Pasqual Oral & Maxillofacial Surgery

Surgical & Prosthetic Options to Enhance Implant Soft Tissue Aesthetics

Over the past 20 years, implant dentistry in this country has evolved from a strictly overdenture discipline to a multi-tooth and single-tooth replacement option. Indeed, it is more than an option; it has become the standard of care for replacement of missing teeth. Improved office-based bone grafting and bone preservation techniques have greatly expanded the patient pool of implant candidates. However, it is no longer sufficient to simply provide enough bone for an implant to be placed prosthetically, it is now desirable in aesthetic areas to try to create ideal soft tissue architecture around these restorations. This can be done in a number of ways including soft tissue site preservation, soft tissue augmentation procedures, and via a prosthetic means.

Soft tissue site preservation is most often accomplished by the implant surgeon. This includes papilla sparing beveled cosmetic incisions when incisions are indicated for implant placement. In many instances, implants can be placed with no incisions in aesthetic areas using tissue punches to create the access for site preparation and implant placement, in fact, the tissue can be punched eccentrically toward the palate and if a single stage implant system is placed, the healing cap can be used to push extra attached tissue labially and provide increased soft tissue bulk along the labial aspect of the future restoration. Finally, in staged implant procedures where an implant is uncovered and a healing abutment or temporary placed, incisions can be designed at the second stage to allow tissue rotation to form papilla or to bulk-up tissue labially.

Soft tissue augmentation procedures include the subepithelial connective graft which is harvested in split thickness fashion from the patient’s palate. This allows linear closure of the palatal harvest site with no exposed tissue and a very comfortable surgery for the patient. When greater bulk is needed, vascularized palatal rotational subepithelial flaps can be employed. These are best employed in the anterior maxillary region and allow a large bulk of tissue to be rotated in similar fashion to the technique used for subepithelial connective tissue grafts, but the graft is not completely detached from its base, allowing it to maintain a good blood supply. Finally, a material such as AlloDerm®, a donated processed human dermis, can be used in many instances to perform gingival grafting or augmentation procedures,

Finally, and perhaps most importantly, prosthetic means exist for optimizing soft tissue architecture around implants. When an implant is to be placed at an edentulous space, or an extraction is to be performed and it is deemed undesirable to place an immediate implant; a well-designed flipper partial denture or a resin-bonded temporary can be used. This will include an ovate pontic set down into the tissue to help create an emergence profile for the future implant, as well as to promote the development of the interdental papilla. Then, at the time of implant placement, using a tissue punch, these papillae can be maintained and an implant can be performed. In some instances, an anterior tooth can be replaced with an implant and an immediate provisional can be fabricated. One clear advantage of this has to do with the positive effects of a well-designed temporary restoration on the soft tissue architecture and papilla around the implant restoration.

Additionally, well-designed temporaries and final restorations with proper emergence profiles dictate soft tissue architecture and papillary health for the long-term. The ability of the restorative dentist to achieve proper emergence profiles and contour of the restorations is predicated on the surgeon having placed the implant in the proper location, to the proper depth, and at the proper angulation.

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Third Molar Site Grafting

I recently attended a symposium on alveolar grafting and ridge preservation. One of the speakers, Thomas B. Dodson, DMD, presented an interesting paper dealing with the effects of mandibular third molar (M3) removal on the periodontal health of the adjacent second molar (M2). He also addressed weather additional surgical procedures at the time of removal such as guided tissue regeneration (GTR), grafting with bone substitute, or platelet-rich plasma (PRP), improved the outcome to M2. He reviewed about 20 quality articles on this subject.

In brief, his findings help answer the following clinical questions:

  1. Does the extraction of 3rd molars adversely affect the periodontal health of the 2nd molar? The bulk of evidence suggests that the periodontal status of M2 remains unchanged or improves following M3 extraction. Ninety percent of the time the periodontal attachment was unchanged or improved following M3 removal. In no case was there an increase in probing depth of greater then 2mm.
  2. Do additional surgical procedures at the time of M3 extraction improve the periodontal outcome of M2? Routine application of additional surgical procedures did not improve the periodontal parameters on the distal of M2 except in High Risk Patients where there was significant improvement over the control groups. The amount of pocket reduction varied from 2mm to 3mm in the control group to 4mm to 6mm in the treated group (bone grafting or PRP).

The high risk patients were identified as:

  1. Unusual large bony defect such as seen when there is an associated cyst involved with the M3.
  2. Patients over the age of 25 with a mesial or horizontal impaction and existing periodontal probing depth of greater than 4mm.

In summary, his presentation concluded that removal of M3 will improve the periodontal integrity of M2 in most cases. And, additional surgical procedures, such as bone grafting or PRP can significantly improve the periodontal health of M2 in specific individuals that are at risk for periodontal defects.

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Alveolar Osteitis “Dry Socket” Prevention

Many exodontists ardently adhere to their method of prevention and treatment of AO without any sound scientific data to base their rationale upon. This is unfortunate, but most likely due to the paucity of well-controlled double blind studies in the occurrence, prevention, and treatment of AO.

One method, which has been scientifically proven to decrease the likelihood of AO, is pre-operative oral rinse with chlorhexidine .12% (Peridex, Proctor & Gamble Co., Cincinnati, OH). Immediate pre-operative oral rinse with Peridex has been clinically proven to decrease the quantity of oral microbes involved in AO.

Another scientifically proven method to decrease the likelihood of alveolar osteitis is the delivery of Lincomycin in an absorbable gelatine sponge to the immediate post-extraction site.

Many other methods to decrease the likelihood of AO have been discussed in the literature. These include topical and systemic antibiotic or steroids, placement of absorbable material in the extraction site with and without antibiotics and/or antifibrinolytic agents, or various combinations of the above. No method has proved superior to any other.

Despite the unknown etiology and the ambiguous contributing factors of AO, its clinical presentation is well known to all practitioners of dental exodontia. Patients typically present to the practitioner with intractable pain three to five days after extraction. Halitosis may or may not be present. Typical infection hallmarks, i.e., fever, malaise, pus, are absent. Examination of the surgical wound may or may not reveal erythema. The wound is usually tender to palpation. Rinsing out of the wound is typically quite painful, and often yields debris of food and dead tissue.

Treatment of the patient with AO or suspected AO is simple. After thorough irrigation of the site, a medicated sedative dressing, usually containing eugenol and oil of cloves, is placed in the extraction site. This is often quite uncomfortable to the patients initially, but relief soon follows within the hour. Systemic analgesics are often prescribed, but rarely necessary. Prescription of a systemic antibiotic is unnecessary. The patient is re-appointed to return to the office in 24 hours time for irrigation of the surgical site and change of the packing. Appropriate relief of symptoms usually takes two to four appointments. The patient should be encouraged to discontinue all tobacco products during this time.

If after four such appointments the patient’s condition has not improved, careful re-evaluation of the patient and the wound is necessary. The patient may be suffering from a subperiosteal infection, foreign body reaction, damage to the adjacent teeth, or even a fractured jaw. All these conditions may present similar to AO, but the treatment would, of course, be different.

Irrigation of the extraction site with an antimicrobial solution, such as Peridex, is desirable, but hardly a pre-requisite for success. Although an antimicrobial solution acts locally to decrease the number of microorganisms in the wound, and therefore decrease the local bacteria count, the primary reason to irrigate the wound is to remove any debris. Remember, the solution to pollution is dilution.

Placement of a medicated pack serves to deliver local analgesia to a healing wound. Since packs may spontaneously dislodge or be difficult to remove, use of a radiopaque material is recommended.

In summary, every surgeon should employ all reasonable efforts to decrease the likelihood of any complication in his patient. Although AO is a relatively minor post-operative complication, it does result in significant patient discomfort, and loss of productivity by both the patient and doctor. As practitioners of exodontia, we should strive to decrease the incidence of AO on all our patients. This includes the use of scientifically proven methods, i.e. pre-operative rinse of Peridex and use of local antibiotics, to decrease the incidence of AO. Anecdotal methods commonly employed and passed on from one dental practitioner to the next have merit; yet, should be carefully and scientifically evaluated with respect to their efficacy in treatment of Alveolar Osteistis.

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The Use of Platlet Rich Plasma in Oral Surgery

For many years, clinicians in various specialties of dentistry and medicine have been searching for materials that can accelerate and enhance bone and soft tissue healing, especially that of bone and soft tissue grafts. While bone morphogenic protein appeared to be a promising alternative for the enhancement and promotion of bone grafts and bone growth, the reality was this material was tremendously expensive to manufacture in even small quantities.

More recently, in both the oral surgical and the orthopedic literature, platelet-rich plasma has been shown to accelerate and enhance bone graft maturation and density. Platelet-rich plasma (PRP) is an autologous source of concentrated platelets. When it is combined with thrombin and calcium chloride, PRP leads to the release of platelet-derived growth factor (PDGF) and transforming growth factors beta-I and beta-2 (TGFB-1 and B-2). These growth factors have been shown to produce increased blood vessel formation, to stimulate the arrival of bone precursors and also to promote the differentiation toward mature osteoblasts, stimulating the deposition of collagen matrix, and inhibiting osteoblast formation and bone resorption.

Technology introduced in the last few years allows clinicians to withdrawal minimal amounts of the patient’s own blood (50-60 cc of blood), which are then centrifuged in a double-spin protocol which allows platelet-rich plasma to be prepared within about 15 minutes. When mixed with topical thrombin, the platelet-rich plasma forms a gel which can be mixed with and/or sprayed over bone grafts or sprayed underneath the tissue flap. This platelet-rich plasma has been shown to accelerate bone and soft tissue healing and to reduce the amount of postoperative swelling and discomfort associated with surgery. In fact, in patients where bone harvest sites are minimal, PRP can be mixed with bone substitutes in certain instances and successful grafting can occur. For example, in a study by Valentini, et al., twenty sinus augmentations were performed using Bio-Oss, and six months later, 57 implants were placed. The implant survival rate was 98.1%.

Currently, in my practice, where I have been using PRP for the past three years, I have found that block bone grafts that previously required 5-6 months of maturation time now require only 3-4 when PRP is used.

Additionally, I am often able to use bone shavings mixed with PRP to perform much of the onlay grafting that I was unable to perform without block bone grafts prior to this. Furthermore, PRP sprayed under the soft tissue prior to closure at the conclusion of the surgery has been very effective at promoting much more rapid healing and reducing patient discomfort. I have also found PRP to be very effective in promoting healing in those patients who heal poorly.

In short, PRP is a wonderful surgical adjunct and can be used to not only enhance healing of hard and soft tissue, but also shortens recovery times and promotes patient comfort.

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Implant Site Preservation

Since the introduction of dental implants into North America in the early 1980’s, we have witnessed an evolution in how implants are used to replace missing teeth. At the outset, implants were seen as a means to provide support to overdentures for edentulous patients. Subsequently, implants began being considered for single tooth replacement and even full arch dental replacement. In the infancy of this type of usage, implants were generally placed in the most available area of bone without regard to prosthetic restorability. As it became apparent that many of these restorations were not very functional and were difficult to maintain, implant dentistry became a much more prosthetically driven discipline.

The current ideal would have the implant placed in such a way that it ideally supports the proposed restoration. If the hard or soft tissue in the proposed placement region are deficient, then these can be augmented prior to implant placement. The development of new and innovative ways to augment both hard and soft tissue as well as to preserve existing hard and soft tissue have greatly enhanced our ability to perform highly esthetic and functional implant restorations.

Clearly the time to begin to preserve an implant site is at the time that a tooth is extracted from that site. If a patient is referred for an extraction of a tooth, the patient is asked at the consultation visit if he has considered his options for replacement of that tooth. The various options are reviewed with the patient and if a dental implant is a possibility, then site preservation is discussed with the patient. This generally involves a discussion of cleaning the socket out well and then grafting the site with a processed bone matrix. There are several that are quite good, one of the most popular being Bio-Oss, which is the bovine derived and purified mineralized matrix of bone. It is explained to the patient that this material when placed in the socket and covered over in proper fashion serves as a scaffolding to prevent soft tissue in-growth into the socket and maintains the optimal amount of bone height and density for subsequent implant placement. It is further explained that this will require a consolidation time for the graft of approximately four to six months before implants can be placed at the site.

While we all know that extraction sockets heal well without grafts, it is common to lose 1-2 mm of bone height at the area of an extraction site in general. In implant dentistry this is unacceptable in a proposed implant site for many reasons. In an esthetic area 1-2 mm of bone and soft tissue loss results in an overly elongated restoration. In posterior maxillary areas, 1-2 mm of bone loss may place the crest of the ridge too close to the maxillary sinus to place an implant of adequate length without a more extensive procedure such as a sinus floor augmentation (aka “sinus lift”). In the posterior mandible, 1-2 mm of bone loss can be the difference between being able to place an implant safely above the nerve, or having to modify or even abandon implant treatment planning.

Once the patient agrees to this type of socket preservation, then it is the responsibility of the surgeon to preserve the site in a number of ways. One of the most obvious ways is to perform an atraumatic extraction, often sectioning the tooth to avoid having to remove bone around the tooth root itself. Extra time is involved in attempting to remove the tooth without removal of any of its bony walls. If incisions are necessary, then papilla-sparing incisions are used to ensure optimal esthetics with regard to the adjacent teeth. Once the root is removed, the area is curetted out aggressively to remove any debris at the root apices and provide an optimal bed for the subsequent graft. The socket is then packed densely with a material such as Bio-Oss or freeze-dried demineralized bone or a mixture of the two, and covered with a resorbable membrane, or in many instances, a plug of gelfoam. Depending on the circumstances, attempts are made to close the soft tissue flap over the extraction socket in a tension free manner. In the anterior regions, every attempt is made to not have to make an incision in removing the tooth, and the labial and lingual flaps are pulled together over the graft with suture tension. Finally, a non-absorbable suture is used and removed typically one week later. Depending on the needs of the case, soft tissue grafting can also be done at that time in the proper setting, or can be deferred two to three months later and performed as a separate procedure prior to or at the time of implant placement. It is certainly easier, in clinical experience, to retain hard and soft tissues than to replace these tissues at a later date. By carefully planned site preparation through socket preservation, subsequent, more extensive surgical augmentation procedures can often be avoided.

One can see with the substantial advances in hard and soft tissue grafting techniques as well as in hard tissue grafting materials, that the potential for implant replacement has expanded exponentially. By working together with the surgeon who thinks prosthetically and works to not only prepare implant sites, but also to preserve them, the optimally functional and esthetic implant restoration can be achieved for our patients with a minimum of surgical procedures.

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The Current State of Laser Treatment for Chronic Periodontitis

The use of lasers in periodontal practice has become a desirable alternative to traditional scalpel surgery; however, a deficiency in published evidence supporting the efficacy of such treatment exists. A recent review by Cobb, Low, and Coluzzi (2010) presents the current peer-reviewed evidence on the use of the most commonly used dental lasers over the last decade and explores why the use of such lasers in periodontal therapy remains controversial. The results of this review are summarized below.

Cobb, C., Low, S., Coluzzi, D. (2010). Lasers and the Treatment of Chronic Periodontitis. Dent Clin N AM 54 (35-53).

Nd:YAG Laser (1064 nm) – well-designed and adequately powered studies are severely limited with insufficient evidence to support evidence-based decision making when using this laser. Specifically, the derivation of evidence-based conclusions from the published literature is speculative due to weak and confusing evidence. When laser therapies are compared with conventional open-flap procedures, the conclusions consistently reveal no statistical or clinical significant differences between traditional surgery and laser-mediated periodontal surgery. Although proponents of Nd:YAG have promoted the laser as being effective against pigmented bacteria (i.e., Porphyromonas spp, Prevotella spp), common periodontal diseases exhibit a diverse population of non-pigment producing bacteria.

ER:YAG and ER,CR:YSGG Lasers (2940 nm and 2780 nm, respectively) – erbium lasers are effective in removing calculus and reducing PPD. Several studies have demonstrated safe and effective root substance removal without negative thermal effects. A collective average of 11 clinical trials shows equivalent or slightly greater reductions in PPD (2.29 mm vs 1.93 mm), gains in CAL (1.73 vs 1.26 mm), and decreased BOP (47% vs 43%) when compared to control treatments. Interestingly, of the four studies reporting effects of treatment on subgingival microbial levels, none showed a significant difference between treatment groups.

Diode Laser (809-980 nm) – the purported benefits are based on the premise that subgingival curretage is an effective treatment and significant reduction in subgingival microbial populations are predictably achieved. In the five published clinical trials, none measured all four of the usual clinical parameters (reductions in PPD, BOP, subgingival microbes, or gains in CAL), therefore a meta analysis could not be performed by Cobb et al. Specific trends showed greater reductions in PPD and BOP in laser groups with a nearly equivalent gain in CAL. Two studies reported no significant difference between treatment groups. Despite the equivalency between laser-treated sites vs controls, uncontrolled case studies report successful periodontal therapy when using diode and Nd:YAG lasers as adjuncts to SRP. Although diode lasers are effective for soft-tissue applications, offering excellent incision, hemostasis, and coagulation, when combined with the appropriate choice of parameters can result in soft tissue penetration ranging from 0.5 mm to 3 mm.

CO2 Laser (10,600 nm) – carbon dioxide lasers are effective in removing soft tissue and inflamed pockets while achieving good hemostasis. Only two published clinical trials show the effect on PD and the investigators reported no significant differences between treatment groups for reduced PPD and reduction in BOP. CAL gains were statistically significant in favor of only one of the CO2 treatment groups. The primary caution when using CO2 laser relates to the high absorption by hydroxyapatite and water. Therefore, clinicians are well-advised to carefully direct energy beam and use low energy densities to avoid damage to healthy hard tissues.

Photodynamic Therapy (PDT, 635 nm to 690 nm) – uses a combination of visible light and a photosensitizer; however, as with the diode laser, there are a small number of published clinical trials and the collective differences for measurable clinical parameters are not particularly noteworthy. The main premise for using PDT is to reduce subgingival microbes; however, only one of the five published trials measured this parameter and reported no significant difference between PDT and SRP treatments.

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The Management of Pre and Post Operative Pain

As dentists we are commonly faced with fearful patients. They anticipate and expect a painful experience during or after their treatment. They tend to procrastinate to the point where they are presenting with pain and a high level of anxiety, only perpetuating their status. These situations are a challenge to the practioner. It is important to effectively manage the preoperative and post-operative pain in all of our patients to help alleviate these situations. This can be a great practice buildwould like to review the most common drugs used for controlling pain and discuss a protocol that you may apply in your practice for the management of preoperative and postoperative pain.

There are many classes of drugs that can be used in order to manage the pain induced from various dental procedures. The model that has been most effective in studying the effects of these analgesics is the post extraction pain experienced after third molar surgery. The attributes of the oral surgery model of third molar post extraction pain are so consistent and reliable that the United States Food and Drug Administration considers it as one of the most sensitive assays for the evaluation of analgesia.(1) All of these drugs have been studied according to this model and can effectively be applied to various other situations.

The first class of drugs is the non-opioid analgesics; this includes the NSAIDs and acetaminophen. The NSAIDs are a non-opioid analgesic possessing analgesic, anti-inflammatory, and antipyretic effects. The efficacy of the NSAIDs in reducing postoperative hyper-algesia has been hypothesized to result from their ability to inhibit prostaglandin synthesis at the site of tissue damage. This class of drug is the most effective in the reduction of pain that is inflammatory in origin. One of the greatest limitations of this drug class is its “ceiling effect” associated with their analgesic properties. Increasing the dose above the ceiling dose does not offer any additional analgesia. Regardless of the degree of pain the source is always inflammatory in origin. For this reason the NSAIDs are the drug of choice when used appropriately.(2)

Acetaminophen is another non-opioid analgesic, containing analgesic and antipyretic effects. It does not possess anti-inflammatory properties. The analgesia is thought to occur via mechanisms mediated primarily within the CNS. This is drug can be substituted in situations where there are contraindications to the use of NSAIDs.(3) The limiting factor is the maximum allowable daily dose.

The second class of drugs is the opioid analgesics. The analgesic properties of the opioids are well appreciated through- out time. They are indicated in situations when the pain is not relieved with the use of NSAIDs or acetaminophen. The analgesic properties of opioids are attributed to the activation of opioid receptors expressed on the membrane of neurons in the central and peripheral nervous system. The opioid analgesia is very effective. However, the limiting factor is their unwanted side effects. Although they do not have a ceiling dose for analgesia, as the dose is increased the risk of undesirable side effects such, as nausea and vomiting and mental cloudiness are markedly greater. These drugs are usually combined with acetaminophen or NSAIDs in various formulations in order to decrease the necessary dose. An important point to understand is that even though oxycodone and hydrocodone are much more potent (10-12 times greater potency than codeine) the formulation of these two synthetic opioids in most combination analgesics such as percocet and vicodin results in an opioid dose equipotent to 60mg of codeine.(1)

When prescribing, it is important to remember that pain is subjective and can present in various forms and can also have various sources both central and peripheral. Therefore, we must tailor our regimen to the patients’ individual needs. We must have a good appreciation of the properties and limitations of the drugs that we use in order to maximize their effectiveness. The most effective pain control strategies must result in adequate pain control with minimal undesirable side effects. It’s how we use the drugs not what drug we use.

The non-opioid analgesics (NSAIDs, acetaminophen) are considered to be effective in the management of mild pain. This is very unfortunate since these drugs have characteristics that make them very effective in the treatment of patients with moderate to severe pain. According to the third molar model, the period of maximum pain intensity is the first 12 hours after the procedure.(4,5) This is a very important point to keep in mind when establishing a pain management regimen for the patient.

The administration of 400mg of ibuprofen 30 minutes before the initiation of surgery has been proven to delay the onset of postoperative pain and decrease its severity.(5,6) In addition, when you are working on the mandibular teeth, and prior to completion of the procedure, administering a bupivicaine block will keep the patient numb during the acute phase of the pain cycle. You must instruct the patient to take the ibuprofen (400 – 800mg) around the clock for the first 48 hours and as needed for pain (PRN) thereafter. The most common mistake made by patients is that they wait until the onset of pain before taking their medication. At this stage they have missed the opportune time to manage their pain and they must now reach for the opioid for pain relief. This still may not be as effective.

In situations where the pain is not relieved with the opioid alone the patient can combine it with the NSAID following the recommended frequency. If the pain is not relieved following this protocol it is prudent to have the patient return to your office for further evaluation.

It is imperative that we not loose control over the inflammatory cycle and plan ahead to prevent the breakthrough pain that becomes very difficult to manage. We must keep in mind that pain is subjective and every patient’s response will be different. Following the protocol will minimize the use of the opioids and their unwanted side effects and allow the patient a preferred method of pain management.

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Tobacco and Dental Implants

Tobacco has been long recognized as a significant health hazard. Cigarette smoking, in particular, has been implicated with several cancers including:

  • oral
  • lung
  • and bladder.

Additionally, smokers have a much higher incidence of:

  • hypertension>/li>
  • coronary artery disease
  • pulmonary infections
  • and emphysema.

In fact, children that live in smokers’ households have a 8 times greater incidence of presentations to the emergency room with respiratory problems than children of nonsmokers. Cigarette smoking also greatly influences oral health and has particular effects on the success rates and health of dental implants.

Most patients assume that this has to do with the irritating effects of the smoke itself in the oral cavity, but, in fact, the problem goes much deeper.

It is well recognized that smokers have a very poor small and terminal blood supply. It is for this reason that smokers often have cold fingers due to loss of blood vessel supply to those areas.

But this small blood vessel loss also affects every area of the body including the skin and jaws. The skin of smokers ages prematurely and this has to do with the lack of small blood supply to repair the damage produced by sun and aging.

Face-lifts and other facial cosmetic procedures in smokers are often contraindicated due to the unpredictable healing in these patients. The problem from the nicotine and other vasoconstrictive chemicals found in cigarette smoke that are absorbed in the lungs and that cause constriction particularly of the small blood vessels.

This effect can last for hours after a single cigarette and when someone smokes multiple cigarettes a day, the chronically constricted vessels quickly atrophy and disappear. For this reason, the nicotine patch is not an appropriate substitute for smoking during the time of implant treatment.

The effects of this poor blood supply are especially noted at implant interfaces where that blood supply is called upon to promote bone ingrowth into the surface of the titanium implant. Although statistics vary with regards to implant failure rates in smokers, in general, implant failure rates in one-pack per day smokers can range from 10-30%.

This means roughly that for every four implants placed, at least one can fail. In fact, cutting back smoking does not appear to help because the small blood vessel supply does not reappear as long as someone is smoking even to a small degree. A prudent measure to assure a blood supply that is comparable to that of a non-smoker’s is to have a patient completely discontinue smoking for three months prior to implant placement.

If a patient, after counseling, is simply unwilling or unable to quit smoking, implants may still be offered. In that instance, additional informed consent is obtained and the patient will sign a waiver in which he or she expresses their understanding that they recognize that their smoking can increase the failure rate of their implants throughout their lives.

Smoking is a terrible health problem in this country. We as dental professionals have the opportunity to educate our patients regarding the substantial health hazards of smoking.

In the state of New York, it is now the law that physicians must discuss the hazards of smoking and offer some options to help the patient quit their habit. Failure to do so can result in action against the physician by the medical board.

Previous studies have shown that many physicians and dentists routinely do not address the hazards of tobacco use with their smoking patients.

We have a tremendous obligation and responsibility to point out to our patients these health risks, and we are in a unique position to do so. Doing so may not only add years to their lives, but also add life to their years!

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Implant Myths Versus Facts

Over the past twenty years, dental implants have become a standard of care for the replacement of missing teeth. Still, it seems clear that there is reluctance on the part of some clinicians and patients to provide and receive implant treatment. This reluctance on the part of clinicians to provide the treatment and on the behalf of patients to accept it largely resides in the persistence of several myths related to dental implants. The purpose of this article is to attempt to dispel these myths by providing more factual current information. Here, in no particular order, are the most common misconceptions related to dental implant treatment.

1. MYTH: Implants are too expensive.

FACT: As we know, dental implants are most often not covered by insurance carriers. This, in no way, however, should dictate our choice of treatment for the patient. Obviously, our role is to provide the patient with treatment options and to emphasize those options which are in their best interest regardless of insurance coverage. Still, when one looks at the cost of a single-tooth dental implant versus a three-unit bridge, one can make the argument that implants are actually cheaper. We all know that posterior bridgework has an average lifespan between 5-10 years when evaluated critically. Insurance companies will often pay to replace a bridge as frequently as every five years. Obviously, the patient has an out-of-pocket share for this each time it occurs, and each time a bridge is replaced, the likelihood that the teeth serving as abutments will fail increases. In my office, patients are advised that a properly cared for dental implant can last as long as a properly cared for natural tooth. The same cannot be said of bridgework.

2. MYTH: Tooth #3 is missing and #2 and 4 are heavily restored and require crowns anyway. It is probably best to provide this patient a 2 x 4 bridge instead of an implant at #3.

FACT: While this appears reasonable when taken at face value, it is not logical. If teeth #2 and 4 were virgin teeth, no one would argue that an implant should certainly be placed at #3 to avoid having to unnecessarily prepare these unrestored teeth. However, when one thinks logically, why would a clinician take two heavily restored teeth, crown them, and then hang a third tooth onto them, thus increasing their load? The logical thing to do would be to crown each of these teeth individually and then perform a dental implant at #3 and let each of the three teeth stand alone supporting only themselves. Thus, one does not unnecessarily increase the load on already compromised teeth.

3. MYTH: Implants are somewhat experimental.

FACT: Implants not only are no longer experimental with 40 years of data behind them, they now are the standard of care. Straumann (ITI) provides international statistics of 96% success rate for dental implants and other implant companies provide similar success rates. These are better statistics than one can often provide for natural teeth! When faced with a tooth that might require crown lengthening and extensive restorative work with a questionable prognosis, a much more predictable alternative is often removal of that tooth and placement of a dental implant.

4. MYTH: Implants in the anterior region are not as aesthetic as bridgework.

FACT: Implants actually provide greater aesthetics than bridgework when properly placed. The key is proper site preparation prior to the implant placement. Patients who are missing a tooth in the anterior region are usually also missing some degree of hard and soft tissue. Replacement of this tissue or simply placement of the implant using an osteotome technique to expand the bone recreates the lost volume as well as the appearance of a root eminence through the tissue. A properly performed dental implant will have aesthetics equal to that of a healthy natural tooth, something that a pontic in a bridge will never achieve.

5. MYTH: Implant placement and associated bone or soft tissue grafting are very painful.

FACT: Dental implant placement is one of the most comfortable procedures performed by the Oral and Maxillofacial Surgeon, allowing most patients to resume normal activities the following day! Additionally, the vast majority of associated bone and soft tissue grafting procedures are performed in the Oral Surgeon’s office, harvesting tissues for grafting from intraoral sites (connective tissue from the palate, bone from the mandibular ramus). Clinicians should know that if they do not hesitate to refer patients to a specialist for third molar removal, then they certainly should not hesitate to refer for bone or soft tissue grafting of deficient sites as these are very similar procedures with similar recoveries.

These are just some of the myths surrounding dental implants. Our challenge as clinicians is to educate our patients regarding the predictability and desirability of anatomic replacement of missing teeth by adding dental implants rather than settling for subtractive dentistry with bridgework and partials. Many patients have already accepted the life-changing benefits of dental implant treatment. As these numbers continue to increase, the positive “buzz” surrounding dental implants will also increase and patients will become more active consumers of these services. It seems, therefore, incumbent upon us as dental professionals to continue to participate in the continuing education required to not only provide these services with excellence, but also to educate our patients as to their benefits.

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The Benefits of Intravenous Anesthesia

Until the advent of local anesthetics, surgery was a very traumatic and painful experience. The very best surgeons were by no means the gentlest; they were the fastest. General “ether” anesthetics helped alleviate pain, but were very dangerous to administer and unpredictable in the dosing. The advent of local anesthetics truly revolutionized in-the-office surgery, particularly in the dental profession. Our understanding of the anatomy of the head and neck and the efficacy of local anesthetic nerve block has enabled dentistry to be routinely and painlessly performed in an office setting. The advent of safe intravenous sedation and deep sedation/general anesthetic techniques have enabled the oral and maxillofacial surgeon to perform complicated oral and facial surgery procedures in the comfort and convenience of the office surgical suite, thus allowing the patient to return home that day. Intravenous anesthetics in use today are rapid in onset, very potent, and rapid in elimination. This assures that the patient is completely relaxed and unaware for the surgical procedures and allows for a rapid recovery and the ability of the patient to be discharged home.
Our knowledge of local anesthetic techniques coupled with our training in intravenous sedation/deep sedation/general anesthetic techniques allows us to perform procedures of a complexity that too often is taken for granted. The removal of impacted wisdom teeth, for example, is usually more difficult than the removal of tonsils, but due to the fact that it is most often performed in an office surgical suite instead of a hospital, it is deemed by patients and oftentimes referring clinicians to not truly be “surgery”. In fact, many procedures performed in the hospital under general anesthetic could be much more easily, economically, and conveniently performed in an office surgical setting if the physician were trained in local anesthetic and intravenous general anesthetic techniques. Due to the general lack of training among physicians in these techniques, procedures such as the placement of ear tubes in children, digital and extremity amputations, and soft tissue facial plastic procedures requires the use of an anesthesiologist and a general anesthetic or block local anesthetic and, therefore, are performed in a hospital setting.
In the everyday practice of dentistry, extractions are performed. While many of these extractions are simple and can be accomplished with minimal manipulation and quite comfortably under a local anesthetic, a surgical extraction requiring the use of a handpiece and adequate visualization are much more easily accomplished under a monitored deep sedation. Such a sedation produces amnesia for the event, enables the patient to be completely relaxed, not only emotionally, but also from a musculoskeletal standpoint, and allows the safe completion of the procedure. By performing procedures under deep sedations, the procedures are almost always shorter, are almost always performed more gently due to improved access and visualization, and produce a much quicker recovery than when the patient is awake during the procedure and involuntarily tensing and tightening cervical and facial muscles. Briefer procedures produce less postoperative swelling and discomfort and a lower incidence of infection.
These considerations might be kept in mind in evaluating a patient for a potential oral surgical procedure. In private practice, I have rarely had a patient say to me after a surgical procedure that they wished they had been awake for it, but I have had a few wish they had been sedated. Certainly, treating a patient in a fashion in which they are completely relaxed, comfortable, and have an uneventful recovery promotes a happier patient for both the surgeon and the referring clinician.

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