Category Archives: Extraction

Same-Day Extraction Immediate Lower Molar Dental Implants And Nerve Injury Discussion

Immediate Extraction and Implant Planning –deeply placed nerve.

It is not every day I see a case like this. This patient is going to lose her lower first molar which is the one that is second from the back typically if you are missing your wisdom teeth. It is the most common tooth to be pulled mostly because it has been in your mouth since you were 6 years old. In her case, the tooth is not savable because of severe root decay on an existing crown with a root canal. (Remember that you can get a cavity on a crown which typically happens at the edge or “margin” which is where the tooth meets the crown near the gum line.)

Decay in first lower molar root canal

Usually the lower molars require a “staged” procedure. This means that the tooth is usually extracted first in the implant is placed at a later date.

Most often, a socket preservation bone graft is done to prevent the bone from shrinking after the tooth extraction.

Because the procedure is done in stages, it typically takes 6-12 months to complete often based on how hard or soft your bone is or how fast or slow your bone heals.

What is so unique about her case is the depth of her nerve!! It is DEEP in the jaw! Most of the time, an immediate lower dental implant is not able to be done because this nerve is too close to the surface. Typically I like to place the implant a minimum of 1-2 mm away from the nerve. So if the nerve is high, your oftentimes limited to a short implant or an implant that cannot get enough stability when it is placed into a socket. This nerve gives sensation typically to the lip and chin. There are other branches of the third division of the trigeminal nerve that give sensation to the cheek and tongue.

The nerve is like an electrical cable which carries sensation back to your brain. If you’ve ever gone to the dentist and gotten your lower jaw numbed up, this is the nerve responsible for this.

By keeping a safe distance away from the nerve, an altered sensation or nerve injury complication can be reduced…. But not completely eliminated.  Complications can still occur with either method.

The nerve has several “tributaries” that are like in the fine fibers of a plant root system that you pull out. There is usually one main root and then thousands of little small rootlets. Most of the time as long as the main nerve is avoided, a nerve injury does not occur.

Plant roots —one main one and many tiny extra roots

If the nerve is bruised, you may feel like the numbness and last longer than normal. This is called a paresthesia. The numbness may last an additional 3 days, 3 weeks, 3 months or may become permanent.

It can be a feeling of slight tingling all the way to feeling fully numb. Most are temporary and return within about a month to full sensation.

It is my belief that this procedure should really only be done by a very experienced dental implant provider.

The advantages of same-day extraction/ lower molar dental implant:

  1. Decreased cost
  2. Single visit procedure
  3. Time savings of 4-8 months
  4. No need for socket preservation bone graft ( usually still need a “void” bone graft though which is much more minor)
  5. One time on antibiotics
  6. One sedation
  7. Virtually eliminates bone loss from disuse atrophy
  8. Ability to place a very wide diameter implant

The disadvantage of same-day extraction/ lower molar dental implant:

  1. Slight increased risk of nerve injury
  2. Lack of implant to be able to achieve primary stability
  3. Often the implant needs to be buried and later and covered with a minor surgical/laser procedure
  4. The tooth extraction must go smoothly
  5. Centering of the implant can be more difficult if not impossible

Nerve injuries can be prevented by a skilled/experienced dentist, intravenous/intramuscular steroids, L PRF/PRP blood product, a 3-D scan planned procedure.

This patient’s case is really cool because her nerve is a mile away! The implant is one of the largest available… A 7.0 x 13 mm which obliterates most of the socket. Obliteration of most of the socket works well to gain stability of the implant, reducing the need for bone grafting, and gives molars a hefty base for a good emergence from the gum line. It also helps carry the high bite force is the back teeth which is important to prevent bone loss around an implant-peri-implantitis.

Obliteration of the socket is not a good idea in other areas of the mouth such as the upper front where the implant should be placed closer to your tongue and the implant ideally be smaller diameter. The rules are very different from each area of the mouth to another… what applies in one area of the mouth can be disastrous and other areas of the mouth!

In some extreme cases that I treat, the nerve is so shallow that I have to move it out of the way in order to put implants in the jaw. This is called a nerve repositioning/lateralization

Plan for immediate extraction and implant. Deep nerve position.

After Immediate Implant –DEEP nerve.

Regular nerve position with dental implant

Same day extraction and implant of lower molars is a wonderful procedure. In my hands, it is very predictable and I have been doing this for about 20 years now as of 2017. It is only intended for probably about 10% of molars. It can be done on the upper jaw as well as the lower jaw. During the surgery, if I feel like there is any increased risk, I will generally abandon the implant and only extract the tooth with a bone graft. You have to be flexible and change if needed for safety and predictability.

The red lines drawn into the 3-D scan indicates the placement of the nerve.

I hope this helps you understand this procedure. The images showed the 3-D scan before extraction and implant placement and another limited field 3-D scan taken after the implant.

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

Wisdom Teeth Extraction/Coronectomy With Simultaneous Baby Tooth Dental Implant Replacement -Case Example

IMG_1137Can you take out your wisdom teeth and place an implant at the same time? I often hear this question. Yes!!! This is a common procedure for a younger patient who has a baby tooth well into their 20s. Oftentimes baby teeth cannot be saved and need to be replaced with a dental implant since the permanent one was missing from birth. We call those “congenitally missing” teeth.

In this case, this young 24-year-old man came to me with wisdom teeth that continued to bother him and flare up occasionally. He also had a baby tooth in the upper jaw that was fused to the bone. This fusion into the bone is called ankylosis. Ankylosed teeth are very difficult to remove because they don’t have a ligament between them…so they don’t move at all. He did not like the way his smile looked with the tooth not being level with the rest of them and knew that the baby tooth was in bad shape and decaying.


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The plan was too extract the baby tooth and simultaneously place a dental implant at the same time of extraction and do a bone graft into the voids around the socket. While he was under IV sedation, two wisdom teeth are going to be treated at the same time. One of them on the upper left was extracted in a typical surgical fashion. This means that the gum is lifted, and the tooth is removed sometimes by sectioning it and/or by minimal bone removal.

His lower wisdom tooth is very unique. If you notice, I only removed two of the four wisdom teeth. In fact, I really only removed 1-1/2 teeth. On the lower right, a procedure called a coronectomy was completed at the same time the dental implant was placed with the baby tooth extraction and the wisdom tooth extraction on the upper jaw.

Dental implant baby tooth (1) The nerve that gives sensation to the lip, teeth and chin is directly below all of the lower teeth and was touching the wisdom tooth. In his particular case it would’ve been too risky to remove the entire tooth and cause a possible permanent numbness or nerve damage from the removal.

A coronectomy allows the head of the tooth to be removed and purposely leave the roots behind. It is a procedure that is accepted in modern oral surgery but is not that common. In his case, avoiding a nerve injury was very important so only part of the tooth was removed.

It is very rare for the roots to cause a problem later in life; they usually just sit under the bone forever. Very rarely, a complication can occur where the roots begin to move and need to be taken out, but at least it is much easier and less risky because the root is no longer touching the nerve. Nerve injury is also a risk of having a dental implant or bone graft on the lower jaw.

Dental implant baby tooth (2) The dental implant was allowed to heal for four months. I restored this case with the prefabricated titanium straight contoured abutment and layered zirconia crown. This provided the patient with an excellent profile and reproduction of his original tooth. If your situation is similar, consider extraction of the baby tooth and placement of the implant at the same time. Sometimes placing the baby tooth implant has to be done in coordination with orthodontics because most baby teeth are bigger than the adult’s teeth in the premolar region.


RIGHT
before-ankylosed baby tooth on upper impacted wisdom teeth on lower
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final dental implant crown

final dental implant crown

dental implant abutment

dental implant abutment

after coronectomy on lower wisdom tooth and placement of dental implant for baby tooth

after coronectomy on lower wisdom tooth and placement of dental implant for baby tooth

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

Antibiotics for a Tooth Infection, Dental Implant, Bone Graft… Do I Need Them? 

In this short, but highly informative video, I review some of the common truths and misconceptions about antibiotics in relationship to tooth infections, dental implants and bone grafting.

Use of antibiotics should be judicious and carefully thought out.  Just because you have an “infection” in your tooth, it does not mean you need an antibiotic.  Also, not all “infections” are actually infections.  Not all infections can be cured by antibiotics alone.

Antibiotics are commonly needed for procedures that involved cutting through bone or addition of bone graft materials.  There is a limited supply of new blood vessels that can get your natural immune system’s protection in the first few days following a significant procedures such as a surgical extraction, a bone graft, sinus graft, apicoectomy and dental implants.

Antibiotics are extremely helpful in many situations.  I also discussed common questions such as antibiotic resistance and what happens with common stomach issues and what to do about them.

I think you will find this video helpful.  Please feel free to ask questions below.

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.
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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.

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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.

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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

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

 

Root Canal Apicoectomy Failure – Relation to Dental Implants (Ramsey Amin DDS – Burbank, California)

If you have a root canal and now need a dental implant there are some very important issues to be aware of.  This is especially important if the tooth to be extracted is in the upper front area. It will have consequences on the final result and cosmetic appearance of the implant.

A previous failed root canal can be a major detriment to having an implant.  The problem is related to a hole that develops in your bone which dissolves the very thin outer wall of bone.

Although root canals work, they are not 100% effective. Some teeth may not respond as expected to the root canal therapy.  Sometimes, it is clear from the beginning that the root canal is not working as planned. Other times, it may be years later that a problem arises.

The problem is usually re-infection of the root canal or a broken, fractured root. This usually shows up as a painful pimple on your gums.

Often times a root canal is “re-done” if the root becomes re-infected.  I have seen patients that have had the same root canal done 2-5 times before finally

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Upper Molar Dental Implants to Replace Missing Teeth – Case Study -Dr. Amin, Burbank

Here is a nice basic case to follow from beginning to end.

This man's upper molars on one side were in bad shape:

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The teeth were extracted and replaced with three dental implants in my office in Burbank.  He also had a deep cleaning.

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The color denotes the size of the implants.

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Standard abutments were able to be used rather than custom abutments.  This helps reduce cost, but most implant surgeons don't know how to place implants to prevent having to use custom abutments. 

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Final Teeth: 
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He was really happy to have teeth again.  He can eat anything he wants!

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

Burbank Implant Dentist on Extraction Defects…Relation to Dental Implants and Bone Grafts

Teeth are removed for several reasons, including periodontal (gum) disease, extreme decay, and for orthodontic reasons.  Once a tooth is removed, the shape of the ridge (i.e., the supporting bone and gum in which the tooth was situated and retained) changes. If there has been extensive bone loss, or if the tooth needed to be surgically removed (bone had to be cut away to gain access to the area), the change will be more dramatic. The ridge shrinks, collapses into itself, and over time decreases in width and height. As more time passes after the extraction, the more change occurs.

This is an extraction site defect. Look how skinny the bone is compared to the image next to it!

Lr     Lr-----

The extraction site defect presents a problem when the area is to be restored with an implant.

When the ridge architecture has significantly changed, the replacement tooth will have to deviate from the ideal shape. This could easily make the area more difficult to keep clean, difficult to restore, and cosmetically quite unsightly.

Perhaps the cosmetics may not matter to you when there is a back tooth being replaced one that is not visible when you speak or smile. An extraction site defect in an area visible when you speak or smile will create a severe esthetic problem.  The more the ridge has changed, the more your tooth will need to be either longer, wider, or fatter in order to fill up the extraction site. If you have a smile line that shows the tooth or gumline, the replacement tooth will be very obviously misshaped. It will never look right and will be a cosmetic failure.

Here is a dental implant on a patient from Burbank that I did:

missing tooth 2004
front tooth dental implant --Dr. Ramsey Amin -Burbank 2009

It is clear that for the dental implant replacement tooth to have a normal appearance, the extraction site must be rebuilt. The closer it can be made to the ideal, the better the replacement tooth will appear.  The site (or ridge as it is really named) can be restored through gum tissue grafting and/or bone grafting.

If the ridge needs only a small amount of augmentation, only soft tissue procedures may be needed. If there is a large defect, the underlying supporting bone will have to be replaced as well. If the site is especially visible or needs an extensive amount of rebuilding, more than one augmentation procedure may be necessary. My goal is to make the replacement tooth appear to be growing out of the extraction site, not merely lying against the gum.

If a dental implant is to be placed to act as an anchor for the replacement tooth, the extraction site must have enough bone thickness and height to properly surround the implant.

Here is an example of a 20 year old girl from Los Angeles that I had to do an onlay bone graft and gum graft to fill the major bone defect from a roller-skating accident.

IMG_0870gg Major bone loss.

IMG_7607After a onlay block bone graft, implant and custom Abutment. Note how there is no longer a depression of bone after the bone is built back up.

DSC_0017_4 Final result. Restored Dental Implant!

As you can see, extraction site bone or gum defects are really important.  Choose the right dentist for your implant! 
 

Ramsey Amin, DDS
 

Orthodontic Dental Implants…They Help With Braces Too!

Orthodontic Dental Implants???

Yes you read that right…temporary dental implants to make braces go faster and easier!

They are called “Temporary Anchorage Devices” or “TADS.” They are essentially tiny screws that are placed very shallow on the outside part of the jaw in between your teeth.  Rubber bands or wires are attached to.  TADS can help move teeth that are not moving well, or have to be moved in a difficult direction.  They are removed when braces are done.

Mini-implant%20Mini-screw%20in%20Typodont Ortho implant

They can really help to "upright" molars that have collapsed into spaces where teeth have moved such as this situation:

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In the picture below you can see two temporary ortho implants used to move the canine teeth.

Ortho

Another type of implant can be used to eliminate the use of headgear. 

This type of implant is placed in the center of the upper palate and allows your orthodontist to use it like headgear, but no one can see it!  Unfortunately, headgear can be embarrassing to wear.  Often, people avoid wearing headgear, and they end up wearing their braces for much longer than anticipated or they don’t get a good result.

Palatal

Palatal orthodontic dental implants are mostly used to correct an overbite.  When the braces are done, the implant can be easily removed or just left in place.