The Hybrid Implant Bridge

This is absolutely my favorite transformation. Rita had smoked for many years – not good for teeth and gums. What happens is that the bone resorbs, leaving long and loose teeth. Eventually these teeth fall out. The process can be delayed or halted with proper dental and periodontal treatment but, like so many people, Rita was afraid of having dental treatment. She also had a serious gag reflex. She was very happy to learn about us and about the care that we take with our patients and their dental health. She was very unhappy with her smile,  with her displaced and missing teeth. She would not smile – and Rita was a beautiful woman. Her teeth were beyond repair, and she was afraid to wear a denture because of her gag reflex.

 

Upper and lower hybrid implant bridges were the best solution to give her a beautiful smile without the embarrassment of removable dentures. The hybrid implant bridge is screwed into bone supported implants and functions like natural teeth. We call it a hybrid because the dentist can remove it, but the patient cannot. Some people call it “teeth-in-a-day” because the teeth are removed, implants are placed and the hybrid can be seated immediately. Sometimes we will seat the hybrid the following day for better cosmetics. This is a temporary hybrid – once the implants are integrated into the bone in approximately three months, we take impressions and measurements for a final hybrid. We give the temporary hybrid to the patient as a spare in case a repair is needed. All-around a wonderful service. Rita did beautifully; the result is spectacular. What you see in her photos below is the temporary hybrid. The final one will look even better! She is thrilled to have teeth again. Read what she says on our testimonials page at http://drterryshapiro.com/testimonials/.

 

Look what we can do in a day to change your smile!

 

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Thursday: Loose and displaced teeth

 

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Friday: Temporary screw retained upper and lower hybrid bridges

 

I’ve saved many teeth in my years of practicing dentistry – after all, it’s my goal to help people keep their teeth.  But now I can say that I have saved a life.  It wasn’t a patient or a family member or a close friend but an acquaintance who has since become a friend.  I was at a dinner party when Lois approached me and said she wanted to ask my opinion.  She was having a crown made but the dentist couldn’t complete the work because she had sores in her mouth that hadn’t healed.  She wanted me to complete the dental work. She said that she was sucking her cheek and this caused the sores but she couldn’t stop the sucking habit.

 

I took her aside and asked her to pull aside her lip so I could see the area.  The entire cheek side of her lower right back teeth was covered with white pustules and much of the normal tissue had sloughed off. I had never seen a condition so serious.  I didn’t want to alarm her but I was emphatic that she needed to immediately see an oral surgeon for a biopsy.  She asked me if it was cancer. She said she didn’t want to know if it was.  My reply was that she needed to know so that it could be treated.  The next day I called her to be sure that she would follow through.  It took several phone calls on my part until she finally saw an oral surgeon for a biopsy.

 

Sadly the test was positive for well differentiated squamous cell carcinoma.  Lois will need surgery to remove the cancerous tissue and part of the jawbone, and then possibly undergo chemotherapy and radiation treatment.  Rehabilitation will take over six weeks, with limited speech and swallowing.  Lois is grateful to me for recognizing the pathology and for insisting that she have it diagnosed.  She has a long road ahead of her, but hopefully the cancer was caught in time.  I know I have saved a life.  Please don’t neglect yours. Don’t let fear keep you from the doctor – oral cancer that is caught early can be treated and cured.

 

 

 

 

When I first met Laurie, she was 15 and in the middle of orthodontic treatment.  Her upper left canine tooth was impacted (hidden in the bone and not in a position to erupt.) We determined that the tooth could not be saved and we elected to extract it and have an implant placed.  The tooth was removed and a bone graft placed. The adjacent teeth were repositioned orthodontically so there would be enough room for the implant.  The implant was placed and it was allowed to integrate to the bone.  During this time Laurie wore a flipper type partial denture to replace the missing tooth.  Once the implant was integrated, the implant was exposed and a screwed in temporary implant crown was placed.

The photos below show the space where the tooth was missing and the temporary crown in place.  The crown looks terrific – but the permanent crown will look even better. Laurie is thrilled not to have to wear the removable denture anymore.  Once further healing of the surrounding gum tissue takes place we will place the final implant abutment and crown.

Laurie just left for college, but she will be back in Coram for Thanksgiving when we will place a permanent implant crown.  This type of dental treatment is complex and cannot be rushed – it takes a lot of planning and coordination among myself as restorative dentist, the orthodontist, the oral surgeon and periodontist.  But is the wait worth it? You bet!

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New dental implant temporary crown

In reading Robert Massie’s fascinating biography of Catherine the Great, I came across the following account of a toothache and high fever that persisted for months.  It got unbearable when the Princess was traveling in an open sleigh from Moscow to St. Petersburg during a brutal Russian winter.  In her diaries she describes the agony she felt.  Of course at this time there were no antibiotics and no analgesics.

When the entourage arrived at their destination, the Empress’s chief physician was finally called in to extract the offending tooth.  The chief surgeon was French – apparently there were no dentists so medical surgeons filled in as needed.  He sat on floor with another surgeon, and both held the Princess down.   He wrenched and pulled until she could feel her jaw bone breaking.  He had extracted the tooth and with it, a piece of lower jaw.  She was confined to bed and was in pain for 4 weeks, her jaw exhibiting blue and yellow bruises from the physician’s fingers.

She survived the ordeal – but aren’t we lucky to have the benefits of modern dental medicine!

What do you think John Lennon’s molar tooth sold for at auction this past November?  Would you believe $31,000!  The decayed tooth was bought by Michael Zuk, a dentist from Alberta, Canada.  He is a collector of animal teeth and celebrity memorabilia.  The dentist plans to have the tooth mounted and placed on display in his office.  He said he would also lend the tooth to dentists or dental schools or anyone who would like to display it.

John Lennon gave the tooth to his housekeeper who lived in England at the time the tooth was extracted in the mid 1960’s.  She then moved to Canada and has kept the tooth ever since.  She provided an affidavit confirming that the tooth was authentic.  Even so, I doubt I would want to display it!

 

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Yesterday I wrote a response to the New York Times article that claimed that too many wisdom teeth were being unnecessarily extracted in the U.S.   So this morning I got to the office and what do you think I see in my first two patients? Wisdom teeth dilemmas.

The first patient, a 40 year old mom, had all of her wisdom teeth, but one was severely decayed.  The only option was extraction.  She was not doing an adequate job of keeping the teeth free of plaque.  The second patient was a younger woman, also with retained wisdom teeth.  Her home care is good, but her wisdom teeth are semi-impacted in the soft tissue and difficult to reach.  These teeth were coated with plaque.  Extraction is certainly a viable option but I left the choice to her.

If the teeth are problematic, it is better to do the extractions while a person is younger because the healing capacity is better in younger people and as people age, other health problems have the potential to complicate any extractions.  So this is another factor weighing in on early extraction.  Again, experience and judgment as well as patient communication are key.

Are wisdom teeth expendable? – that is the question.  Pros and cons appeared in an article “Prudence of Having That Tooth Removed” in the September 6, 2011 New York Times at http://www.nytimes.com/2011/09/06/health/06consumer.html.  The article advises against routine extraction of wisdom teeth (third molars) as scientific evidence supporting routine preventive extraction is lacking.  The author notes that “Each year, despite the risks of any surgical procedure, millions of healthy, asymptomatic wisdom teeth are extracted from young patients in the United States, often as they prepare to leave for college.”  I don’t know how she came up with the figure of “millions” but it seems excessive.  I don’t know of any oral surgeon who routinely extracts “healthy, asymptomatic” wisdom teeth nor would I routinely refer such teeth to a surgeon for extraction.  I only recommend extraction if there is a reason to do so.

However I think that the author underestimates the percentage of problems we see related to wisdom teeth.  If I see a problematic tooth then I would discuss extraction with the patient and guardian.  Sometimes there is a problem that is not obvious to the untrained eye.  There might be pathology evident on a radiograph but not visible to the patient.  The tooth might be decayed.  It might be impinging on the second molar, affecting the  prognosis of the second molar.  The tooth might have soft tissue impaction and recurring infections.  These are all good reasons for extraction, and all of the above do occur quite frequently.  People are often concerned that their third molars are causing crowding of the lower front teeth – but there is no evidence that this is the case.

An issue not discussed in the article is the prevalence of periodontal disease among adults, possibly affecting 60% or more of the adult population in the U.S.  If the patient is not adept at removing plaque from hard to reach third molars, it might be prudent to extract them, for the health of the rest of the dentition.

Nevertheless, surgery always carries a risk, including possible nerve damage and complications from the anesthesia.  If you do opt for extraction, ask for local anesthesia, which is generally safer than general anesthesia.  Follow post-op instructions: soft food for a couple of days, ice on the area, and analgesics if necessary.

Whether or not to extract wisdom teeth, like everything else in dentistry,  is a matter of judgment.  Your dentist needs to have good judgment and experience and have your best interest at heart.

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One of the most controversial topics in the dental profession is the issue of temporomandibular disorders (TMD’s), also known as temporomandibular joint disorders (TMJ).  Last year the American Association of Dental Research (AADR) issued a revised statement based on a review of the literature. The American Dental Association considers the AADR statement to be the standard of care for TMD/TMJ.  The goal is for patients with TMD to have less risk of inappropriate treatment.

The policy statement recommends that “unless there are specific and justifiable indications to the contrary, treatment of TMD patients initially should be based on the use of conservative, reversible and evidence-based therapeutic modalities.  Studies of the natural history of many TMDs suggest that they tend to improve or resolve over time.  While no specific therapies have been proven to be uniformly effective, many of the conservative modalities have proven to be at least as effective in providing symptomatic relief as most forms of invasive treatment. Because those modalities do not produce irreversible changes they present much less risk of producing harm.  Professional treatment should be augmented with a home care program,  in which patients are taught about their disorder and how to manage their symptoms.”  http://www.iadr.org/i4a/pages/index.cfm?pageid=3465#TMD.

This statement sounds very reasonable to me and yet it caused a firestorm of criticism from some of my colleagues.  But I have successfully treated TMD with noninvasive treatment consisting of exercise of the muscles and bite splints.  I have also on occasion discouraged patients from having surgery of the TMJ – surgeries which are now infrequently performed.

I’ve been reading Life, the fascinating autobiography of the Rolling Stones guitarist, Keith Richards.  He gives a wonderfully chilling yet funny account of his early dental experiences in Great Britain.  Here is the quote in its entirety:

“I should have a badge for surviving the early National Service dentists.  The appointments were I think two a year – they had school inspections – and my mum had to drag me screaming to them.  She’d have to spend some hard-earned money to buy me something afterwards, because every time I went there was sheer hell.  No mercy.  ‘Shut up, kid.’  The red rubber apron, like an Edgar Allan Poe horror.  They had those very rickety machines in those days, ’49, ’50, belt-drive drills, electric-chair straps to hold you down.

“The dentist was an ex-army bloke. My teeth got ruined by it.  I developed a fear of going to the dentist with, by the mid-’70s, visible consequences – a mouthful of blackened teeth.  Gas is expensive, so you’d just get a whiff.  And also they got more for an extraction than for a filling.  So everything came out.  They would just yank it out, with the smallest whiff of gas, and you’d wake up halfway through an extraction; seeing that red rubber hose, that mask, you felt like you were a bomber pilot, except you had no bomber.  The red rubber mask and the man looming over you like Laurence Olivier in Marathon Man.  It was the only time I saw the devil, as I imagined.  I was dreaming, and I saw the three-pronged fork and he was laughing away, and I wake up and he’s going, ‘Stop squawking, boy.  I’ve got another twenty to do today.’  And all I got out of it was a dinky toy, a plastic gun.”  (Life, pages 28-29)

A terrific description of how it used to be, but thankfully is rare today.  Richards is a powerful writer.

 

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Keith Richards

In 1890, at the start of his second term of office, President Grover Cleveland noticed a rough spot on his palate.A biopsy confirmed a diagnosis of cancer, and surgery was indicated.The Government wanted to keep the President’s health a secret because there was a financial crisis at the time, and they did not want the public to be alarmed.

So the surgery was done in secret while the President was aboard his friend’s yacht traveling up the East River in New York.The surgical team, including a dentist, was sworn to secrecy.Dr. Hasbrouck, a New York dentist, administered the anesthesia. Two teeth were extracted and part of the maxilla was removed.Dr Hasbrouck also constructed an appliance to close the defect caused by the surgery, and the President was able to make a planned address to Congress shortly thereafter.

The President lived for many more years without a recurrence of the oral cancer, and he died in 1908 of a heart attack.The government did not officially acknowledge Cleveland’s oral cancer until 1917.Dentists today, as in Cleveland’s day, play a crucial role in the diagnosis and treatment of oral cancer and post-surgical reconstruction.In my dental office I routinely check my patients for oral cancer.Early treatment of cancerous lesions saves countless lives each year.For more on oral cancer, visit my blog post on oral cancer.