirements, I will approve the plans, and ClearCorrect will make a set of trays. Typically, I prefer to insert the first set of trays in the office to ensure the trays can sit perfectly on their teeth as planned, and the patients can remove and insert them properly in my chair. During the first visit or subsequent visits, I will also add the engagers on the teeth if needed. Sometimes even interproximal strippings are done if they are required to gain more spacings for teeth to move and align properly. I will provide the patients with the rest of the trays to bring home to change to the next sets on their own if the patients are capable.

      The trays can also be mailed to the patients directly if they can follow instructions online with me. Either way, the patients will be given supervision over the internet using the DenToGo apps on their phones. During the treatments, patients will need to scan their teeth periodically using their phone and upload the images to me to monitor their compliance, the fitting of the trays, and the expected improvements. Additionally, it also can detect some dental diseases like gingivitis and cavities. It allows for more efficient patient scheduling, increased patient compliance, and personalized messaging.

      For Affinity Dental Care’s existing active patients who want to have straight, nice teeth and smile, I will review their file to ensure enough required information. I will also check whether their oral care is up-to-date and no contraindications against having aligner treatment. Once I see that all the criteria are met, my office will mail them the DenToGo package to take the diagnostic photographs of their teeth and facial aesthetics necessary for the orthodontic diagnoses. After the patients complete the pictures, they can send the information to my office using the provided secure messaging apps.

      The apps can also do virtual checks and scans, communicate with Affinity Dental Centre, and book the necessary appointments whenever and wherever the patients want.
      Patients can have the treatment, monitoring, and supervision done virtually without stepping into the office, except for adding engagers on the teeth, interproximal stripping, auxiliary attachments and teeth cleaning and check-up, etc.

      If you are interested in getting your teeth straightened out using the Clear Aligners, you can contact Dr. Wong at Affinity Dental Care for more information.

      Office Is Open

      Call Dr. Wong at his dental clinic at (289)-861-5111, Affinity Dental Care, if you want to speak to Dr. Wong about your oral health issues that can be related to your overall health. Smile is the key to better total body health. Check out our Burlington Affinity Dental Care location.

         

        Blog

        Happy Thanksgiving

        Affinity Dental Care Thanks YOU

        We, Dr. Kenneth Wong, Josie, Jovina and Natalia, as a Burlington wellness-based family dental practice, would like to express our huge gratitude to our patients who have trusted us for their dental care in the past year.
        We have grown in the number of patients who choose us as their family dentist, and a big part owes to those who have referred their friends and family to us; thanks for sharing the love and Affinity Dental Care’s commitment to providing dental services to our community.
        We are also fortunate enough to have strong support from some advanced equipment providers like Biolase for dental lasers, ClearCorrect for their orthodontic aligners, and Biohorizon for their dental implant and surgical equipment.
        It may sound too cliché but we truly appreciate every one of you and your continuous support from the bottom of our hearts.

        Call Dr. Wong at his dental clinic at (289)-861-5111, Affinity Dental Care, if you want to speak to Dr. Wong about your oral health issues that can be related to your overall health. Smile is the key to better total body health. Check out our Burlington Affinity Dental Care location.