DrToddWelch: Immediate Dental Implant Placement

DrToddWelch: Immediate Dental Implant Placement: "Dental Implants Overview Dental implants are rapidly becoming a routine procedure in today’s dentistry. In many clinical situations, impl..."

Immediate Dental Implant Placement

Dental Implants Overview Dental implants are rapidly becoming a routine procedure in today’s dentistry. In many clinical situations, implants are the number one choice of restoration for missing teeth. The most commonly used implants are The Endosseous implants.There are also other kinds of implants  in dentistry, but they are used rarely today.  I will try to describe here procedures and use of endosseous dental implants. Implants in dentistry is a very fast developing field. That is why there are many different manufacturers producing endosseous implants. The will differ in shape and form; their available sizes can slightly differ. The most accepted material for dental implants is either high grade Titanium (Commercial Pure) or Titanium alloy. The titanium alloy implants tend to be stronger than the CP titanium implants. The bone integration shows no difference to the two different types of titanium.

Renova Implant

Endosseous Implants If you look at the implant from the side, it resembles a screw. The outer surface of the implant may have different coatings stimulating bone growth, or it may just have smooth or roughened surface.

Bicon Implants

External and Internal Hex Implants The top part of the dental implant is called Hex. It has a locking mechanism, which may be inside the body of the implant- internal hex implants, or stick as a platform above the body of the implant-external hex implants. Also, if you look at the implant from the top you will see the threaded ‘canal’ in the middle of the hex going down the body of the implant. The future restoration will be seated on the hex and screw tightened to the implant. It is doctor's preference which type of implants to use. I prefer internal hex implants for these reasons: they give a better retention for the future restoration, and they can be placed slightly deeper allowing for more cosmetic restorations.

External Hex Implant Internal Hex Implant

Dental implants come in various thicknesses and length.  Your anatomy and bone levels dictate the size of the implant that can be placed.  The longer, thicker implants usually last the longest.

 It is each doctor’s preferences to decide which type of implant to use. However, their basic principle is the same. Endosseous implants or Root-formed implants are the anchors, which are placed inside the bone of the jaw and substitute the root part of the tooth. You must remember that implant is just a support for future restoration.Endosseous implants can be used:

·       To support single crown for one missing tooth,

·       Two or more implants can be used as a support for fixed bridge restoration and one of best alternatives in restoring missing teeth

·       Implants can be used as a retainer of removable dentures

Integration of live tissue with the implant

How and why implants work?

After dental implant is placed inside the bone, it usually takes about 2 to 6 month for the implant “to heal”. Actually, we are waiting for the implant to bond with the surrounding tissue – a process known asosseointegration. Osseointegration was a term coined by a Swedish Professor Per-Ingvar Brånemark in 1952 when he discovered the ability of living tissue to integrate with titanium.Osseointegration has been described as a direct structural and functional connection between living bone and the surface of a load carrying implant. During his original research, Prof. Brånemark found a way of using pure titanium as an anchoring unit and support for a variety of prosthetic reconstructions. The long-term predictability and success of Dental implants is based on the fact that an active bond between bone and implant is created at the molecular level. The fixture is not only accepted but also incorporated within the bone. 

The implant procedures

There are different techniques that can be used for the surgical placement of the dental implant. It depends on the particular conditions of the case, doctor’s preferences, and dental implant system used. First let's take a look on a classical 2 step implant surgery, which is the most common technique used for dental implant placement. 

Classical 2 step implant surgery   1. When you come for the surgery, you will be given a surgical consent form, describing the procedure and possible complications. It is a good time to address any questions and concerns. After you sign the consent form, you will be anesthetized and surgery will soon begin.

Edentulous area to be restored by implants

2. Doctor will make a cut in you gum along the crest of the bone and push it to the sides to access the bone.

3. Using different sizes of special drills, doctor will drill inside the bone to make a path for an implant. Doctor will start with thin drills, gradually moving to thicker ones. The diameter of last drill will be slight smaller than the diameter of the selected implant. Surgical drills have a canal inside its body to allow constant water irrigation, which is necessary to cool down the bone, preventing it fromoverheating. 4. Implant is screwed inside the bone. Necessary x-rays can be taken during the procedure

X-ray showing surgically placed dental implants

5. A surgical cover screw is inserted into the top if the implant to prevent bone and tissue to grow inside the implant.

6. Gum is placed back and sutures are used.

Doctor will give you all necessary prescriptions and instructions. In 7-10 days, you come back for suture removal and follow up. There will be several other follow-up visits to monitor the healing process until such time that the implant is ready to be restored with a prosthetic.

Stage 2 –Uncovering the implant What happens after dental implant is osseointegrated? After the doctor has concluded that implant integration is complete, the dental implant has to be uncovered: Local anesthesia is administered. A small incision is done in the gum, allowing doctor to unscrew the surgical cover screw. Healing cover placed instead of the surgical screw, projects above the gum preventing it from closing over the implant. Sutures  are placed to hold the gum back in place. One week later doctor will remove stitches, and after few more days of healing implant is ready for restoration.

Left dental implant with healing collar Implants with restoration abutments (posts)

Immediate Placement Of implant

(Implant Placement into fresh extracted site)

When the tooth has to be extracted, and the implant is a choice of treatment for substitution of removed tooth, immediate placement of implant into extracted site could be done. There are a lot of advantages to this technique. In aslassical 2 stage technique described above, after the extraction is done, we would wait for about 6 month for the bone to build up, and then proceed with the implant surgery. The immediate placement of implants eliminates this 6 month waitng period, no second surgery required, healing process of implant (osseointegration) runs as natural process(your body buids up the new bone in the extracted site where the implant placed. There are some limitations though, when this procedure can be done (severe infection, cortical bone lose). Your doctor will advise you if the immediate placement of implant is the right procedure for you.

The next implant case presentation describes surgical placement of two implants, one of them is classical two stage technique, another is the extraction and immediate placement of implant.

Implants case presentation 53 years old female presented in the office for exam. Intaraoral and X-ray examination revealed severe decay under the crownsupporting the bridge. The decay was so extensive, that the tooth was unable to be saved. Since the other teeth under the bridge did not require any urgent treatment, it was decided to cut the bridge, leaving anterior crowns intact (teeth # 20,21), extract back tooth (#18), and place teeth implants in the area of missing #19 and extracted # 18. Patient accepted treatment plan and scheduled appointment for surgery. 4.7 mm diameter and 13 mm length internal hex Zimmer implants were planned to be placed. Patient was explained the nature of the surgery and possible complications. All her questions were answered.

X-ray showing Decay under the crown # 18  Intraoral picture of existing bridge

Patient was anesthetized, and the bridge was cut between crown # 20 and pontic 19. Back part of the bridge was removed.

Bridge was cut

Demolished # 18 ( after bridge removal)

 Incision was made along the crest of the bone between demolished # 18 and tooth #20. Periosteal flap reflected using periosteal elevators. The remaining roots of the # 18 carefully extracted with luxators to preserve integrity of the bone.

Periosteal Flap opened

Tooth # 18 is removed

Osteotomy was performed in the area of planned implant sites. Drills of increasing sizes were used. The widest drill 4.4 mm was used to make a 13 mm path for the implant.

Each tooth implants is placed in corresponding sites. Hand ratchet is used to screw the implant (with implant driver) into the place. Control X-ray is taken.

Implant with implant driver placed in the bone

Same picture from a different angle

X-ray showing implants in place

Implant drivers removed and position of each tooth implant was verified.

Implant driver removed

 Surgical cover screw placed into the tooth implant

Gum placed in its place and silk sutures placed to hold the gum. Patient is given instructions and due back in the office in one week for removal of sutures.

Sutures placed

One week later sutures were removed and patient is scheduled in two weeks for the follow up visit.

Sutures removed

One Step Implant Placement Procedure

Depending on the particular situation 1 step surgical implant placement technique may be used. Instead of making a line incision and opening the flap doctor will use the special round knife("tissue puncher")  to cut off a round piece of the gum in the area of projected implant(punch technique). Ostoetomy performed thru this opening, and the implant screwed directly in. Instead of puting the surgical cover, doctor will place righty away the implant healing color, having itexposed above the gum line and preventing the gum from closure.Implant remain exposed and there is no need for the second surgical stage -openning of the implant. This technique is used more and more. Besides the fact that there is no need for second surgery, the postsurgical discomfort and pain much less than in a 2 stage technique procedure.

 

Immediate Load implants

Please come back soon for revolutionary Immediate Load implant restorations

Indications and Contraindications

Generally, any edentulous (toothless) area, having enough bone support can be an indication for restoring missing tooth with implant. A decision has to be made whether it is a good idea based on the patient’s requirements and expectations, and on case-by-case bases. The doctor will consider many things before advising you on one or another treatment options. Even though there is practically no absolute contraindications for placement of implants, there are few factors that can put it in a high risk situation.
 The risk factors are

·       Endocrine disorders, such as uncontrolled Diabetes Mellitus, Pituitary and Adrenal insufficiency and Hypothyroidism can cause considerable healing problems.

·       Uncontrolled granulomatous diseases, such as Tuberculosis and Sarcoidosis may also lead to a poor healing response to surgical procedures.

·       Patients with cardiovascular diseases, taking blood thinning drugs and patients with uncontrolled hematological disorders such as Generalized Anemia, Hemophilia (Factor VIII deficiency), Factor IX, X and XII deficiencies and any other acquired coagulation disorders are contraindicated to surgical procedures due to poor hemorrhage control. (In most cases medicine can be stopped for a few days with permission of your medical doctor)

·       Patients with bone diseases, such as Histiocytosis X,  Paget's Disease and Fibrous Dysplasia may not be good candidates for implants, because there is a higher chance for the implant to fail due to poor osseointegration

·       Cigarette smoking

·       Patients receiving radio and chemotherapy should not do implants within 6 month period of therapy

If you have any questions concerning this procedure please contact Dr. Todd Welch at West Tennessee Periodontics and Dental Implants at 731-215-2347.

DrToddWelch: Under Armour Performance Mouthpiece available at C...

DrToddWelch: Under Armour Performance Mouthpiece available at C...

Under Armour Performance Mouthpiece available at Columbus Family Dental ...

DrToddWelch: Improving A Gummy Smile

DrToddWelch: Improving A Gummy Smile: "Improving A Gummy SmileIs your smile more red than white? Large gums or short teeth can give your mouth an imbalanced, 'gummy' look. Fortun..."

Improving A Gummy Smile

Is your smile more red than white? Large gums or short teeth can give your mouth an imbalanced, "gummy" look. Fortunately, periodontal options can give you a brand new smile.

Excess gum tissue can create the appearance of short teeth and a "gummy" smile—and make your oral health more difficult to manage. A periodontist, or gum specialist, can remove excess gum tissue to give your mouth a new look. A number of factors can cause "gumminess":

    · Inadequate Normal Gum Recession or Altered Passive Eruption: As the teeth erupt (grow out of the gums), the gums recede upwards—most of the time. In some cases, the gums remain and cover part of the teeth, making normal-sized teeth look short.

    · Irritation from Braces: If a patient has excessive gum tissue at the time of orthodontic treatment, the gums can become irritated by the braces, in spite of proper oral care.

    · Mouth Breathing: Nasal or adenoid problems can lead a patient to breathe through the mouth, especially at night. This habit dries out the gum tissue, leaving it susceptible to disease and overgrowth.

    · Medication: Medicine such as Diclatin and Cyclosporine can lead to gum tissue overgrowth.

    · High Lip Lines: The shape of the patient's mouth can sometimes bare more of the gum tissue than is visible in the average person's mouth.

Gummy smiles can also be caused by attrition, a condition where the teeth have been severely worn down. This case is one where the teeth seriously are too short. Bad habits such as nighttime teeth grinding can cause this wear. This problem can be corrected by tooth lengthening surgery, topped off with caps or crowns to cover the newly lengthened teeth.

Gingivectomy/Gingivoplasty. Gum tissue is surgically excised. The underlying bone is not exposed. A periodontal dressing covers the teeth and gums post-surgery to protect them while healing. The patient may experience pain during the procedure, but usually not after.

Flap Surgery. Some of the underlying bone is removed. This surgery is required for short or worn down teeth, or for thick or irregular bone contours (the bone at the meeting point of the gum and teeth). Post-operative care includes sutures, or stitches, and a periodontal dressing to cover the healing gums. This surgery tends to bring more discomfort than a gingivectomy.

Crown Lengthening. The dental equivalent to trimming cuticles. A cosmetic dentist or periodontist shifts your gums to a position that reveals more of your teeth and less of your gums. This procedure can also be called gum lift or gum re-contouring, and may involve cutting out gum and bone around the teeth. In cases where the tooth is badly damaged or decayed, the goal of the crown lengthening procedure may simply be to expose enough of the tooth so that a restoration procedure can be performed.

Laser Gum Surgery. Dr. Welch uses a laser to remove excess gum tissue. The results are similar to a gingivectomy.

For more information, contact Dr. Todd Welch at West Tennessee Periodontics and Dental Implants at 731-215-2347 or visit his website at www.wtnperio.com.

DrToddWelch: Periodontitis

DrToddWelch: Periodontitis: "Periodontitis is inflammation and infection of the ligaments and bones that support the teeth.Causes Periodontitis occurs when inflammation..."

Periodontitis

Periodontitis is inflammation and infection of the ligaments and bones that support the teeth.

Causes 

Periodontitis occurs when inflammation or infection of the gums (gingivitis) is untreated or treatment is delayed. Infection and inflammation spreads from the gums (gingiva) to the ligaments and bone that support the teeth. Loss of support causes the teeth to become loose and eventually fall out. Periodontitis is the primary cause of tooth loss in adults. This disorder is uncommon in childhood but increases during adolescence.

Plaque and tartar accumulate at the base of the teeth. Inflammation causes a pocket to develop between the gums and the teeth, which fills with plaque and tartar. Soft tissue swelling traps the plaque in the pocket. Continued inflammation eventually causes destruction of the tissues and bone surrounding the tooth. Because plaque contains bacteria, infection is likely and a tooth abscess may also develop, which increases the rate of bone destruction.

Symptoms 

• Breath odor
• Gums that appear bright red or red-purple
• Gums that appear shiny
• Gums that bleed easily (blood on toothbrush even with gentle brushing of the teeth)
• Gums that are tender when touched but are painless otherwise
• Loose teeth
• Swollen gums

Note: Early symptoms resemble gingivitis.

Exams and Tests 

Examination of the mouth and teeth by the dentist shows soft, swollen, red-purple gums. Deposits of plaque and calculus may be visible at the base of the teeth, with enlarged pockets in the gums. The gums are usually painless or mildly tender, unless a tooth abscess is also present. Teeth may be loose and gums may be receded.

Dental x-rays reveal the loss of supporting bone and may also show the presence of plaque deposits under the gums.

Treatment 

The goal of treatment is to reduce inflammation, eliminate pockets if present, and address any underlying causes. Rough surfaces of teeth or dental appliances should be repaired. General illness or other conditions should be treated.

It is important to have the teeth cleaned thoroughly. This may involve use of various instruments or devices to loosen and remove deposits from the teeth (scaling). Meticulous home oral hygiene is necessary after professional tooth cleaning to limit further destruction. The dentist or hygienist will demonstrate brushing and flossing techniques. It is often recommended that patients with periodontitis have professional tooth cleaning more frequently than twice a year.

Surgery may be necessary. Deep pockets in the gums may need to be opened and cleaned. Loose teeth may need to be supported. Your dentist may need to remove a tooth or teeth so that the problem doesn't get worse and spread to nearby teeth.

Outlook (Prognosis) 

Some people find the removal of dental plaque from inflamed gums to be uncomfortable. Bleeding and tenderness of the gums should go away within 1 or 2 weeks of treatment. (Healthy gums are pink and firm in appearance.)

You need to follow careful oral hygiene for your entire life or the disorder may return.

Possible Complications 

• Infection or abscess of the soft tissue (facial cellulitis)
• Infection of the jaw bones (osteomyelitis)
• Return of periodontitis
• Tooth abscess
• Tooth loss
• Tooth flaring or shifting
• Trench mouth

If you have any questions, pleased call Dr. Todd Welch at West Tennessee Periodontics and Dental Implants at 731-215-2347.

DrToddWelch: Cold Sores

DrToddWelch: Cold Sores: "Image via Wikipedia Signs and symptomsHerpes infections often show no symptoms; when symptoms do appear they typically resolve within two ..."

Cold Sores

Image via Wikipedia

Signs and symptoms

Herpes infections often show no symptoms; when symptoms do appear they typically resolve within two weeks. The main symptom of oral infection is inflammation of the mucosa of the cheek and gums—known as acute herpetic gingivostomatitis -- which occurs within 5–10 days of infection. Other symptoms may also develop, including headache, nausea, dizziness and painful ulcers—sometimes confused with canker sores—fever, and sore throat. Primary HSV infection in adolescents frequently manifests as severe pharyngitis with lesions developing on the cheek and gums. Some individuals develop difficulty in swallowing (dysphagia) and swollen lymph nodes (lymphadenopathy). Primary HSV infections in adults often results in pharyngitis similar to that observed in glandular fever (infectious mononucleosis), but gingivostomatitis is less likely.

Recurrent oral infection is more common with HSV-1 infections than with HSV-2. Symptoms typically progress in a series of eight stages:

• 1) Latent (weeks to months incident free): The remission period; After initial infection, the viruses move to sensory nerve ganglia (Trigeminal ganglion), where they reside as life-long, latent viruses. Asymptomatic shedding of contagious virus cells can occur during this stage.
• 2) Prodromal (day 0-1): symptoms often precede a recurrence. Symptoms typically begin with tingling (itching) and reddening of the skin around the infected site. This stage can last from a few days to a few hours preceding the physical manifestation of an infection and is the best time to start treatment.
• 3) Inflammation (day 1): Virus begins reproducing and infecting cells at the end of the nerve. The healthy cells react to the invasion with swelling and redness displayed as symptoms of infection.
• 4) Pre- Sore (day 2-3): This stage is defined by the appearance of tiny, hard, inflamed papules and vesicles which may itch and are painfully sensitive to touch. Eventually, these fluid-filled blisters form a cluster either on the lip (labial) tissue, the area between the lip and skin (vermilion border), and can occur on the nose, chin, and cheeks.
• 5) Open Lesion (day 4): This is the most painful and contagious of the stages. All the tiny vesicles break open and merge to create one big, open, weeping ulcer. Fluids are slowly discharged from blood vessels and inflamed tissue. This watery discharge is teeming with active viral particles and is highly contagious. Depending on the severity, one may develop a fever and swollen lymph glands under the jaw.
• 6) Crusting (day 5-8): A honey/golden crust starts to form from the syrupy exudate. This yellowish or brown crust or scab is not made of active virus but from blood serum containing useful proteins such as albumin and globulins. This appears as the healing process begins and should not be scraped or picked at. The sore is still painful at this stage but more painful, however, is the constant cracking of the scab as one moves or stretches their lips, as in smiling or eating. Virus filled fluid will still ooze out of the sore through any cracks.
• 7) Healing (day 9-14): New skin begins to form underneath the scab as the virus retreats back into latency. A series of scabs will form over the sore (Called Meier Complex), each one smaller than the last. During this phase irritation, itching, and some pain are common.
• 8) Post scab (2–14 days): A reddish area may linger at the site of viral infection as the destroyed cells are regenerated. Virus shedding can still occur during this stage.^[8]

The recurrent infection is thus often called herpes simplex labialis. Rare reinfections occur inside the mouth (intraoral HSV stomatitis) affecting the gums, alveolar ridge, hard palate, and the back of the tongue, possibly accompanied by herpes labialis.

Herpes labialis infection occurs when the herpes simplex virus comes into contact with oral mucosal tissue or abraded skin of the mouth. Infection by the type 1 strain of herpes simplex virus (HSV-1) is most common, though cases of oral infection by the type 2 strain are increasing. Cold sores are the result of the virus reactivating in the body. Once HSV-1 has entered the body, it never leaves. The virus moves from the mouth to quietly reside (“remain latent”) in the central nervous system. In approximately one third of people, the virus can “wake up” or reactivate to cause disease. When reactivation occurs, the virus travels down the nerves to the skin where it may cause blisters (cold sores) around the lips, in the mouth or, in about 10% of cases, on the nose, chin, or cheeks. Cold sore outbreaks may be influenced by stress, menstruation, sunlight, sunburn, fever, or local skin trauma. Surgical procedures such as dental or neural surgery, lip tattooing, or dermabrasion are also common triggers. HSV-1 can rarely be transmitted to newborn babies by family members or hospital staff who have cold sores; this can cause a severe disease called Neonatal herpes simplex. People can transfer the virus from their cold sores to other areas of the body, such as the eye, skin, or fingers; this is called “autoinoculation." Eye infection, in the form of conjunctivitis or keratitis, can happen when you rub the cold sore, then rub your eyes before washing your hands. Finger infection (herpetic whitlow) can occur when a child with cold sores or primary HSV-1 infection sucks his/her fingers. HSV-1 can infect the genital area by engaging in oral sex with a partner with a cold sore.

Treatment

Acidophilus and yogurt, full of lactobacillus, also helps get rid of cold sores more easily. Its cultures can halt a cold sore from growing if taken right when the sore begins to develop. Acyclovir and penciclovir are used, although the shortening of duration of healing, pain and www.wtnperio.comdetectable virus is, at maximum, one day. Both are nucleoside analogues, being purine analogues of guanine. Furthermore, Famciclovir and Docosanol are in use for treatment against Herpes labialis. Laser therapy is a new option: A single 5 minute 1072 nm narrow waveband light application treatment has been shown to significantly reduce cold sore healing time by 4 days.

Lysine has been found to be effective for decreasing the frequency of outbreaks.

Zinc oxide/glycine cream is an effective treatment for facial and circumoral herpes infection. Zinc sulphate appeared to reduce both the number of episodes and the time to recovery of herpes labialis.

For more information on cold sores and how the PerioLase can help, contact Dr. Todd Welch at

West Tennessee Periodontics and Dental Implants at 731-215-2347.

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