What Color Do You Want?

The Story

A new patient in her 60’s came in today with a broken piece of her tooth in a mini zip lock baggie. She was really bent out of shape. “Not another tooth….I can’t lose another tooth “, she frantically screeched.

The Evaluation

She sat uncomfortably in the chair, when I said,”smile”. With a slight demure hesitation she released her puckered lips and showed the faintest smile. It was her upper left first bicuspid that suffered a shattering. The tooth was within her esthetic zone (it showed BIG when she smiled). She reported no pain or temperature sensitivity. “Those damm almonds”, she said (you can read about that one in one of me previous blogs).  I quickly instructed my assistant to take an X-ray, but deep inside I knew before evaluating the digital radiograph, that she was keeping the tooth based upon her clinical symptoms. In my head, I knew with my technical talent and technology that I could save the remains of her tooth and her, the torment of another extraction, but that was not the problem. What freakin color do I go with? That was the biggest problem…….

Fractured First Bicuspid

The Assessment

Radiographic confirmed that the overall remaining  tooth structure  was sound and No Problem for me to restore. 

The Plan

I told her that I could save the tooth easily with the CEREC technology. One visit crown. Done! I then asked the question, “What color do want?

The Discussion/Options: The Following are only THOUGHTS  that go through my head when faced with the complexity of tooth shade selection.

Option #1  Do I match the pre-existing previously selected  dentistry tooth shade?

1a

This is always preferred. On the other hand, what if there is no other pre-existing dentistry? This may be the patient’s first crown. How about, what if the patient has tetracycline stained “ribboned colored” teeth from taking antibiotics as child? I have never met a patient who loved their wrecked enamel dark stained teeth.

or

1B

What if all the pre-existing crown dentistry  was simply mis-matched? A classic checkerboard smile. It’s my experience, when it comes to color that some patients just don’t care…. “Ahhh doc, it’s a back tooth. Who’s going to look back there anyway?” A patient may have many dentists over a life time. For instance, different lighting in operatory rooms will offer different shading. Some days may not offer the benefit of natural lighting for optimal tooth shade selection. Incidentally, some dentists are just bad at color selection. I have multiple assistants come to a consensus to pick color for dental work. They are experts at that.

Option #2  Do I CREATE a new potential tooth shade Standard?

Do I say to the patient,”Get rid of that  corn cobb yellow.  Just screw it! Go for those bright white teeth that you always wanted. Now is the time to commit. Let’s do them all!” (some what exaggerated perhaps)

Option #3  Do I keep everything the same and custom shade and blend ceramics?

This option requires multiple visits and time. Many returns back and forth to a specialized local laboratory sculpted by my kind, patient, valium induced ceramist.

ANSWER: Not for me to decide. I’ll give you all the options. They are your teeth, your body. Your Choice.

The End Result

Restored tooth via CEREC Crown

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Pass this Link to Your Friends:  robertemilioddsblog.wordpress.com

Why Can Dentistry Fail?

Dentistry

A Quick Story about a Failure

Several days ago, I had recall a 70 year old female patient several months ago who came in for a recall visit since her last recall visit 5 months ago. Five months ago, in the hygiene room, it was determined that she had a massive implant failure in the upper left quadrant of her mouth. Three teeth on two implants were failing. There was a tremendous amount of bone that just disappeared over a period of 6 months. She had no pain or symptoms. The amount of bone destruction was radiographically staggering. The only choice was for me to remove the implants and curette the site clean. Soon after the procedure, I had a “sit down” follow-up with the patient. Nothing made sense to me. Medical history was clear. Her home care was excellent, recall great, implants not fractured, lab work looked awesome…”why the failure?” , I asked myself.

I asked the patient, “when was the last time you went for a medical check-up?” She replied, that she did not remember the last time. I suggested to start there.

Upon follow up with her PCP, it was determined that she had never gone for a colonoscopy. The GI doctor found a 5 centimeter cancerous mass in her colon with minimal metastasis. She had subsequently had the resection surgery and chemo. All was back to normal 5 months later. She currently feels great( the same prior to surgery) and we plan to replace those implants in 2020.

The Practice of Dentistry

The practice of dentistry involves, technical ability, artistic vision, emotional empathy and constant troubleshooting  of the most esoteric situations. Dentistry is 95% predictable. Technical materials and delivery systems have greatly improve over the decades. However, with that being said, not every filling, root canal or implant is a success.Why?????? I would like to think we as Dentists are only as good as our materials, but it’s much more.

Dentistry fails for either One of            Three Reasons.

First reason for failure and most common. The patient neglects home care and professional prophylaxis maintenance with routine check ups. This is tacit. You got to show up. I can catch something when it’s small,  easy and inexpensive to fix.

Second reason, “Ugh. I’m having a bad day.” The least probable and thankfully, usually not the case. We are imperfect beings working on other imperfect beings hammering away at a microscopic problem with macroscopic instruments in a sea of emotional conflict saddled from previous dental experiences. I approach work everyday enthusiastic, rested and prepared. I love being a dentist.

The third reason for failure is third party associated. For example, an out sourced local laboratory technician mis stepping in model preparation or just not reading a lab slip correctly. Sometimes their technical abilities are stretched and they may often struggle with their own limitations.

My solutions are as follows:

We have a strong recall program in the office. Eight hygienists full time by 2019. The hygienists are up to date with C.E. training and are always free to suggest their opinions on how to improve their care. Approaches to prevention and elimination of periodontal disease and peri-implant related diseases is always being updated with the most current findings.

I eagerly await to acquire more advanced educational training and knowledge. So far, I have scheduled  three dental seminars for 2019. This upcoming year, I am on track acquire 50 more C.E. hours to achieve my Full Diplomat with the I.C.O.I..  This  drive to learn more and apply fuels my passion. Everyday is my first day at work.

Third party outsourcing has been limiting over the years. I currently create 90% of my dental work via the CEREC in house lab CAD/CAM and milling unit.This control ultimately insures a better product for you. The Dental Laboratory as I knew it, will be no more. The great Old school technicians are a dying breed,  and  sadly shall be never more.

The 5% Stress

What about the other 5%? The human body ultimately decides on what works. Dentistry is invasive.  My feeling is that the body when stressed with a subtle covert underlying illness may not be able to tolerate an additional stress such as a dental implant, a root canal or a bone graft for example. Immunity resistance is a subjective quality that can not be quantified or measured. It’s best to know your body and respect it’s limitations.

What’s a Sinus Lift?

A Sinus Lift is a very technical surgical procedure, that a dentist will employ to create bone capacity in the maxillary sinus for dental implant anchorage.

The maxillary sinus is essentially a hole in the maxillary aspect of your upper jaw. It is composed of several bones. The maxillary sinus reduces the skull’s weight, produces mucus which moistens our noses and affects the tone of an individual’s voice. Internally, the sinus is lined with a what is called the Schneiderian Membrane. The membrane can be tissue paper-thin or orange peel thick.

When posterior upper teeth are extracted, the superlying maxillary sinus naturally expands to occupy the former root area of the extracted teeth. This is a normal biological consequence of tooth extractions; loss of bone support and atrophy. The extraction of a tooth may seem fine when you are in dire pain, but the subsequent consequences of tooth loss are many, such as: loss of function to eat properly, significant bone loss associated with advanced aging, esthetic nightmares and the obvious social stigma of failure.

Most often people regret the extraction of their teeth and are often confronted with regaining what was. In situations of upper posterior tooth loss and significant bone loss, dental implants may be elusive, unless the Lateral Wall Sinus Lift Procedure is performed.

A dental implant must have at least 10mm of bone to have a long term success. In maxillary expansion after tooth extraction( pneumatization), the floor of the maxillary sinus can expand so much as shrink down the alveolar crestal  bone down to as  thin as 0.5 mm thick from as much as 15mm of bone height when you were a teenager. This process of pneumatization occurs very quickly over a period of several years with the greatest changes in the first 6 months after tooth loss.

My  sinus lift procedure involves,  administering local anesthetic to the upper jaw. A single long incision is made and the gum retracted away from the upper jaw. The underlying maxilla jaw is revealed upon reflection of the tissue. A small window is then created by my dental surgical drill just down to the fine membrane WITHOUT it’s perforation. A dedicated set of instrument curettes are then utilized to reflect the membrane off the inner aspect of the sinus, thus releasing and creating a relative space. Think of sticking your hand in between the pillow (sinus floor) and pillow case (membrane) and making a space. Eventually with patience, a big lift is created into which allograft ( human cadaver bone) is gently packed to create a new maxillary floor (or  new implant ceiling).  Essentially the relative dimensions of space are reformulated to create new “room” for the dental implants to be placed several months later. Once bone is  nicely  packed, I then insert a temporary collagen blanket  seal over the aforementioned window and close the flap down with many sutures. With time, everything heals and the patient’s actual bone cells replace the donated bone graft to create a unified body of gorgeous healthy viable foundation ready for dental implantation.

The patient goes home with ice to the face, pain killers, antibiotics for the week and chills with Netflix for the evening. The procedure is predictable and usually results in a substantial amount of regenerated healthy bone. It takes me about an hour and 20 minutes start to finish.

Check it Out( GRAPHIC BEWARE) !

My You Tube Channel to see Me in Action Live! performing the Lateral Wall Sinus Lift procedure on my patient.

My You Tube Channel,  Robert Emilio DDS and Associates

 

Pre-Op view Panoramic View of maxillary sinuses
Pre-Op View Cross Section of the Right Maxillary Sinus via CBCT
Post Op Panoramic View of Sinus Bone Augmentation of Right Maxillary Sinus

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Pass this Link to Your Friends:  robertemilioddsblog.wordpress.com

Lower Implant Over Denture……. AKA Snap On Denture

Mandibular Implant Over Denture

Dentures can be incredibly problematic for many denture wears. They slip and slide. They pinch and gouge soft tissues. You really can’t chew hard foodstuffs with them. Are you getting the hint? They are difficult to eat with, even the “best of them”. Quality of life can suck!

The lower denture tends to be worse that the upper denture. The upper denture is self retained via simple suction onto the roof of the mouth.  A seal of the soft palate is created upon insertion of the prosthesis. The lower denture has no such luck. The tongue and floor of the mouth always wants to lift the lower denture out of its stability. The bone of the lower jaw tends to be thinner while the overlying tissue is more so fragile than the upper jaw gum tissue. The lower jaw also has two major sensory nerves called the Inferior Alveolar Nerves that can at times become compressed by the hard merciless overlying mandibular denture acrylic creating a tremendous amount of pain; a feeling of shooting electricity thru the lip. This adds to the everyday misery of the wearer.

A simple affordable life changing procedure which I routinely deliver in my office is the Implant Over Denture. This is a fabulous solution which simply remedies all of the aforementioned problems that lower denture wears suffer with everyday.

The procedure requires a Cat Scan of the lower jaw. This scan is most beneficial because it allows me to choose the most appropriate sized implants and relative positioning to be best supported by the jaw bone. Also, there are several areas of anatomic concerns for me as a surgeon that I need to respect. Knowing where not to place my implants is equally important as knowing where to place my implants. It’s advantageous to have a road map before the journey begins and the Catscan offers that.

On the day of surgery, I usually place 3-5 implants in the lower jaw in one surgical event. This takes me about an hour appointment. After placement of implants, tissues are approximated and the surgical site is closed tightly with numerous sutures of  both resorbable and non resorbable types. One of my assistants takes the existing denture and temporarily relines it with a medicated packing to aid and accommodate the post surgical tissue changes. The patient is given 600 mgs. of Advil in the chair, instructed in the basic post operative care by another of my qualified assistants, appointed to return for a 15 minute suture removal appointment in 12-14 days, leaves the office with their existing lower denture in place and an ice pack on their face. Total appointment time takes about 90 minutes completed with simple local anesthetic only.

It is important that the patient is instructed to wear the denture overnight and everyday as they normally do after surgery. The denture in place keeps compression on the surgical site and facilitates the healing process. It’s okay. The implants will be fine  submerged below the gum line beginning the process of osseointegration (fusing to the bone). For the first two weeks, until the wound seals closed,  I emphasize wearing the denture, without denture adhesive paste for the obvious concerns of wound contamination.

At the two month mark after surgery, I dremel  divots out of the patient’s existing acrylic denture base to create space for future female housing attachments that are engineered to accept the male counter component of the previously placed implants.

A chair side cold cure acrylic process of fusing the female attachments is done with in 10 minutes time.

The “Snap” is the sound of the male and female components engaging. A First Snap always garnishes a smile from me and a bewildered look of curiosity by the patient.

The patient is free to leave an enjoy a slip free lower denture. Inevitably, patients return for follow-up, happier, more enthusiastic about life and 10 pounds heavier. I am most satisfied everyday knowing that my staff and I are responsible for improving the quality of life of one human at a time.

Four Implants with Locator Male attachmentsUnknown-1.jpegimages-1.jpegUnknown.jpegimages-4.jpegimages-2.jpeg

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Pass this Link to Your Friends:  robertemilioddsblog.wordpress.com

Mini Implants.

I recently had a new patient (Patient B) come in for a consultation in regards to “fixing her rocking”, upper 4 Mini Implants over-denture. The patient said that her previous dentist was not able to fix the problem and she was recommended to me by a friend who had a similar problem for which I was able to remedy.

Initial inspection of the under surface aspect of the rocking denture revealed only two, properly imbedded  metal “female” basket housings. There were also two gouged out areas  where two other two baskets formerly resided within the denture.  In the final processing of an implant over denture, the female basket component is imbedded within the denture and designed to receive the “male” counter which is usually the “ball” component of the Mini Implant (see photograph above). Consider the ball aspect as an extension of the implant. This ball aspect of the Mini Implant protrudes thru the gingiva, and is responsible for engaging the imbedded denture basket and thereby creating the “snap” you hear upon insertion of the over denture. Because all Mini Implants are of narrow diameter, they must be manufactured as one solid fixture. They would be inherently  too weak  and unable to resist forces of chew during mastication if they were not one piece.  They would snap like a toothpick. A Mini Implant is not like a traditional implant where you have component parts and abutment choices (see previous blog on implants for description of What Is An Implant).

Immediately, I thought to myself, easy fix with just a simple chair-side cold cure. Add two new basket attachments where she had lost the two, twenty minute appointment, go to lunch.  I  keep baskets on hand inventory for such an emergency. Everybody happy.

Boy, was I wrong!

Upon further inspection during the intra-oral examination, I realized that, unfortunately, her over denture had never and would never work properly.

The 4 mini implants were originally placed in divergent directions. As a result of  implant placement and choice of the implant ( a one-piece fixture ), the denture had No One Path of Insertion or Withdrawal. It just could never engage all the ball fixtures.  In defense of the doctor. The one piece nature of the Mini Implant offers no room for error in surgical placement. All implants MUST BE Parallel. The female basket may offer a slight degree of variance for the slightest bit of angulation error.  The dentist had good intentions to help this patient via the advantage of implant stability. He lacked the surgical skill in pre-implant placement; specifically bone augmentation. He had not anticipated the prosthetic hurdles created by his in experience. This was truly a very difficult case because the patient had minimal bone quantity and poor quality to start with. The implants were also placed too close to each other and too far anteriorly in the maxilla (upper jaw) where the bone naturally becomes very narrow and flares upward dramatically. Her denture never engaged  her implants. Subsequently, the metal balls of the Mini Implants were responsible for smacking and cracking the acrylic. Ultimately  the metal baskets became dislodged from the denture. The fit of all components when they come together in a snap on denture must be passive. A passive fit leads to less lateral loads on the implant fixture. Lateral loads are disastrous on a dental implant.

It is of my opinion that, lateral loading onto excessively angled placed implants, in poor quality bone, with compromised bone volume with inadequate implant diameter led to this catastrophic failure for patient and dentist.

Patient A: This patient her MINI Implants were placed sideways. Denture’s female housing could never engage implant male aspect properly

Patient B: Note the proximity and angulation of these Mini Implants. All have been since been removed from this patient.

A rocking denture does not mean a failing implant case. There are many reasons for a rocking denture other than failing implants. Patients can lose weight or change medications resulting in physical changes of their oral tissues. Metal housings can pop out due to manufacturing flaws by the laboratory, “O” rings wear out, denture acrylic cracks, things can just break yet, the implants can be just fine, do not despair.

There are many important difference to remember in type of rehabilitations there are. A subtle and very significant difference with an Implant Over Denture Prosthetic versus a totally Fixed Implant Prosthetic is chewing power.

An acrylic implant Over Denture engages the implant’s male part, however, the denture is still 100% tissue supported. Gum tissue is compressible. The oral tissue carries the chewing load. The implants only keep things in place from shifting. The acylic denture does not drop or slide. You will bite and chew 100% more efficiently than the non implant denture person. You’ll be fine with 95% of the foods out there with confidence of knowing they will not fall out when you sneeze or laugh.(This has been reported to me by previous non implant denture wearers). You can not bite nearly as hard as the fully implant supported prosthesis on 6-8 implants. This is the real deal. Hardcore chewing power. Totally implant supported with no tisue compression discomfort.  Your brain magically knows thu the wonders of muscle physiology. You can break rocks with your prosthesis(not advised). This is not a denture snap on option.

A bit of Trivia: The hardest food in the human diet is a raw carrot.

 

The previously case failed for this patient for numerous reasons:

1-The Mini Implants placed were just too narrow.  It is my clinical experience that mini implants in the maxilla have a very high failure rate; more so than a regular traditional  diameter implant. I only utilize mini implants for the mandible ONLY (mandible jaw) because the quality of the lower jaw bone is much better than the quality of the upper jaw bone.

In General in terms for categorizing Quality of Bone: The Best Quality bone is in the lower anterior mandible. The Poorest quality of bone is in the upper posterior maxilla (upper jaw bone).

As a Rule: If the implant Diameter is increased by 1mm (in a 10mm long implant) you will have increased the surface area of the implant 25%. That much more surface will be available to osseointegrate.

2-The Mini Implants were too short. The more length the more surface area to stick to the bone. That’s better than shorter implants. As mentioned previously, the dentist attempted to fit the implant for bone available. There are several options to overcome this issue; not to mention for this discussion.

3-The Mini-Implants were too close to each other. Think of this simple analogy. A table has a better foundation when the legs are spaced further away from each other as opposed to next to each other. Better spread of the implants leads to a better stable over denture

4-The angulation of the Mini Implants were less than Ideal, NOT parallel. This was a function of bone architecture available to the dentist upon surgery.

5-Lack of Preparation. A 3-D (CBCT) analysis preoperatively providing visualization of bone morphology  PRIOR to picking up the scalpel would have demonstrated the degree of difficulty ahead for surgeon and patient. I personally refer out to dentists in my area frequently for the most challenging cases that require super I.V. Sedation or more advanced surgical care.

 

Don’t get me wrong…………I love Mini-Implants. When used appropriately in the anterior mandible, they are fantastic! Many of my elderly patients benefit from this life changing approach of stabilizing their lower denture. I only use 2.8 mm x 14.0 mm Mini Implants and place a minimum of two and as many as five to deliver a “snap on” lower denture . It’s tremendous. Every implant patient I treat must have a preoperative CBCT so that I can anticipate complications and plan appropriately to avoid any surgical or prosthetic nightmares.

Treatment rendered for this patient B: Removal of all  4 Mini Implants  with simultaneously bone grafting to implant removal the sites and bilateral Sinus Lift procedures. She now has a ton of available bone waiting for implant placement this upcoming month.

Some of My Cases:

Patient C: Pre-Operative Radiograph of a 87 y.o. patient with failing lower dentition

 

Patient C: From same patient as directly above. Mini Implants Placed. This x-ray is a post op three years after placement of 3 Mini Implants with locator attachments. Everything looking good.

 

Patient D: Full Arch Upper and Lower Implant Case. I post because we utilized non -Mini implants here for both arches. I restored Upper arch with a fixed non removable ceramic arch. I will restore lower arch with the same material. Currently we are utilizing these lower implants to act as an over denture(over engineered) with the intention of converting in the near future.

 

Patient E: All upper Mini Implants are almost gone here. All 5 failing Upper Mini Implants are at different stages of failure. I have intermittently placed 4 Non Mini Implants (not seen here) in-between the Mini Implants and converted to a fixed denture in transition. The patient was adamant and did not want to go back into the denture in the process. Technically a difficult case for me. It will be successful. Ultimately, to deliver a totally screw down case here; 100% implant supported.

 

Dr. Emilio & Associates,  Always Accepts  New Patients. He especially exceeds at treating same day emergencies patients suffering from tooth ache pains.

His goal is to keep his patients’ Teeth and Gums Healthy For Life.

Feel Free to appoint a Consultation with the Doctor. Open Six Days A Week

OPEN on Weekdays.  7:30am -8:00pm  (M<T<W<T)

Fridays.  7:30am-2:00pm

Weekends (Saturday only).  8:00am-2:00pm

111 East Avenue, Norwalk, Connecticut 06851.

You can always contact me directly via email  blog@robertemiliodds.com

Instagram:  dentist_in_connecticut

Office (203)866-7164      www.robertemiliodds.com

Pass this Link to Your Friends:  robertemilioddsblog.wordpress.com