Combo Case

Implants are everywhere in people's mouths today...
here is a case where there are two implants in the back section of the mouth and I connect those two implants with a natural tooth that had a root canal and a post.
The natural tooth is somewhat questionable as to its longevity so i am hoping that by stabilizing it with the impants I will get extra years from it...
If in the future the natural tooth needs extraction then I will have a single tooth implant placed there...we shall see

4 little teeth/caps

Well when you are in dental school they sort of scare you away from doing crowns/caps on the lower front teeth..why...well they are very small and hard to prepare properly..the angle to work on them is tough even though they are right up front...and the teeth are small and any mis-prep and you hit the nerve...
but sometimes we have no choice..this gentleman had radiation and chemotherapy about two years ago and since that time his lower front teeth were continuously getting new areas of decay...
finally we decided to cap them all and hopefully prevent future decay...I had to make sure to get the crown margins below the gum level to prevent gum level decay and that made it even harder..but here he is and here are the crowns at the cementing visit..
the gums are a little puffy from irritation from the temp but i am optimistic that they will tighten up around these little caps!!
It helps when they come out looking this good..the patient loved them!

sometimes you get lucky...

A long time patient came in about two months ago...reported that she took a fall and may have injured her front teeth...clinical and xray exam showed nothing unusual.
About a week later the tooth took a turn for the worse..it was still asymptomatice but it had turned a dark grey...I explained this was due to the traumatic injury and would need to be treated ASAP with a root canal treatment to remove the damaged puly tissues.

Root canal treatment was successful but she still had a greyish tooth..and being that this is right up front and center it was no good!!!

A crown or laminate was ruled out as the whole tooth was basically intact and I felt that due to the unusual prominence of the tooth any artificial restoration, no matter how good, would be obvious...

So we decided to do an internal bleaching, often called a walking bleach...although this can sometimes have some unintended side effects...we decided to go ahead with it.

It basically involves placing a bleaching material in the tooth and letting the bleach penetrate the internal discolored aspect of the tooth...well the patient came in ten days after the first treatment and we had a huge success.

The patient and doctor were thrilled!
Please click on the photo to get a larger version!

Ouch..that's got to hurt...

Unfortunately when you have a practice with a lot of elderly patients you occassionally get the phone call telling you that one of your patient's took a fall and stopped that fall with their face...
In any case this wonderful woman was just in last week for a routine procedure and yesterday she called to say she took a fall yesterday and needed to see me right away...
I told her to come on down and here she is..fresh out of the emergency room...

Clinical exam shows that although none of the teeth are unusually loose there are some chips evident on the two central incisors...take a look...


Now we have a machine to tell us the vitality of the nerves that are in the teeth and the test revealed that all of the teeth except for these two respond normally..
these two teeth show no response to an electrical stimulus...
so stay tuned...she is returning next week and we will re-examine her and see if
she will need to have work done on these teeth....

Did you say white???? Yes Dr. - I said WHITE!

As dental students one of the first things you learn about cosmetic dentistry is that you don't want to give someone really white white teeth...it just looks too fake.
Well in today's world it seems that patients will occasionally want that overly too white to be true look and here is one of those cases.
This gentleman has seen his share of dentists over the years and he wants to have a certain look at all costs...
He had his upper teeth capped with really white porcelain and now he is in my office to have his lower teeth "fixed"....He says he wants them to be whiter, and bolder, and stronger ...and bigger and so on and so on.
So take a look at these two pictures and you can see how the lower front six teeth are looking pretty poor next to what was done on the upper...
As usual for this blog..click on any picture to get a larger version then hit the back button to return to the blog!

Now the upper six teeth, were like I said, done elsewhere....and I made the 2 back teeth that you see on each side on his lower jaw...

And to tell you the truth in this particular case I see his need to have his lower teeth whitened, since they are so off shade from the uppers...so here goes...
I determined that in order to make them a bit taller and stronger I would have to
open his bite slightly...which he was able to easily tolerate with the temporary caps I made for him...
After about three try in visits in which our patient had numerous requests for changes we finally settled on this result....
He loves it and is very happy...and he is especially pleased with the slight overlapping of the teeth to give them a more natural appearance instead of the straight line across look.
Would I do it from the outset...probably not..but he claims he is in show business and he needs it...
so there you go....white as white can be...maybe he should say he is in snow business with this level of white! Here are a few different views.


Of course, now the upper teeth don't look as white as he would like them to look..
I would not be surprised if he wanted his upper teeth redone to look this white...
and by the way these crowns are pressed porcelain and are very easy for the labs to work with and modify!

And now for something completely different...

Had to leave the office early yesterday...was one of the semi-official photogs at a wedding for a family member..second wedding for both so now real official photogs there but nonetheless lots of pressure to get the shots!

Front tooth face...

so far pretty busy today but not much to really blog for you..
so how about a small little one..
really nice gentleman comes in and has a chipped front tooth...right in the middle..

And he tells me that this tooth has been bonded several times and it keeps chipping off...and he wants to know if I can help him out..
Well my bonding is not going to much different than the next dentist's bonding..we all really use the same materials..but i decide to give it a shot even though he may need a full veneer to really give this tooth a long term fix..so I bond the tooth with tooth colored acrylic and we hope for the best!!

now of course the teeth around this need some cosmetic work but that will wait for another visit...

I can chew... continued...

About a year ago we told the tale of a woman who had to lose all her lower teeth..
we replaced them with implants and here is how the implants looked about a year ago, right after they were placed and before the tissue had healed...

Now fast forward to the present and here is a picture of those implants with the gum tissues healed up nicely and the final teeth in place...in this first photo, you are looking at the gold custom posts upon which the porcelain teeth will be cemented...


Still to come..we are doing the same to the upper teeth!!

It helps to have connections...

This patient has braces as an adult and to prevent the lower teeth from drifting back to the original crooked positions we try to connect the teeth by bonding them together.
This patient had it done about a year ago and now the plastic that was used was starting to loosen...

The treatment is to drill out the old plastic and create a fresh channel to place a new connection..here is the new channel prepped...

A twisted steel wire is fitted to the space and will be bonded into place to help hold the plastic and teeth together..here i am fitting the wire to get the right size...

Once the wire is sized I then take the soft plastic and embed the wire as you see here...I then continue to fully cover the wire and polish it so that the patient has no feeling whatsoever that anything is even there...


Unfortunately the mouth is a tough place to survive and this procedure will have to be repeated every so often..but the patient does not mind..her teeth are straight!

Cracked!

Most of the time, no matter what you do to your tooth/teeth we can figure out someway to save them...whether a filling or crown or root canal or something else.
But occasionally a patient presents with a situation where no way no how can I fix the the problem...and here is one of those situations. A cracked tooth, where the crack runs the entire width of the tooth and the two pieces are now separated.
Usually this can be a rather tricky diagnosis...because the tooth pieces that are cracked are not separated..but in this case it is rather obvious...
In this photo..rather gruesome, you can see an up close picture of a molar where the crack has developed and the tooth is now in two pieces! Amazingly the patient has no pain whatsoever and was not even aware of the seriousness of this situation.
The patient has been referred to a surgeon for removal of the tooth and hopefully we will be able to place an implant to restore him back to full function.

Which camera do you use...

That is probably the question I get asked most..
Most of the dental pics that you see are taken with a simple point and shoot camera..
in the old days before digital we had fancy set ups with single lens reflex cameras and ring lites and macro lenses..Wow..things have changed..now I use a simple little camera with a built in flash on the macro setting..and I am very pleased with my results..


For pictures that require me to get deep into the mouth I will use an intra oral camera...it is a small camera placed on the end of a wand which has a lens and two lights to to illuminate the dark workspace.
The intra oral camera has been especially useful in educating my patients as to dental situations in the mouth that they would normally not see!
This is a good example of new technology which I use daily.


and this is what it looks like with the lights turned on...

More implants

This gentleman came to me twenty years ago and was missing a front tooth right up front..he is clarinet and oboe player and I made him a removeable tooth that held up well while he played...now he wants more!! He wants to get rid of the removable tooth...so I had my surgeon place an implant..and here it is...the implant that is..
We will start working on the replacement tooth as soon as the gums heal up around the implant...

Before and After

So lets return to an old posting and see how a patient is doing..you may recall seeing these pics when i posted them telling you how i fixed the upper teeth and now the lower teeth looked lousy..so she came back to do the upper teeth..
well see the following three pics for the before middle and after!
here is the photo with the upper teeth fixed but not the lower teeth...

and here is the picture of the lower teeth prepped for new crowns...

and finally here is a picture with the lower teeth finished...she loves it!!

Freshen Up..

Here is a simple one..Patient is a middle aged woman..has receding gums but the gums are healthy..
she wants a cleaning to get rid of the grime..especially on the lower teeth.
Well the cleaning certainly gets rid of the grime but I cannot make them whiter unless she wants to do some dental bleaching.
As usual click on the picture to get a nice big one for detailed viewing!

Identical twins...Identical teeth??...not!

Identical twins came in today..13.5 years old..girls..
So the question is..are the teeth identical also..well you be the judge..
they both need braces but the teeth are certainly not identical!

The top three are one twin...the bottom three are the second twin.
Click on the picture to get a larger version for comparison purposes.

Sunset atop Mauna Kea on the Big Island of Hawaii...awesome!

Tough Choices...Photoshop it!!

A young woman came in today and although we have discussed doing some aesthetic dentistry on her front teeth she has always declined. Well today she tells me that now when she smiles and is photographed the photos clearly show something wrong with the front teeth. This has prompted her to finally get these fixed.
I gave her some choices..none too easy...
1. bond them with tooth colored acrylic..not a bad choice but has a limited lifespan and will probably need rebonding rather often...and the color will be close but not perfect.
2. porcelain veneers or laminates...i can probably get a great color match and this would last a long time without any maintenance needs..but this is much more expensive..
She will think about it and let me know which solution she wants..
Of course being who I am..I gave her a third option which is probably the easiest..Just photoshop the pictures after they are taken!!
Click on the picture below for a close up view of the problem!!

And of course here is the photoshopped version...
while I was at it I could have done all the teeth but the front two incisors are all for today.

Implants

So what do you do when you lose teeth and you dont want to make a conventional fixed bridge because you don't want to grind down perfectly healthy teeth?
Implants...perfect solution.
This patient lost the lower front four teeth and we did not want to have to make a bridge involving the adjacent canine teeth which were healthy..so the implant surgeon placed two implants in the toothless space...and this is what the implant fixtures look like before teeth are built on them...

Onto these implants we now build a metal framework that gets screwed into the implants and eventually we will bake porcelain onto the metal to make this patient beautiful..
here are two photos of the framework and you can clearly see the screw holes which will be used to secure the implant into place.

Pinned down

So what happens when you break a tooth and half is gone and you need a quick fix because you've got a big dinner date later tonite?
Well that is what i was up against today.
A long time patient broke a tooth and needed a quick fix...here is the broken tooth

Now you just can't put a filling into this tooth and even with modern dentistry's miracle bonding agents we still need some old fashioned help...and for that we turn to small pins...so i drilled two pin holes into the teeth in the area where the tooth broke as you can see here...

Into those pinholes I can now place/screw two titanium pins around which I can rebuild the tooth.

Decay... decay... where art thou?

So the patient says what do you mean I need a filling..everything feels great...no way!!
Well I say you do need a filling..and here is the proof..
Bicuspid tooth...young woman...20 years old...tooth looks OK and on the X ray there is no evidence of a problem...but the central groove looks suspicious..on both of these teeth..but I am only doing one today...take a look...

So after a little novocaine I take my small drill and carefully open into the groove and sure enough there is more than just a little decay...this is rather significant for a tooth this size...

So with a careful excavation I am able to clean out all the affected tooth structure until it looks nice and clean...

and in just a few minutes I can bond a tooth colored filling into place and it
is like it never happened...everybody is happy and the patient now sees these photos and says ..Wow doc..how did you know! Next visit we do the tooth next door!