Category Archives: Dental Bone Loss

Ramsey Amin DDS Case Review – Replace Loose Long Bridge With Dental Implants And Bone Expansion

This Burbank patient had a loose lower bridge.  She had had the bridge for about only 8 years before it failed and became loose.  You know a bridge is failing when it feels painful to bite down or there is movement.  This unfortunately is a daily thing I see every day.  Teeth were never intended to be hooked to other teeth.  She came to me because she wants dental implants to replace the bridge.

The existing lower bridge was made with a metal biting surface because the patient has a VERY  strong bite.  She wanted to make sure that her new dental implants could withstand her bite force.  She has broken other bridges in the past. You can see in her photos that she has worn through some of the porcelain showing through to the old metal layer on the opposite side next to the yellow gold crown.

First day exam visit

First day exam visit – broken root under the bridge

First day exam visit –side view

First day exam visit -panoramic x-ray

First day exam visit — full lower jaw. Failing bridge is the one with the metal biting surface.

thin bone prior to grafting but after extraction of the broken root

Bone grafting showing webbing of Vicryl stitches

10 days of healing after bone grafting showing webbing of Vicryl stitches

Clay model of the patient after bone widening expansion bone graft. Please note how wide and square the bone is compared to how thin it was before.

3-D printed models showing abutment contours

3-D printed models of abutments from top view

top view final bridge on 3-D printed model

side view of final bridge on 3-D printed model. This patient happens to have very short teeth which makes it even more important to have the teeth connected to avoid food impaction between the teeth.

sandblasted abutments in the mouth showing very wide bone and excellent healthy thick gum tissue

postoperative panoramic x-ray showing three dental implants in the lower right jaw.

postoperative panoramic x-ray showing excellent fit of abutments and monolithic zirconia bridge.

final bridge seated over the abutments. The final bridge is on the right of your screen.

When I removed the bridge I found one of the teeth anchors broken.   That broken root canal tooth is not savable and will need to be extracted. The back wisdom anchor tooth is healthy in and of itself but is tilted towards the front.  This patient is unique in that she has very long roots as shown on her panoramic x-rays.

The biggest issue is that the bone in the area where the teeth used to be is super thin.  When you lose a tooth or a segment of teeth, the bone thins out because it is not being used.  This process is called atrophy (BONE LOSS) .  So even though her bone was tall enough, it was not wide enough to have implants properly placed in the center of where the teeth used to be.  If you try to have your implants done without a bone graft, the implants would have to be pushed towards your tongue side and the implants would be a very small diameter with minimal bone on the outer wall… a recipe for disaster.

In her case, I did a bone widening/expansion ridge split.  In this process, I actually purposely “break” the outer layer of bone towards the outside and push the outer layer of bone away from the inner layer of bone.  This creates a big trough which can then be filled with donor cadaver/cow bone and L PRF/PRP made from your own blood.   This is a very advanced bone grafting technique that is not just a typical mild expansion of bone.  It is a full repositioning of the outer wall of the lower jaw bone.

This bone graft was allowed to heal for 4-6 months prior to placing the implants.  In her case I would not advise placing implants at the same time of the bone graft although in many cases I do place the implant simultaneously.  Her case was special and that she was on a bisphosphonate medication in the past for cancer treatment.  The bisphosphonate medications can slow down bone healing and can have really detrimental complications so going slow was better than going fast.  I did some blood tests for her and also consulted with her physician prior to initiating treatment.  It is always best to be safe especially when dealing with dental implants and medications similar to Boniva and Fosamax.

After a few months of healing I decided to place 3 dental implants for a connected-splinted dental implant bridge.  Remember she wants the “strongest possible” solution so I advised her to have 3 implants and a 3 tooth bridge rather than 2 implants and a 3 tooth bridge.  Connecting the teeth is definitely the strongest way and helps prevent food impaction.

In the photographs, you can see how wide the bone is and how the implants are well centered and spaced now that she has the proper amount of bone.  The implants are long and of a really good diameter for a proper emergence from the gums for large molar teeth.

After 3 months of healing, I began to take my initial 3-D video scans of her mouth to fabricate her teeth.  I made 3 titanium abutments on the 3-D printed model in a virtual program.  This way the teeth are fabricated using a computer and not typical gypsum clay molds and messy impression material that gets stuck in your mouth!

The abutments were steam cleaned and sandblasted for proper cement hold and sterility.  This is a another important step which is commonly skipped.  The implant abutment junction must be super clean and the smooth metal must be roughened slightly for micro retention.

The implant bridge was then fabricated using monolithic zirconia.  This material is wonderful because it is white, strong and aesthetic for back teeth.  It is stronger than original bridge with the metal support.  I use this material quite commonly for my full mouth Prettau zirconia dental implant bridges.

Needless to say, she was very happy with the final result of her teeth. I am sure they will last a very long time. The best part was the big hug she gave me at the end. 

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Bone Graft Correcting Dental Implant Peri-Implantitis Bone Loss ~ Case Example

Bone loss can and does occur around dental implants.  Often this is called peri-implantitis and there are a few treatment options.

Review signs and symptoms of peri-implantitis dental implant bone loss in this previous article.

Bone loss on implants happens on about 1-15% of dental implants. That percentage is variable depending on the experience of the dentist. How to deal with it is the big question.  In certain situations your dental implant or implants can be recovered with bone grafting procedures but in some instances the bone loss associated is so significant that the only option is to remove the implant and start all over again.  Bone grafting for peri-implantitis bone loss defects is not standardized and varies widely from dental surgeon to surgeon.  Over many years of doing this I have developed a specific technique for recovering some of the worst bone loss.

Correction of bone loss on dental implant--Ramsey Amin DDSBone loss can occur as a “moat” defect going 360° around the entire implant or it can be just localized to one side of the implant.   If it is 360°bone loss it is much worse than if it is localized to just one side.  The best area to have bone loss is in between the teeth rather than on the outer aspect.  This is easier to graft and has a higher success rate.

If the implant is in the front of the mouth versus the back of your mouth this can make treatment options very different also.  The back teeth are more forgiving and then the front.  The gum and bone is typically thicker in these areas. There are times when the final outcome leaves you with some metal of the abutment or implant showing but disease process was stopped.  Of course in the front of the mouth this is typically unacceptable especially if any metal shows in the smile.

In this example case I will show you the more difficult of the two….  A case where bone was lost on the outer aspect.

In this case this is a 29-year-old female that had a dental implant placed in another country.  The implant overall looks good but it has become tender on the outer aspect of the gum.  One reason in her particular situation why bone loss happened was because the bone was a  too thin to begin with and then the crown on the dental implant became loose at the abutment.  This particular dental implant crown/abutment had a design flaw which caused loosening.

If you look at the implant on a 3-D CBCT scan view from the side you can see that in the mid body of the implant there is very little bone.  Because I never treated this patient to begin with,  we don’t know if the bone was like this from day one or it dissolved to this situation because of the loose dental implant abutment.  Either way it needed to be treated.  We discussed the possibility of removing the implant versus grafting bone and saving the implant.

If you look closely at the gum tissue, of both center upper front teeth you will notice that there is more of a hump on the natural tooth than there is on the dental implant.  This was the first sign that the implant was lacking bone when she smiles.  What makes this case very difficult is that the teeth are generally very long and when she smiles she shows her gumline….  Everything is going to show so this is going to be a critical surgical correction.

You have to be really careful with these cases because sometimes the correction can make the tooth look worse if it is not successful.

The most critical factor in all of this is prevention.  I go to GREAT lengths to prevent dental implant bone loss from occurring in the first place by having a tremendous amount of bone on the outside of the implant if the patient’s anatomy allows.  By having the original implant surgery done well, this is the best way to preserve the bone on the outer wall.  Also when the crown and abutment are made by the dentist, there are so many techniques and choices to make things last and be problem free for many years.  Many patients think that the crown and abutment portion are “easy” and can be made by any regular dentist.  For some patients anatomy, dental implants would not be wise choice…that is the exception rather than the rule.

In her case, I am certain that the result will be long lasting.  The good thing was there was no exposed threads at the very crest of the bone.  The surgery was done under IV sedation through a tunnel flap which is the equivalent of a laparoscopic medical procedure.  I was able to remove the crown and place a temporary crown during the procedure which helped with surgical access. The sutures seen here are designed to be dissolvable because the incision is far away from the actual tooth being treated.

I know these specific and detailed articles but a lot of this information does not exist on the Internet.  I hope this helps those of you that have this problem and those of you to prevent if possible.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

What Is A Membrane? Do I Need One For My Implant Bone Graft? My Membrane Fell Out/Sticking Out And Exposed

socket membrane Ramsey Amin DDS membrane space membrane ramsey amin dds What is a membrane?  Do I need one for my dental implant bone graft?  My membrane fell out or is sticking out and exposed.

These are questions and comments I receive constantly on my blog and from patients that come to see me in Burbank, California.

Let’s review what a membrane is and its purpose.

A membrane is a barrier.  Its purpose is to prevent gum from growing into the bone cavity.  On many bone grafts for dental implants, a membrane is placed over the bone but under the gum.  There are many different types and styles of membranes but they break down into basically 2 categories.

  1. Dissolvable (resorbable) membranesBurbank Dental Implants membrane
  2. Non-dissolvable (non-resorbable) membranes

Both resorbable and non-resorbable membranes have their use.  A resorbable membrane will dissolve on its own. Non-resorbable membranes typically need to be removed at some stage during your bone graft/dental implant procedure.
collagen membrane

Resorbable membranes:

Most resorbable membranes used, as of 2014, are made of collagen.  Collagen is a protein which you may have heard of in products such as shampoos and conditioners.  It is heavily cross-linked and makes an excellent barrier.  Most commercially available collagen membranes are 15 x 20mm in dimension and look like a flat, white piece of cardboard.

They are trimmed with surgical scissors by a dental implant specialist and typically covered over bone.  Most collagen membranes are made from bovine Achilles tendon or porcine origin, which basically translates into cow and pig.  Some resorbable membranes dissolve very quickly in just days; these are typically called plugs, while other resorbable membranes can last approximately 4 months.  Most resorbable membranes are not tacked in place with titanium fixation tacks.  Some are even pericardium from heart tissue.

The other types of natural resorbable membrane would be one made from your own blood!  Platelet rich fibrin or also known as PRF, can be used to make membranes from your own platelets.  Basically 1-6 test tubes of blood is drawn at the time that I start your IV.  Those test tubes are spun in a machine called a centrifuge, which separates out the layers of your blood.  It also concentrates your blood to be used for other platelet rich preparations called PRP and PDGF.

PRF can be used as a resorbable membrane as it tends to last 7-14 days.  It is stretched out and made thin so that it can be sutured.  It becomes a durable, kind of slimy consistency which can protect a bone graft.  PRF membranes can be used in addition to resorbable or non-dissolvable membranes for dental implant bone grafting.  PRP/PRF can speed up your healing and reduce pain and complications.

There are also synthetic membranes that dissolve, such as Vicryl, which are not as commonly used.

Non-resorbable membranes:

Most non-resorbable membranes can be made of titanium and dPTFE (Dense polytetrafluoroethylene).  They are materials that form a barrier that cannot be dissolved by your saliva.  Some non-resorbable membranes, such as PTFE, are often combined with bone tacks in order to hold the membrane stable and cover the grafted bone.

One benefit of a non-dissolvable membrane– they are very predictable in generating bone.  The main downside– it has to be removed at a second procedure.  Sometimes that second procedure may involve just plucking out the membrane off the top of your socket graft or it may be more involved, such as completely reopening the gum, removing the bone tacks, and then removing the membrane.  Typically when membrane removal involves removing tacks, the dental implants are placed at the same time that the membrane is removed.

PTFE has been used for over 30 years in cardiovascular applications such as suture, vascular grafts, and heart valves. PTFE is bioinert and does not cause inflammation.

Titanium reinforced membranes, or titanium mesh, is best at holding a space.  It works like a tent and prevents collapsing of your gums to build new volume and mass underneath.

Sometimes the membrane on a socket graft will be removed after 1-4 weeks or may even fall out if it is a dPTFE style membrane.  This is okay, generally.  The purpose was to allow your gum to grow underneath it and cover over the bone graft as the membrane protects it.  Once the membrane falls out or is removed from a socket bone graft, the bone still needs to heal for usually another 3-6 months before dental implant placement.

Is it okay that my membrane showing??  It depends!!  If the intention of your membrane was to be exposed from the beginning, then it is okay that it is exposed right now.  If it was the intention for your gum to remain covering over the membrane for 4 -9 months, then you are likely having a minor complication called a dehiscence where the gum becomes exposed and naturally exposes the membrane and bone graft.  The more critical the bone graft is, the more critical it is that the tissue remained closed and the membrane is not exposed at any time.  Critical bone grafts would be onlay block bone graft, lateral window sinus bone grafts, nerve repositioning, and advanced guided bone regeneration (GBR).

A standard socket bone graft (where an outer wall is not missing) would not be considered a critical bone graft; so leaving a membrane exposed is okay.  If an outer wall is missing, this would be considered a critical size defect.

It is important to maintain proper follow-up with your dentist throughout the procedure.  It is likely that you will be on an antibiotic, such as amoxicillin or clindamycin, and a mouth rinse called chlorhexidine gluconate.

Keep in mind there are literally hundreds, even thousands of different membrane manufacturers each claiming to be better than one another.  Yes, there are better manufacturers than others, but ultimately the surgical technique, training, judgment, and expertise of your dental implant specialist is going to be the most critical factor in the success of your bone graft…choose wisely!!!!!!

You can use all of the best materials in the world, including growth factors such as  PRP/PRF/PDGF/BMP, but in the hands of an inexperienced surgeon, results may not be that good.  Of course your ability to heal is of paramount importance.  Smoking never helps.  Alcohol does not help either… Both of these slow down the healing of bone and greatly increase your chance of complications.

Wearing a removable, temporary “flipper” over a bone graft is to be done with extreme caution.  Pressure from a removable temporary will cause the bone graft and membrane to move and almost always results in failure.  Be sure you and your dentist speak about the use of a temporary and how to create space underneath it so there is no chance that it can apply pressure to the bone graft.  Some bone graft membrane reconstructions are so critical and so large that the temporary cannot be worn at all, but that is the exception rather than the rule.

Ramsey A. Amin, D.D.S. (http://www.burbankdentalimplants.com)
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

 

What is Peri-implantitis and What Do I Do About It? – Bone Loss Around Dental Implants ~Burbank Dentist, Ramsey Amin Reviews

One of the long-term risks associated with dental implants is a condition called Peri-implantitis.

Peri-implantitis Definition: Infectious disease that causes inflammation of the surrounding gum and bone of an already integrated dental implant, leading to the loss of supporting bone.

These two x-rays show implants with bone loss.Peri Implantitis review ramsey amin dds bone loss implant ramsey amin dds burbank

Bone Loss Around Dental Implants

Bone, for a variety of reasons, is lost around the dental implant.  This condition generally occurs without the patient being aware of it. There are many factors on why this can happen.  Some dental implants on some patients will develop bone loss which can happen very early after having the crown put on the implant or it can happen many years down the road. Dental implants are fantastic, but nothing is without risks. If your dentist tells you they are 100% successful and have no problems ever, I would suggest seeking another opinion.

This condition is difficult to treat. Fortunately, most patients never develop this.

Most patients are unaware that they have bone loss around the dental implant. Peri-implantitis generally progresses in a painless fashion. Once it is established, you may begin to develop symptoms.

There are several risk factors. Smoking definitely causes constriction of blood vessels which leads to bone loss. Medical issues such as diabetes, osteoporosis and poor immune systems are more at risk for developing bone loss around dental implants. If you have had gum disease in the past, you are more at risk. Your home care is critical… Brushing twice a day for 3 to 5 minutes with an electric toothbrush, flossing once a day and using adjuncts such as a rubber tip need to happen every single day… Forever!!  Grinding your teeth is another risk factor for dental implant bone loss.

Of course there are surgical factors that cause peri-implantitis to happen:

Soft bone, lack of tightness when the dental implant is placed, bone that was grafted in a vertical fashion, implant size too big, overheated bone, and many others.

 Signs of peri-implantitis

  • gum pockets deepen
  • pus comes out from the implants and gums
  • bleeding at the gumline
  • appearance – gum is red, or slightly purplish bluish, tartar/plaque build up
  • progressive loss of supporting bone on x-rays
  • metal thread exposure
  • long tooth

It is not always symptomatic and typically there is no pain. Some of my patients have complained of dull aches or tenderness when they brush or touch the area. You can also develop a bad taste if pus has developed. If it is very severe, the glands in your neck may become swollen and you may even feel the dental implants being loose.

Who Should Correct Your Dental Implants?

I treat many patients with this problem.  Unfortunately many of these patients had implants done with inexperienced dentists or large supercenter practices. Correction of dental implants with problems should be performed by a dentist who routinely performs this procedure.

The first thing I check for is to make sure the crown or bridge was made properly. The x-ray tells so much. Sometimes a 3-D scanning is necessary to see the inside surface. Extra cement is often the cause of peri-implantitis. The cement oozes beyond the abutment and gets down below the gum near the bone. The cement becomes an irritant. There is often good reason to make crowns held in by screws rather than cement in some cases. The technique of cementation and choice of cement used is a big factor on whether or not this will become an issue for you.  You would be surprised to know that most novice dental implant dentists are not aware of proper cement choices although they have no ill intentions just lack experience and knowledge.

Occasionally I will find a loose abutment screw which may not have been torqued properly or it broke. That can be caused by someone with a really heavy bite. Patients with heavy bites need to have their crowns designed to protect the implants. How the crown is made is ultra critical for the longevity of the dental implant in the bone. So many patients view this step as minor, but it is major. Some low-budget implants have poorly designed screws or have micro motion when you chew.

Sometimes we find gum disease on other teeth just nearby which can stimulate peri-implantitis to start on the implant. Generally some type of exploratory surgery needs to be done to find out the cause and do a simultaneous bone graft in an attempt to save the implant. Not all implants that have peri-implantitis can be saved.

Normal Implant Bone x-ray (Implant by Dr. Ramsey Amin Burbank, California)X52609

Treatment

The long-term goals are to stop the progression of bone loss and maintain your dental implants! Generally speaking the area will need to be cleaned thoroughly using dental instruments. Oftentimes antibiotics will be prescribed and special antibacterials will be applied to the implants itself such as iodine or tetracycline.

Most peri-implantitis dental implants require surgery and bone grafting. This means that your gums have to be opened and the area has to be detoxified. All of the bacteria must be killed in order to have bone regrafted onto the implants. I will definitely place you on antibiotic after this procedure.

The physiology and the type of bone that is used is critical. I would also suggest using your body’s own helpful blood products such as PRF/ PRP.

Time will tell if the procedure works. There are no guarantees on grafting around implants that have pre-existing bone loss. It is far more successful if the bone missing is in the shape of a moat rather than an entire wall missing.

Over the last 14 years of placing implants, I have developed many techniques to avoid this from occurring. When it does occur I have also developed techniques that seem to be more predictable. I have successfully regenerated bone around many implants over the last 14 years in practice. We have to be realistic when an implant has had too much bone loss though. The success rate can be as low as 35 to 50%. Some severe cases of peri-implantitis are better off removing the implant and placing a new one.

Just because one implant may have failed or develop bone loss, it doesn’t mean the second one will.

Please feel free to comment or ask questions below that are relevant to this post.

Floss!

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

After Extraction and Bone Graft…The Bone is Showing. Now What? Ramsey Amin, DDS Reviews Options

Exposed bone in mouth after graft

Exposed bone in mouth after graft

You may have had your tooth extracted and a bone graft placed at the same time.

About once or twice a week I get emails from around the world with patients that have had this very common (pre dental implant) procedure.

You may be worried because you can see that the bone is exposed inside your mouth.

You may also be worried because small, hard granules, pieces, or particles of bone coming out of the socket. You see white bone showing.

extraction socket bone graph by Dr. Ramsey Amin, DDSDON’T PANIC!

Socket bone grafting is very common and is encouraged when the outer wall of bone is very thin. The goal is to prevent the bone from shrinking and preserve the bone mass.

Most socket bone grafts have particulated bone added to the socket and are covered with some type of membrane at the same time of the surgery. The bone may be from your own body, from a human cadaver, from a cow or synthetic bone.

The bone on your cheek and lip side of your teeth in general is no thicker than 0.5mm to 2 mm at the most. When a tooth is extracted, the thin wall of bone will naturally collapse inward leaving a depression indent in your jawbone. It is that very same bone that you need to have a dental implant.

Ideally over the course of the first week, the gum heals over the top and no bone is showing at all. It is not uncommon for some bone to become exposed during the process of healing. It is also not uncommon to have some of these granules come out during the healing process.

I strongly encourage antibiotic use during most socket bone graft procedures as this will help reduce (not eliminate) the chance of infection. I routinely administer antibiotics right before your appointment so that the blood clot (scab) will have the antibiotics within it.

If you are not allergic to penicillin, then amoxicillin 500 mg is an ideal choice. If you are allergic to penicillin, then clindamycin would be another good choice.amoxicillin

What do you do if you see bone or you are getting small flecks of bone coming out in your mouth? Don’t panic…see your dentist and let them know what you are experiencing. As long as you are not infected then it should not be a problem. If you have an infection of the bone graft and socket then you will likely need to continue antibiotics for a second or third round or sometime switch antibiotic families altogether. I generally prescribe an antibiotic mouth rinse also such as peridex. You will need to have some of the top pieces of bone removed.

Signs of infection would be redness, pus, pain and in some cases fever.

The most crucial thing to ensure your socket bone graft extraction success is that the procedure is done well by someone who specializes in implant dentistry. The correct choice of bone product for your situation is important but not as important as the surgeon and your healing ability.

3d scan burbank ramsey amin (4)

Extraction and bone grafting at the same time is not as simple as just sticking some bone into the socket. The internal cleaning of the socket is super important. All remnants of tooth and inflammatory tissue must be removed. This is not as easy as just scooping it out. The socket must be debrided very well to get down to bare, bleeding bone and is a sensitive procedure especially when you are pulling out a failed root canal tooth.

Fractured root canal teeth are probably the most common extraction that leads to a socket bone graft. Choosing bone that comes from your own body, from a cadaver, from a cow, or totally synthetic all have their pros and cons and you must discuss these with your dentist.

The socket bone grafting for upper front tooth dental implants are critical in establishing the right amount of bone so your front tooth looks great! If there is a dent in the bone, the tooth will look long and may have open black hole triangles near the tooth.

Bottom line…some exposure of bone and bone graft migrating pieces is common, but it is preferred that all of that stays in the socket. It does not mean the graft has failed. Do not confuse a socket graft losing bone with an exposed onlay block bone graft. The rules are different.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Dental Implant is Too Deep, Tooth Looks Long

Dental implants, especially in the front of the mouth, need to be placed with a high degree of accuracy. When an implant is placed too shallow or worse yet too deep in the front of the mouth it creates a cosmetic failure– a long tooth and sometimes black triangles.
IMG_3920

This is especially true on a patient who has what we call a “high smile line“. This is when you smile and you show more of your gums than average. If she had a low smile line, then it wouldn’t be noticeable when she smiles.

Here is an example of a patient that had an implant placed in about the year 2004. The dental implant was placed as an immediate tooth replacement which is a great option most of the time. Unfortunately the dental implant was placed too deeply into the bone. She hated this tooth.

IMG_3922IMG_4309

When this happens you end up with a very long tooth. And worse yet, there is not a lot of good options that can be done to correct it once it is in this position. So in her case, I had to actually extract the implant and rebuild her jaw bone with 2 to 3 bone grafting and gum grafting procedures in order to put a new implant in a more shallow position. A block bone graft was needed also.

This is about as difficult as it gets. This case is difficult because I had to regrow bone vertically, closer to the edge of the natural teeth. Building bone vertically rather than horizontally is always more tricky and requires several very advanced techniques.

You can see in the picture with the white dental implant custom abutment, that the new implant is at a better level because the gumline is more even with the tooth next to it.

IMG_5788

Unfortunately the deeply placed implant permanently stripped bone off of the teeth on the side, and that is not repairable.

Compare the levels of the two implants on the x-rays.  One is much more shallow than the other. The shallow one was placed by myself and the deeper one was placed back in 2004 by another dentist.

Occasionally you can recover a deep, long tooth implant with a new custom abutment and gum graft. But I caution you that this is truly a very difficult procedure and should be completed by an expert in implant dentistry so that you can anticipate a result before you ever even get started.

Please feel free to ask questions or leave comments below.

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Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry

Losing Bone on My Dental Implant -Too Much Cement?

Too much cement used on a dental implant crown or bridge can easily cause bone loss around both new and old implants.  It sounds counterintuitive to purposely use less cement for an implant than you would for a crown on a natural tooth.  If left untreated, it can be one of the worst dental implant complications to occur and can cause implant failure.

Unfortunately this is a complication that I see here in my office in Burbank fairly routinely.

Here is how it works:

When a crown is cemented on to an implant, the cement can get beyond the gums and touch the bone. This is possible because the gum pocket around a tooth and the gum pocket around a dental implant are very different from a biologic standpoint. Your natural teeth have a tighter seal at the gum level.

The straight red line indicates the good bone level. The dipped down line indicates the bone loss

There are different cements and bonding agents that I use for dental implants, but the bottom line is no matter what is used, the cement gets so thin, it can easily slip below the pocket.  It is near impossible for the dentist or the patient to see this.  A seasoned dental implant dentist understands this concept and should go to great lengths to prevent it.  It is based on the technique of the dentist, not the brand or type of cement.

I have developed a specialized technique for cement and bonding dental implant teeth over a decade ago.  Aluminum oxide blasting, dental implant analog cementation, and retraction cord are just a few of several techniques I use.

The center portion of the dental implant was removed by Dr. Amin. The bone loss was too severe to correct. The teeth on top stayed unharmed though.

How do you know there is too much cement?

Shortly after having a dental implant with too much cement, the gum bleeds, there may be pain and/or infection, and the gum may recede. If this is not handled quickly, permanent bone loss may ensue.  The gum usually does not grow back.  Bone can be grafted back only in some situations.

What is the disadvantage of using special techniques to use less cement?

The main disadvantage is that the crown or bridge may come out. A crown  that comes out is easily replaced, while bone and gum loss from too much cement is not easy to fix.  It is worth it.

There are many other reasons why a dental implant can lose bone; too much cement is only one of the reasons.  Please read more of my blogs and watch other videos if you would like to learn more. Dental implants are still the absolute best way to replace one tooth or all of your teeth.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry
Burbank, CA

What is Sinus Expansion? Do I Need a Sinus Lift? Sinus is Big and Close…Burbank Dental Implant Expert Reviews

Your sinuses are big hollow holes above your upper teeth.  The roots of your upper back teeth are really close to your sinus. In order to have dental implants in that area, sometimes a sinus lift bone graft is necessary to treat the expanded sinus.  Whether you live in Burbank ,Glendale or Los Angeles, all of our sinuses pretty much expand when teeth are lost.

When you lose your teeth, your sinus expands.  This destroys the bone needed to have dental implants. When these upper teeth are removed, there is often just a paper thin wall of bone separating the maxillary sinus and the mouth.

Sinus              Sinus7                    Sinus8
   
Normal                     Moderate expansion        Severe Expansion

When all teeth are present, the sinus is protected from expansion which is really bone loss. The presence of teeth keeps the maxillary sinus in place. The expanding sinus destroys surrounding bone.

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Most of the sinus lift bone grafts I do in my Burbank, California office are to add back the lost bone height from the expansion of the sinus.  If you are missing teeth on both sides, then usually the bone loss happens on both sides too. Dental implants prevent bone loss.

 

You can prevent the need for a sinus lift bone graft by either placing your implant on the same day the tooth is extracted (immediate implant) or by placing the dental implants within a few months of losing the tooth or teeth.

There are two main ways you can add bone to an expanded sinus: (follow links for details)

            Internal Sinus Lift

            Lateral Window Sinus Graft

In cases where the sinus has greatly expanded, your body may form or accentuate “septae” in your sinuses.  Septae are like “cross bar stabilizers in the sinus when the sinus is big and expanded.  Sinuses with septae should be grafted by a very experienced implant surgeon to reduce the chance of  the sinus membrane ripping (perforation.)

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow of the American Academy of Implant Dentistry
Burbank, California
http://www.burbankdentalimplants.com

The “Void” Bone Graft for Immediate Single Implants – American Board Diplomate Explains

A bone graft for immediate single implants is often needed. Most immediate implants are for single rooted teeth like your front and middle back teeth (premolars.) In my Burbank dental implant practice, this type of bone graft is common.

Most implants are round in shape.  Most extraction sockets are oval or rectangular if they are molars.  When I place an immediate implant into an extraction socket there may be a void.  That void is caused by the different shape between the round implant and the larger, non-round extraction socket. See diagram below.

Burbank immediate implant bone graft diagram

That void often needs to be grafted with bone so gum or soft tissue doesn't fill in instead. 

This implies that the extraction was meticulously performed without losing your bone and that the walls of the socket are fully intact.  Sometimes you cannot avoid some bone loss when a tooth is removed.  Often the bone on the outside is missing which can mean that having an immediate same day implant unpredictable. Root canal teeth or teeth with advanced gum disease are often missing the walls of socket.

If the void is really small, no bone graft is needed as it will naturally fill with bone. 

It is possible to have a bone graft, extraction, dental implant and a temporary crown on the implant all on the same day!

If I am replacing all your teeth on one arch as immediate implants, this type of bone graft can sometimes be avoided.  This is because the bone loss caused by gum disease causes the oval sockets to become more round. The lower jaw is really good for immediate, same day, full implants.

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow of the American Academy of Implant Dentistry
Burbank, California
http://www.burbankdentalimplants.com