Too much gums!? What do you do?

It was nice to have a day off and everyone in the city is always in a good mood this time of year...at least those of us who are not vacationing somewhere!!
Today a patient came in who had lost all the teeth on one side of his lower jaw...the implant surgeon placed three implants and we will be restoring the entire lower right area with implants.
Here is the photo of the the front two implants...

Today's procedure is really only about the front two of the implants as they will support a three tooth bridge...while the last back implant will have a single cap restoration...so take a close look at the front two...


This is a situation where the gums that are between the two implants are very high and bulbous and any artificial tooth placed on this will both not look natural and will collect food underneath...so...we will recontour the gums, place a temp bridge for about a month, let it heal and then hopefully have a better gum contour when we see the patient next...
so here we have anesthetized the patient and gently recontoured the gums...

And a three tooth temp bridge has been placed...this bridge will not only provide the patient with some teeth to chew but will hold our gums down in the area that we have reshaped them....we will work on the very back implant at a future appointment!

Happy Holidays!

Just got back from a few days in California...spent Christmas day at my office at 370 continuing to organize and set up the place for our return..now projected at sometime in January...
as usual... spent some time taking some photos...here are a few...click on either one to get a larger version

I can chew...I can chew...

Used to be that when you lost your teeth you did not have much choice...you had to wear a removable set of false teeth...called a full denture, which unfortunately is a poor substitute for real teeth in most cases...but with today's hi tech solutions, we have much more to offer our patients....specifically implants....
and it gives the patient a full set of teeth that are permanently placed in the jaw and really feel and chew like your own natural teeth....
Unfortunately...many people have come in and told me how they have heard that implants are so painful that they would never consider them...but when done properly they are incredibly painless and hugely rewarding...take a look...

This patient has been holding on to several of her own teeth which have been supporting a bridge...but the time has come where the natural teeth have to be removed...
Luckily she is a good candidate for implants and she will not have to wear a denture...she had 8 implants placed into the lower jaw about 6 months ago and now they are ready to have teeth placed on them...
the first step is to take the impressions...here is photo where the transfer copings are in place(arrows point to my transfer devices, including that plastic thing that looks like a lego piece)....and an impression of the entire lower jaw was made.

It is now two weeks later and the lab has fabricated new posts(abutments)that are screwed into the implants(which are in the bone)...The first thing I do is extract the four remaining teeth...I then try in all the implants and due to some good planning and a little luck all the implants screw down nicely....

It is now time to try in the temporary lower teeth...and again we have a nice result..the temps go right to place and with just a few minutes of adjustment we have a patient who has a full new lower set of teeth...they are cemented into her mouth with a temp cement...and she is thrilled...

The first thing you are probably thinking is wow..those are huge long teeth..but keep in mind that these photos are taken with a retractor and the patients lips and cheeks hide that length and she is beautiful...
And belive it or not this patient left the office on her own, met her husband and is going out to dinner!!

Stay tuned for more as we still have to convert these temps to porcelain caps and we are going to be doing the upper teeth as well....!!

New teeth for school...

Here is a satisfying result...
a college girl came in and was in need of some cosmetic work...
we only had a few weeks before she had to go back to school so we decided that we would do the upper teeth this time and the lower teeth at her next college break...
Here is a before and after for this young lady....
now get back to school!!

To drill or not to drill...that is the question?!

Sometimes we see teeth that pose a real dilemma....should I drill into a previously untouched tooth because I see a tiny defect or just leave it alone and watch it?
Keep in mind that just watching it, may mean watching it get bigger and more difficult to treat! Despite all the advances in dentistry and the hi tech tools sometimes diagnosis is still done by intuition and previous experience.
Take a look at today's dilemma...here is a tooth on someone who never had a cavity...while examining her I found that this molar had a defect in the enamel which was very suspicious...

I was actually able to place a pointed instrument called an explorer into this defect and feel that there was soft tooth structure at the bottom of this pit. So I decided to treat this defect.
Without any anesthetic I was able to take a tiny dental drill and sink a tiny hole into this defect which after a few seconds yielded nice clean healthy tooth structure. See the following photo to see how small the drilled area actually is...

The defect luckily had not yet penetrated through the enamel and I was able to bond a tiny little tooth colored filling into this shallow depression.

This tooth will probably retain this filling for many many years to come...and furthermore, I am sure that had I left this untreated, the defect would have continued to grow and the restoration would have been a much larger project.
The patient who had never previously had a cavity was thrilled that this was done with so little effort and no anesthetic...the entire procedure took about 5 minutes.

Scale the walls

So we always tell you to get those teeth cleaned at least twice a year....and some of you seem to always stretch that to once a year...and some of you to even more!! You know who you are!!
Well... just to convince you to get in here on a regular basis consider this set of photos...as usual click on any photo to get a better view...
this patient when viewed straight on seems to have a very nice set of relatively clean teeth...
but just take a little peek at the backs of those teeth and you see stuff that you don't want to see....

but not to worry..because with just one session of scaling and polishing we get back our nice clean teeth...

so next time you miss that cleaning appointment just keep these photos in mind!

Gold Mining..tooth style

A long time ago...in a world long removed from here, patients used to have large fillings made out of gold....and when done properly they would last a lifetime!
However when not done well they are extremely prone to decay and nasty things go on underneath them....and today's story is one of those gold filling failures.
Here is our tooth as we start...you can see several areas where there is a defective margin along the inlay.

After the initial excavation, we have quite a bit of decay evident...

Further excavation cleans up the mesial part of the tooth...however the remainder of the inlay still has decay underneath and I will unfortunately have to remove the entire inlay...

After removing the remainder of the gold we can see there is a considerable amount of decay that needs removal...

Finally after much excavation, although the tooth still is stained it is only discolored tooth structure and not decay...as it is very hard and has not softness...

I proceed to place a large tooth colored filling into the tooth and the patient is re-appointed and will start a crown at the next visit...


Have a good weekend!!

old to new...

I spent most of Wednesday at my office at 370 working to put things back in order...looks like there is no way that we will get in by Jan. 1...so when i had some time i did my other work...
a friend of mine needed an old photo restored and fixed so he came over and gave me some old prints to scan...
after a few minutes here is what I was able to do...black and whites properly restored, eliminated the cracks as best I could and after a few minutes this is what i got....click on the photo for a larger version...

Mix n' Match

Sometimes to get the desired result when a patient is missing several teeth we have to combine therapies. I am going to give you the photos in reverse order today.
This patient has been restored with 4 new teeth today as you can see in the first picture

Now to show you what we did take a look at the next photo and you can see that the first of the missing teeth was restored with a regular porcelain crown on the canine tooth...

The last three teeth have been restored with an implant supported bridge...as you can see there are two implants and a space..so two implant crowns were made and an artificial tooth is between them....

Just a little piece chipped off...

When I hear that phrase, I know there is trouble...the patient says...but doctor...just a tiny piece of the tooth chipped away. Well anytime a piece of tooth chips away the possibility for trouble exists. Take today's example...a new patient comes in and gives me that line! Have a look for yourself ....

So i explain to the patient that the tooth chipped because there appears to be a large amount of decay under the surface...and sure enough my initial excavation shows just that....
As I continue the excavation I have to extend to the other side of the tooth as well and on that side I also find a huge area of decay...
\
After a few minutes I have the area cleaned out of any decay and I have reached healthy tooth structure...
however..there is so much loss of tooth that anything less than a cap(crown)would put the tooth at risk for future breakage....and considering the massive amount of decay and lost tooth structure this patient will need the nerve removed as well....
So next time you've got just a little chip...make sure to come in right away!!

Can't sleep?? Snoring too much? Try this!

Here is something that we don't see too often. A patient came in telling me he was diagnosed with sleep apnea(not to mention snoring)...a condition in which the soft tissues in the back of the throat block the airway while a person is lying on his/her back sleeping.
You don't die from this...however you do not get a normal night's sleep because you are constantly waking up gasping for air...not very restful!
One of the more drastic treatments for this involves wearing a breathing mask hooked up to a ventilator which is on all nite giving you forced air...but who wants that!
So that is where your dentist enters the picture. If the sleep apnea situation is only moderate, we can sometimes solve the problem with a dental device that holds the lower jaw in a forward position. When the jaw is in the forward position the soft tissues in the back of the neck do not block the airway. And this is great to help stop snoring..so all you sleepless spouses out there....keep reading!
Have a look at this seemingly tortuous looking device...something you might see in one of the SAW movies?!

The patient is instructed how to wear this and with the little hooking device built into the front it holds the lower jaw forward as you can see in the following photos.


Now if you can sleep with that you can do anyting!
Have a good weekend and get some rest!!

You've got nerve!

Yes we all have nerve and that is not always bad...except when it comes to tooth nerves!
Sometimes when decay removal extends into the nerve area we have no choice but to recommend removal of the nerve...also called root canal therapy.
Here is a case where a patient had an all gold crown on a tooth...and the arrows point to several defective margins which allowed bacteria and other nasties to get in...

When I removed the crown it was not a pretty sight underneath...fig. 2..lots of decayed area...ugggh!

Well this required a huge excavation...and by the time I reached healthy solid tooth...I had also reached the very top of the nerve, see arrow in fig. 3.

This patient was sent to a specialist for root canal treatment and when he returns he will have new porcelain crown placed...in the meantime I was able to make the patient comfortable with a large tooth colored buildup...which will also make it easy for the root canal specialist to do his work...

Around town

Until I am back in my office Wednesday mornings are free for me..so i took a little walk around the neighborhood taking some photos...here is one taken with a fisheye lens...i thought it was pretty interesting...
Click on the photo to get a larger version.

The Gums are back!!

Here is the follow up to how we push those gums out of the way to make room for an impression and then a crown....
the following link
http://flossnblog.blogspot.com/2007/11/gums-gums-go-away.html
titled...gums gums go away...left us hanging...would those gums we so callously pushed out of the way ever return..or would they just go away and stay away? Well our patient returned today...about a week later and lo and behold I popped of the temp cap and the gums were back...beautiful, pink and healthful...

Now it was time to try in the permanent cap and with the gums so healthy it was a breeze..my lab did a great job and the entire insertion and cementation procedure took less than 20 minutes...and here is the cap next to its neighbors!

Dark trouble!

Hey...this tooth is way too dark for a pretty lady!! As a matter of fact it is way too dark for anyone...i am sure something is cooking in there...let's see...
A view of the biting surface shows a huge old silver filling which is defective...and there are numerous cracks appearing...
click on the photo to get a better view! After a does of novocaine...I removed or as we say I excavated the old silver(amalgam)filling and found a whole lot of decayed tooth structure...

After a full excavation I was able to reach healthy tooth structure...you can still see a crack line but that will be taken care of at a future visit...as this tooth will need a root canal treatment and a cap(crown)

but along the way the lingual wall of the tooth cracked away...
but not to worry..after the crown is placed the wall will not be a factor..but in the meantime I bonded in a tooth colored filling
and the patient will reschedule for the root canal treatment which will be followed with a crown.

But doc...it only hurts when I bite...sometimes?

But doctor...it only hurts when I bite, and only sometiimes...What is that all about??
Turns out this is a very common symptom...it usually is associated with a back tooth and is often caused by a crack in a tooth. The crack is more like a hair-line fracture somewhere down in the depths of the tooth, and is almost never visible on x-ray.(if a crack if visible on x-ray then you have real trouble!) When you bite down and the crack is nudged just a wee bit then you feel that sharp pain...and this must be treated before the tooth cracks and breaks even further.
Here is an example...a nice big molar tooth with a silver filling...on the surface it looks OK but the x-ray shows decay lurking underneat...and the patient has reported the ambiguous pain on biting! So we decided to remove the silver filling and see what is underneath

Once the silver is out we can see the decay quite clearly...
I proceed to carefully remove the decayed portions only and when I am done I begin looking for the crack...and there it is.....to try and visualize it even better I shine a special lite on the tooth and there it is under this lighting...quite clear..running the entire length of the tooth.

There is nothing more I can do right now...the tooth needs to have a cap in order to prevent the tooth from cracking any more...so I bond in a tooth colored filling for today
and the patient is rescheduled and we will begin the cap at the next visit...
see you next time!