Then, three years later, he comes back, and he’s got multiple issues here. We’re not going to be crowning any teeth. We need to remove all of his teeth. He can’t control his caries risk. We can’t control his caries risk with the lack of saliva. So, the ability to see this guy in one day, remove his teeth on the lower arch, degranulate the whole site, we able to place in implants on the lower arch, suture everything nice and clean, and do the same thing for the upper arch and have him, in three months, to heal like this is just tremendous service. This is just for the lower arch.
Now, for the upper arch, if you’re not producing saliva, it’s going to be hard to produce a posterior palatal seal. So, implant-supported dentures are going to be the way to go. So, that’s exactly what we did. We degranulated this area. We removed all his teeth. We did bilateral internal sinuses for this patient, placed implants on the maxillary anterior and posterior regions, let him heal for three months. He came back in, and his tissues looked amazing. What a service for a patient. So, what we did was we didn’t give him a palatal strap. The denture rests on these implants. It’s a metal-reinforced complete denture. The patient is an amazing guy, a great friend now.
Dr. Lavine:
Danny, can we go back to a couple of questions I’m seeing right here?
Dr. Domingue:
Yeah.
Dr. Lavine:
Talking about the uncontrolled diabetes patient, is there a specific A1c value that you’re comfortable with for those patients?
Dr. Domingue:
A1c value, I actually don’t recall that. That’s a good question. I don’t recall that data right now. I have it in my notes somewhere, but I basically say to get the patient controlled, to get the levels under control. Get it controlled. Make sure he’s getting insulin. Make sure he’s following up with his regular [15:21] before we go for an implant surgery.
Dr. Lavine:
I mean a lot of people hear from different places. I believe it’s 7 for the A1c is the max value. Anything under 7 is okay. The other thing is can you define what a meth mouth is? We have people from all over the place not understanding exactly what that term is.
Dr. Domingue:
Yeah. Meth is just a lay term for a patient that has a previous history of drug abuse, and what meth basically does is destroy salivary flow. It just ruins your teeth. Meth mouth is basically a dental condition characterized by severe decay and lost of teeth or fractures of teeth, enamel erosion, and other oral problems with the use of a drug called methamphetamine. It’s the methamphetamine drug, and we just call it meth mouth. We just see the aftereffects of the methamphetamine abuse. The reason why methamphetamine is so bad is because it causes xerostomia, and it also causes other conditions like people grind their teeth and become bruxers.
Dr. Lavine:
The slides that you showed before of that patient, was that a meth mouth or, you said it was a friend of yours so I’m assuming it’s not?
Dr. Domingue:
Well, now he’s a friend of the practice since he’s been coming for regular visits, and he’s a tremendous guy.
Dr. Lavine:
But, that was a meth mouth that you shuld?
Dr. Domingue:
That’s what a meth mouth looks like. That’s exactly what it looks like.
Dr. Lavine:
Okay. What about smokers? Is that a contraindication?
Dr. Domingue:
Okay, that’s a great question. A long time ago we used say that a lot of research supported there was a lower incidence of implant success whenever you have people that are smokers. One of my good friends and I talk about this all the time. If I didn’t place implants on patients that are smokers, I’d lose half my dental population. That’s true to a lot of extent for a lot of different reasons.
You can still place implants on patients that are smokers. You just need to make them completely aware and say, “Look, there’s a lower incidence rate in people that smoke a pack, two packs a day. You’re going to have to taper that effect, get them on a smoking cessation program. With that said, people still want their teeth. They might not quit their oral habits like smoking. Some people will still take the chance. Other people that want to quit, that want to get off smoking, that want to break the habit, it’s a good excuse to. “Look, I’m losing my mouth. I’m losing my teeth.” They’ll blame it on that. They’ll blame it on cigarettes so they’ll eventually stop smoking. I wouldn’t say place implants on every single patient that walks in your door that is a smoker.
Dr. Lavine:
Okay. Let’s keep on moving. I want to make sure you get to your content as well, but there was just some good questions here.
Dr. Domingue:
Okay. Good.
So dental history. Patients that come in for one tooth dentistry. This is a patient that came into our practice these two lower left premolars. They were a couple of months ago from a local dentist, and we got to get our minds off one tooth dentistry and focus on the big picture. Once I took this picture and showed the patient how there’s multiple cervical lesions, caries lesions. There’s external resorption on this lateral incisor. This guy should not have root canals on these premolars. He should not have crowns on these teeth. He should have had these removed. Educate the patient to have the teeth removed, place the implants, and three weeks later, lock down a full set of implant-supported teeth. It’s just tremendous. This is him healed after 12 weeks. It’s just tremendous, nice way to treat your patients. Again, focus away from one tooth dentistry. Look at the whole picture whenever you’re looking at a patient.
Patients that are bruxors, this is a big topic. How do you restore somebody that’s a bruxor? Is it an implant supported tooth? Is it a single unit? Are they multiple units? Is it a full arch? Is it opposing natural teeth? Is it opposing denture teeth? Is it opposing fixed implant-supported teeth? What you don’t want to do is restore it on a full occlusion, and this guy was in our practice this week. This implant that you see was a healed ridge. It was a restored, and a year later, he comes back. We take the implant out with two fingers, and this whole side has granulation tissue ringing around there.
What we noticed was on lateral excursion whenever his [20:34] of the maxillary molar went into working function with a mandibular molar, and it was just restored poorly. They just didn’t check for lateral excursions, and the implant eventually deosseointegrated. So, the method of treatment is to clean the area, get rid of all the granulation tissue, and now we got some nice healing bone in this area. Ideally, what we did that day was to try and place another implant. That’s what we did. We just placed a wider diameter, planned the healing above it that day, and just did a little internal that day. So, when we restore this guy in the near future, we’re definitely going to make sure that his occlusion is checked properly.
Infection is obviously a common concern. If a patient presents with an infection like that, this patient is not going to get an implant in the same day. What we’re going to have to do is make a laceration right here, remove the exudation in this area, clean the area really well, get them on systemic antibiotics, and either remove this tooth and make sure this area’s healed properly before we go and do implant therapy on this patient. This is a shot of removing all that exudate, which was 2.5 cc which was just amazing.
Psych history. This is possible needs for sedation. Patient are [21:59] that have issues with laying on a dental chair and patients that are extremely nervous or have high anxiety in dental procedures would qualify for sedation. Patients that are also have the inability to use denture and have a mandatory need for implants. This patient loved her dentures. Finally, she had her denture given to her six months prior to seeing her some time ago. She said it finally feels nice in her mouth, and now she can use it. The only problem is she can’t get it to stick to her palate, and at her home, she ground this down with a nail filer to literally nothing.
Now, she’s able to use this denture, and she is not a good candidate implant-supported dentures. She’s going to be a good candidate for implant-supported fixe, and that’s pretty much it. She just can’t tolerate anything with a palate on the back of her mouth.
Soft tissue deficiencies. You need to have adequate connective tissue around the site before you develop the implant site. This lady wanted fixed lower implant hybrid dentures. There’s not a lot of attached tissue. There’s almost like 2 to 2.5 millimeters of attached tissue in the anterior area and very poor in the posterior area. So, to get her to this level where we have six implants placed, we took a band of attached tissue either using subepithelial grafting tissue or alloderm grafting and really Louis Cummings is one of the best guys to talk about that. He talks about it all the time on soft and hard tissue augmentation, and he had some really good advice for clinicians on site-specific areas, when to use, what to use, and what materials to use.
So, what you want to do is grow a band of tissue to these attachment sites so that you don’t worry about gingival defects around your bands.
Recession is a concern around single tooth. This guy comes and wants an implant placed right here. Well, soft tissue is supported by the bone, and if you don’t have the bone, you’re not going to have the soft tissue. So, this is going to be a difficult case to restore the bone and the soft tissue back in one piece. So, what we’re going to have to do is place the implant in one day. It’s nice to place a piece of alloderm around this to let the area heal properly before you go back and restore the patient. Again, all these pre-operative complications, you need to be aware of soft tissue deficiencies. If you’re gin got place an implant on this guy, you need to be aware that you’re going to have to augment the site with bone and soft tissue.
Dr. Lavine:
Is there a specific alloderm that you recommend using? I know you don’t necessarily promote any companies, but is there one that you’ve had good luck with?
Dr. Domingue:
Well, I use alloderm, and I buy it from a local sales rep. I know there’s AlloDerm®, and I think that’s specific for a company BioHorizons. I believe Salvin has a product now that’s a derm material as well. I’m not familiar with the term off the top of my head, but I usually just buy from a local rep. We’ve had fantastic results with it. Again, it’s all about knowing how to use it, where to use it, and one of the most important things is suturing technique associated with these grafting sites.
Dr. Lavine:
Okay. Thanks.
Dr. Domingue:
Shallow vestibules are concerned. In this patient, if we had properly treatment planned him, you can see the mucogingival junction at this area around the implants here. You have a nice frenula pull around this implant. You’re starting to get some exposed thread for some thin tissue. This is going to be a very difficult cleaning complication. So, we need to augment the site back with some tissue in this area, clean these implants properly, get rid of this muscle pull. We don’t want to have to treat any complications. It’s just difficult in these small vestibules.