Q: What is a socket preservation, and how do I know if I need one? – Stephen L.

Bone loss around tooth requiring socket preservation

A: Socket preservation is a type of bone grafting procedure that helps preserve the integrity of the jaw bone ridge after a tooth extraction.  Some people experience severe bone loss and consequent collapse of the jaw bone ridge after a tooth extraction. This type of post extraction ridge collapse happens when the bone socket surrounding a tooth is very thin (usually in the front area) or when there is already a significant amount of bone loss around a tooth.

Let’s look at the radiograph to the right. The tooth in question is shown with the red arrow (tooth #5).  You can see the dark color around the tooth.  The bone level is shown with the blue dotted line. From the radiograph, experienced dentists can tell that there is significant bone loss on either the outside (buccal) or the inside (palatal).  It is usually the outside bone that is lost.

After removing the tooth, there was no bone on the outside. Since the patient wanted to have an implant in the area, I placed some bone graft material after cleaning out the socket. Placing bone graft material after a tooth extraction like in this case is called socket preservation.  After the bone graft takes place, a dental implant is placed.

Whether you need a socket preservation or not is best determined by your dentist.  As in the image above, your dentist can tell before the extraction.  Sometimes, it can only be determined after an extraction.

Questions?  Ask Dr. Implant.

Loma Linda Implant - Dental Implants for Non-Dentists

Q: Dental implant bridges? What are they?  When and how are they used? — Alex R.

Dental Implant Bridge: When to Use.

A: Implant bridges are just like dental bridges except that they are placed on dental implants. Let’s consider a dental bridge.  When there is a missing tooth, two teeth next to the missing area are used as abutments for a bridge.  The two abutment teeth must not be next to each other, but one is on the left and the other is on the right side of the missing tooth. The artificial crowns that cover the two abutment teeth are connected together with a fake tooth (a pontic).

Let’s say that you have three consecutively missing teeth in an area of the upper or lower jaw.  Instead of placing three implants, one implant for each missing tooth, your dentist can place two implants at the ends of the edentulous area leaving the middle area empty.  When crowns are placed over the two implants, they are connected to each other with a pontic (fake tooth) in the middle, just like a dental bridge.

If implants are placed too close to each other, it is difficult for the patient to clean around the implants. With an implant bridge, it is easier for the patient to clean around the implants.  It also costs less to have two implants than three implants.

Dental implant bridge and bridge on natural teeth.

Dental Implant Bridge: Limitations

Dental implant bridges can be used in most cases with multiple missing teeth.  You need to remember that two implants will take the load of three teeth.  Therefore, the implants used must be adequately sized and strong enough to take the increased load.  Jaw bone also must be of good quality to withstand the increased load.

Dental Implant Bridge: Cleaning

Cleaning around a dental implant bridge is just as challenging as cleaning around a dental bridge on natural teeth.  Use a floss threader to floss around and under the pontic (fake tooth) of a dental implant bridge. Don’t forget to have your dentist check your implants and teeth regularly.

Your dentist will make the decision whether you are a good candidate for a dental implant bridge.

Questions?  Ask Dr. Implant.

Loma Linda Implant - Dental Implants for Non-Dentists

Q: My dentist recommends a dental implant for my missing back tooth.  I know that dental implants are great alternatives to dentures and bridges.  What are some problems that I can expect from dental implants?  – Albert R.

A: Dental implants are used in place of dentures and dental bridges.  Dental implants are not immune from problems, though.  Some of the problems with dental implants include the following:

1. Bone loss around implants.  Implants are immune from cavities but not from gum disease.  When inflammation or gum disease occurs around dental implants, bone loss and subsequent loss of the implants can occur. Bone loss around dental implants seems to be the most common problem encountered with dental implants.
2. Screw loosening.  The screw that attaches the crown part to the dental implant can become loose over time and needs to be tightened.
3. Implant Fracture. Improper implant size with heavy biting force can fracture dental implants.
4. Crown Fracture.  The crown that is attached to the implant can fracture (when made of porcelain outer cover) just like crowns on natural teeth can fracture.
5. Overdentures becoming loose.  When dentures are held in place by implants (implant overdentures), the connecting mechanism becomes loose due to natural wear from use.  The connecting mechanisms need to be checked periodically and replaced when needed.  Overdentures also do not fit the jaw after sometime due to the natural shrinkage of the jaw bone.  The overdenture can easily be relined to fit the jaw by your dentist.

Prevention of Problems with Dental Implants

Questions?  Ask Dr. Implant.

Loma Linda Implant - Dental Implants for Non-Dentists

Nerve Injury from Dental Implant: What to do.

Q: I think I have a nerve injury from dental implant surgery of last week. What should I do?  My dentist tells me that I should wait another week to confirm that it is a nerve injury from the recent dental implant surgery.

A: Nerve injuries from dental implant usually occur in the lower jaw when bone is drilled or implant is placed in the back area of the lower jaw.  Sometimes traumatic reflection of the flap (pulling soft tissue away from bone) in the premolar area can cause nerve (mental nerve) injury. If you think you are having a nerve injury from dental implant, you need to be sure of the symptoms that you are having after the dental implant surgery.

Symptoms of Nerve Injury from Dental Implant

Some of the signs and symptoms of nerve injury from dental implant are numbness, burning sensation, prickling sensation with or without being provoked or no sensation of pain in the affected area.  Because placing dental implants in the back area of the lower jaw may injure the inferior alveolar nerve, the injury caused by dental implant surgery affects the lower half of lip and cheek of the surgery side.

Dental implant is placed close to the nerve.

If the implant is impinging on the nerve, the dentist must remove the implant as soon as possible.  Most dentists take x-ray of the dental implants after placing them to document the surgery.  The x-ray shows where the implant, the nerve and bordering teeth are.  If the dental implant is too close or penetrating the nerve canal, the dentist will either screw out the implant away from the nerve or remove the implant.

If you are having numbness, burning sensation, prickling sensation or no sensation of pain in the lower jaw or lip area of the implant surgery side, tell your dentist of the symptoms right away. If the dentist decides that your symptom or symptoms are from nerve injury from the dental implant, he will remove it right away.

If there is a nerve injury from dental implant or from any surgery or trauma to the nerve, the symptoms can last a few weeks or several months.  The injured nerve may heal and recover with time.  Sometimes the damage can be permanent.  Prudent and experienced dentists are careful when placing implants and will prevent nerve injuries from dental implant surgeries.

Loma Linda Implant - Dental Implants for Non-Dentists

Implant Fracture

Q: My implant fractured a few months ago.  That is what I was told by my dentist.  What should I do? Do I need to have it taken out like my dentist recommends?  –Heart broken.

Dental implant fracture seen on x-ray image

A: I am sorry to hear that your implant fractured.  When the screw that connects the abutment to the implant is fractured, the screw alone can be replaced with a new one.  Replacing a broken abutment screw, however, is very difficult.  If the implant fixture is fractured, it needs to be removed.  There is no way a fractured implant can be repaired.  Take a look at the images of a fractured implant case that I encountered.  The patient came in for an implant consultation for a tooth in the upper right area.  When a panoramic x-ray image was taken, the implant in the lower left (#18) was found to be fractured.  You can see the bone loss around the implant.  When the patient was informed about the implant fracture, he chose to have it removed.

Fractured implant removed.

While the patient was numb on lower left area for deep cleaning (scaling and root planing), the implant was removed.  Since there was so much bone loss, the implant was turned counter clock-wise and taken out quite easily.  After having so much bone loss, the implant was easy to remove.  The downside of waiting so long is not having enough bone for future implant placement.  Bone grafting is necessary to prepare for future implant placement.  In this case, the patient chose not to have an implant in #18 area.  I think he made the right choice.  Here is a picture of the implant after I removed it.  It appears to be a NobelBiocare Replace Select implant fractured. You can see that a part of the platform fractured away.  When this type of fracture happens to an implant, you can not screw an abutment on to the implant.  Because the patient had waited so long, food debris and bacteria have caused inflammation of the tissues and loss of bone.

So, back to the reader’s questions, if the implant fixture itself is fractured, the implant will more likely have to be removed.

Questions?  Ask Dr. Implant.

Loma Linda Implant - Dental Implants for Non-Dentists

Dry Socket

Q: I had a tooth extracted last week.  My dentist told me not to spit the blood, but I did.  I am worried if I am going to have a dry socket.  Right now I don’t have pain.  Will dry socket prevent me from having a dental implant later on?   — Worried about dry socket.

A: One of the symptoms of dry socket is severe pain.  Since you do not have severe pain, I do not think you are having a dry socket.  After a tooth is extracted, the socket needs to be covered with blood clot.  Constantly spitting blood out prevents blood clot from forming.  Irritating the socket and using straws to take liquid can also dis lodge or prevent blood clot from forming and cause dry socket.  When the extraction socket is not protected by a blood clot, infection of the bone takes place and causes severe pain.  Another symptom of dry socket is foul smell coming from the infected area.

Treatment of dry socket includes using systemic antibiotics and topical analgesics.  Special dressings can be placed in the socket to give some relief.  Sometimes your dentist can numb the dry socket area for temporary relief of pain. While the area is numb, you will have a relief from the severe pain.  Symptoms of dry socket may last two weeks or longer.

The socket usually heals well after the infection goes away.  After the socket heals, dental implant treatment can be done, assuming that there is enough volume of bone to receive a dental implant before the dry socket.

Prevention is the best way to avoid this painful event.  Follow your dentists instructions after a tooth extraction and any dental procedures.

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Q: I had an extraction of a molar and a bone graft yesterday. Tonight I felt that the swelling is more than this morning. The swelling site has an increased temperature than the rest of my face. I am worried that there might be an infection. I am taking Amoxicillin 500mg tid and motrin 600mg q6h. Is this normal to have increase in swelling and the change in temperature? — Extremely Worried.

Swelling After Bone Grafting

A: Because of the extraction and bone graft, some swelling and discomfort are normal. Swelling occurs because of your body’s response to the procedure that was done. Swelling usually gets larger until the third or fourth day and gradually subside. Amoxicillin 500mg tid (taken three times a day) is usually enough to prevent infection after a procedure like yours. Motrin helps relieve pain and reduce inflammation and swelling. I would not worry too much about it, but I have not seen your swelling and not aware of exactly how the procedure was done, so I can not tell you what to do over the internet. Your best bet is to get in touch with your dentist and explain the situation and ask him or her what you should do.   Thanks for your question. Dr. Implant.

Questions?  Ask Dr. Implant.

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Q: What are zirconia dental implants?  Are they better than titanium dental implants?

Zirconia Dental Implant

A: Zirconia dental implants are one piece dental implants.  They are made of zirconia.  Clinical and histological researches have shown good osseointegration (implant and bone forming a tight connection) with zirconia dental implants.  Most titanium implants are used as the root only.  Some one piece titanium implants serve as the root and the abutment for the artificial crown.

Zirconia dental implants are strong and bio-compatible.  One singular advantage zirconia implants have is the white color.  Titanium implants have the metallic color, and the dark metallic color of titanium implants can show through thin gum tissues.  On the other hand, the white color of zirconia dental implants does not readily show through the gum tissues.

FDA has approved the sale and use of zirconia dental implants in the US, and some dentists are placing them in patients with good success rates.

Questions?  Ask Dr. Implant.

Loma Linda Implant - Dental Implants for Non-Dentists

The cause of bruxism or grinding teeth while sleeping is not clearly understood, but the detrimental effects of bruxism has been well known.  Here are some of the possible problems associated with night time bruxism.

• Morning Headaches
• Jaw Muscle Pain
• Broken Teeth
• Tooth Aches
• Worn Teeth
• Tooth Loss
• Ear Aches

Night guards are dental devices worn during sleep.  Night guards are usually worn over the upper teeth, like a retainer that is worn after orthodontic treatment.  Night guards protect the teeth and by allowing easier jaw movement they also ease jaw muscle pain and jaw joint pain.  Night guards are made from the model of a patient.  The dentist will make an impression (mold) of the upper and lower teeth and will have a custom fitting night guard made at a dental lab.  Then the dentist will try the night guard in the mouth and make necessary adjustments.

The patient needs to have the night guard checked periodically to make sure that it is working properly.

Loma Linda Implant - Dental Implants for Non-Dentists

Q:  What is Nobel Direct?  What is going on with the law suit involving Nobel Direct? —  Gene P.

A: Nobel Direct is a dental implant manufactured by Nobel Biocare, one of the largest dental implant manufacturers.  Nobel Biocare, based in Sweden, was the first company to commercially produce and mass market dental implants.    Most dental implants replace only the root portion of the teeth.  The crown portion is later screwed on to the implant.  Nobel Direct is a one-piece implant.  One-piece implants have the prosthetic abutments as a part of the implant.  The idea behind this design is that with no movement between the root portion and crown portion, the jaw bone is expected to integrate better and longer.

Many clinicians, however, have claimed that there have been more than acceptable amount of bone loss around Nobel Direct implants.  Dr. Jason Yamada of California has spearheaded this class action law suit against Nobel Biocare alleging that Nobel Biocare did not provide accurate and enough information to dentists regarding this bone loss around Nobel Direct. Please read more about the law suit  in an article on this website.

Now it seems that a US Distirct Judge in California (Central District of California), Jaqueline H. Nguyen, has certified the class action law suit on August 12, 2011.  Here is a quote from the court document stating such:

IV.  CONCLUSION
For the foregoing reasons, Plaintiff’s motion for class certification is
GRANTED.  The Court certifies this action to proceed as a Class action under
Federal Rules of Procedure and 23(b)(3).
IT IS FURTHER ORDERED THAT, good cause having been shown,
Plaintiff’s Motion to Appoint Jason Yamada, DDS as the representative plaintiff,
and to appoint the law firms of Audet & Partners LLP, Lopez McHugh and
Stephen Ochs, DDS, JD is GRANTED

So it seems that the judge has given her OK for this law suit to proceed as a class action law suit.  No one should make any prejudiced judgements at this time.  The court will decide what the outcome will be. Stay tuned.  Updates will be posted as they become available.

Loma Linda Implant - Dental Implants for Non-Dentists