Grand Central Station

Was playing around with my photo gear...managed to take this shot of the big hall at grand central station...make sure to click on the image to get a larger view...

Top to bottom

So what happens when I make a patient's upper teeth look so good that now the lower teeth which seemed to be good... look lousy??
Well you got it....we do the lower teeth!
Here is the case where the patient had upper caps done and wanted them nice and white and now the lower teeth look like ...well you know...

So we prep all the lower teeth...and if you are looking you will see that one is already an implant....

We are going for the gold here...that is we want the most esthetic result possible so I am making crowns with a gold metal underlay for support...and the gold tone gives a very nice esthetic look to the porcelain which will be baked on...here are the gold substructures(copings)first on the lab model and then on the prepped teeth....


All the copings fit very well...a new bite relationship is recorded and the case is sent back to the lab for the porcelain...so come back next time to see how it all looks!!

Mobility Factor

So what do we do when you are getting on in years and your teeth are getting loose...
sometimes we have to resort to capping the teeth and then connecting the caps in order to stabilize the teeth...but that is a big project...and very costly$$.
So an alternate method is to do an intracoronal splint...and here is a good example...

There is one solid tooth and a few loose teeth...so let's connect or splint them to stabilize the loose ones...
First I drill a channel and fit a metal rod into that channel...

Then we bond the metal rod into the channel with good old bonding material...
I then do the same thing for the tooth next to it...

I will do the same thing for all the front teeth in this area...but this was enough for today..next time we will carry this stabilization to the other side...

Guardian Angels!

So here is something I don't do every day...a night guard. Many patients, sometimes even unknowingly, grind or clench their teeth, mostly at night, but sometimes even during the day. Although it usually does not produce symptoms, it definitely has a negative impact on the teeth. This is sometimes called bruxism.

Teeth are not meant to grind against each other(or open bottles and crack ice)...they are meant to chew food. So when you start to grind teeth against each other, they start to wear out and loosen. Some people will get muscular pain as well...
So what do we do...we fabricate a guard to watch your teeth. It is made out of a clear plastic and it can me made to fit either the upper or the lower teeth. Patients are instructed to wear them when they sleep and even during the day when the grinding is severe...

The first photo shows you what they look like sitting on my lab table...a view from the outside and inside...

They are made on models of your teeth as you can see here...

When the patient comes in we try them in and make sure they fit comfortably and snug and we instruct you in putting them on and taking them off and how to care for them.
And when they are in the mouth they really don't look too bad and some patients do wear them during the day....


So why don't I do this more often...because most of the time when I recommend it to a patient these guards end up in a night table drawer more than in a patient's mouth!
The patients who do best with these are those who realize they have a problem and are actively interested in guarding their teeth!

Drill-etch-glue-fill-polish

I have been away lately due to a death in the family...and have been very busy setting up a blog for the family....
But now I am back and here we have one of my usual cases of bonding an eroded tooth.
In our first figure you can see that this was bonded many years ago but both the bonding and the tooth have eroded even more..

the first step is to drill away the old bonding and prep the tooth to accept a new bonded filling...so i drill away until I am down to clean fresh tooth structure...but that is not all...to get the filling to stick I have to first use a conditioner to etch the surface of the tooth..and that is what this next photo shows...if you look carefully you can see that the arrows are pointing to a frosty surface...that is etched enamel which has micro-porosities...

At this point I take the bonding agent...which is just a fancy term for glue and lightly apply it to our tooth surface....

Once this layer is hardened with my bonding light I then apply the filling material until it blends in with the rest of the tooth...
The filling can now be polished and we have a nice smooth surface ...

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!!