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DENTAL IMPLANTS (EDUCATION)  FEBRUARY 2011

  Four- part film series (YouTube) showing Dr. Ted having a tooth removed and a bone graft in
in preparation for getting an implant:
Part 1  P2   P3  Sequential photos of implant procedure  P4, 5, and 6: Inserting the implant and preparation of molds for the lab (Part 6: attaching the crown to the abutment-implant)
 
My first implant: a video by a dentist

 

Dr. Ted Gets His Implants  (front teeth;  APRIL 2000)

Synopsis of procedure:
   
Appointment with dentist who makes referral to Oral Surgeon. 30 minutes
    Appointment with Oral Surgeon for Consultation evaluation. 30 minutes
    Appointment with Oral Surgeon for molds and x-rays. 30 minutes
    ? May be special appointment with X-ray lab for special and expensive x-ray. 45 minutes
    If natural tooth must be removed appointment with general dentist or oral surgeon to remove it. 30 minutes   
    If natural tooth had to be removed then allow three months for bone to heal.
    Appointment with Oral Surgeon to Implant fixture. 60 minutes
    Appointment with dentist for temporary bridge to fill in space while waiting for healing.
    Allow three to four months for fixture and bone to heal around each other.   
    Appointment with Oral Surgeon to add healing abutment onto fixture. 30 minutes
    ? Appointment with general dentist to rebond temporary bridge? 30 minutes.
    Appointment with general dentist to make molds of your teeth. 30 minutes.
    Appointment with general dentist to try in the crowns. 15 minutes.
    Appointment with general dentist to cement the crowns. 30 minutes.
    Appointment with general dentist to check the work done for cosmetics, function and gum health. 30 minutes
   
Typical number of months to complete the treatment for an implant and crown from the day
         you have a tooth removed:  6-12 months. 

    Range of fees for implantation of fixture: $1,200-$1,900/fixture
    Range of fees for fabrication of crowns: $900-$1600/tooth
    Success rate: 95%

The story:

    I am an orthodontist practicing here in Brooklyn Heights since 1976. Occasionally I encounter patients who have lost, or will lose, one or more teeth for which I usually recommend replacement with dental implants. Being an orthodontist, I discovered, does not immunize me from dental disease. So when I realized I was going to have to lose two front teeth I decided to take my advice and get two implants. Over the years I have had multiple dental experiences for cleaning, cavities, caps, extractions and gum surgery. Each of them has left me with a profound appreciation for just how uncomfortable and frightening dental procedures can be. Perhaps my story will help youÖit has helped me.

    I am 60 now. About one year ago I began to notice one of my front teeth was loose (the upper left front and the second from the front tooth). On November 9th I went to the periodontist (specialist in gum diseases). He examined me and took some X-rays and recommended that the tooth be removed. Loathe to let this tooth be taken from my head, I said, "Dr. Joe (he was 75), if I was your FATHER what advice would you give to me then?" He replied, "Leave it alone and forget about it." That was what I wanted to hear.

    But my tooth did not forget that something was wrong. It became progressively looser and I was forever wiggling it back and forth, (testing to see if it was becoming more solid in its position). I could not forget itÖnot for an instant. So about 3 weeks later I went to another periodontist friend who again examined and X-rayed me. This time he placed a thin pointed ruler down alongside the root of the loose tooth as far down as it would go and took an X-ray with the ruler in place. It went down, down and down until it was almost even with end of the root of my tooth. The bone between my upper left front tooth and the one next to it had indeed quietly and painlessly vanished into thin air.

    "Why not graft new bone into the empty space?" I asked. " Not possible" he shook his head with an aura of authority that could not be dismissed. He left me (I left his office) convinced he was right. Furthermore, that I would have to lose not just one but both of the teeth.

Resigning myself to the inevitable, about one month later I went to my friend who is a specialist in oral surgery and on January 7th he removed the two loose teeth as easily as you might lift a marshmallow out of a sack of its fellows. I immediately felt is if I was 80 years old. I had this gaping space and sounded worse than Elmer Fudd.

    I was a Boy Scout in my younger days, ("Be prepared thatís the Boy Scoutís marching song, be prepared...") so I had prepared a temporary bridge to fill in the gaping hole between my upper front teeth. (In fact, I prepared two of them). I let the office manager, bond it on when we got back to the office.

    I would later find out that she bonded it on so well that only a pneumatic jackhammer, (the kind they use to break up old streets), could remove it.

    When a dental implant fixture is inserted it has to be placed in mature (hard) bone. So I was advised that I would have to wait 10-12 weeks before the bone where the teeth were removed had reformed in the sockets left by removing the two teeth.

    I decided to allow the fourth-year oral surgical resident at the hospital where I am a staff member to place the implant. On March 7th I took a new X-ray of the site where the teeth had been removed and showed it to the surgery resident (Dr. Ned Nix who will be practicing in San Jose, California starting this June 2000). Dr. Ned said the receptor sites for the dental implants were sufficiently healed (resolidified) and he was prepared to do the surgery for implanting the fixtures. He said he had done about 40 of them altogether.

        On April 14, 2000 I went to the St. Lukeís Roosevelt Hospital site at 116th St. NYC and Dr. Ned did the implant surgery. My office manager came along to assist and take photographs. In fact it was she who was enlisted to remove the temporary bridge she had inadvertently bonded on so well three months back. It took about 30 minutes to remove it (about how long it takes to remove a section of road with a pneumatic jackhammer). I rebonded the second temporary bridge in place that same day later in the afternoon after the surgery. I bonded it on with LIGHT cement this time because Dr. Ned told me he wanted me to return to his office to examine the surgical wound and remove the 5 stitches he had placed. (Of course I would have to remove the temporary bridge to allow his evaluation of the healing site to be done carefully.)

    I am writing this story three days after the surgery was completed, I have no pain at all. The day after the surgery I had taken two Advil and that was the only pain reliever I had needed. Joanne, the expert from the company who manufactures the implant (Nobel Biocare http://www.nobelbiocare.se/international/index.asp) had been present to advise Dr. Ned on the intricacies of the newest model of implant that had been selected for my case. She suggested that I would do best to apply an ice pack to my face for at least six hours after the surgery. I did not heed her advice.

        The next day my upper lip was somewhat swollen and had my ego been more fragile I might have preferred not to venture out lest my local public see something amiss attached to my mouth. However, in my opinion the swelling was minimal. As of today I have removed 3 of the 5 stitches that were placed to reclose the gum where it had been surgically cut open. Those stitches were driving me crazy and I could not help but keep rubbing them with my tongue.

    Just about every oral surgeon and some periodontists have the expertise demanded to insert dental implants. I can think of a half dozen between the twenty blocks that  separate Park Slope ** from Brooklyn Heights that can perform this service. For more information on dental implants, or to find an oral surgeon near you with the expertise needed to place implants you can call me.

    The cost of a single implant, and the prosthetic (false) tooth which is fitted on the implant, ranges from $2,900-$3,600. This method of restoring a missing tooth is very beneficial because it spares the teeth on either side of the empty space from having to be specially sanded/filed, which is a mandatory process when a dentist makes a "bridge" to restore the empty space. In addition, bridges often cause the gums around them to "recede" and require having to be remade every 10-15 yearsÖnot so with implants.

Chronologically ordered photographs of the implant process including the surgery

Click the photos you want to see.     (Photos in preparation as of 4/22)

1234

5678

9101112

    1. The molds of Dr. Tedís teeth before the two teeth were removed.
    2. X-ray showing bone recession and how much bone remained surrounding the teeth that were loose.
    3. Dr. Ted just after the two teeth were removed.
    4. Dr. Ted with a temporary bridge in place.
    5. X-ray showing the newly healed bone three months after the two teeth were removed.
    6. The device Dr. Ned made (template) to help him decide where to create the channels (receptor sites) for the dental implants
    7. The device showing how it looks with its guide holes before being placed on Dr. Tedís molds.
    8. The device placed on Dr. Tedís molds with guide pins in place showing how the dental implants will be aligned when they are inserted.
    9. #9-19 were taken on April 14, at the dental clinic during a surgical procedure lasting about 90 minutes.

    10. The Office manager  removes Dr. Tedís temporary bridge.
    11. Dr. Ned gives local anesthesia to anesthetize the area of the surgical site.
    12. Dr. Ned cuts the gum open to expose the bone where the implant will be inserted
    13. Dr. Ned creating two channels into the bone at the receptor site with a cutting instrument
    14. Dr. Ned inserts a depth gauge to check the channel for the correct deepness (about 5/16ths").
    15. Dr. Ned checks the angle of the implant with the device (template) he made at the start.
    16. Dr. Ned attaches the implant fixture onto the inserting instrument and screws it into the receptor site.
    17. Dr. Ned tightens the fixture into the bone with a special implant fixture wrench.
    18. Dr. Ned screws metal covers "healing caps" onto the top of the implant. They will later be removed and replaced with "healing abutments" as a prelude to the fabrication of the prosthetic teeth.
    19. Dr. Ned places 5 stitches to close the surgical wound.
    20. Panoramic x-ray of the implant fixtures in place.
    21. Dr. Ted with new temporary bridge

For the next four-six months the receptor site bone will heal around the newly inserted implant so that the implant fixture and the bone become one. This is called "Osseo-integration." When it is complete the implant becomes rooted as solid as a rock and the general dentist will be called upon to create the false (prosthetic) tooth upon it.

Additional Information about Post-operation complications:

May 12, 2000

    Sometimes after a surgical procedure is completed problems/difficulties may arise. Here is what happened to me: About 3 weeks after my dental implant surgery was completed I began to feel a tender swelling on the gums above my teeth in the area of the surgical implant site. I went back to the clinic on Friday 12 thinking I was developing an abscess. Doctor Nix decided to surgically reopen the gum above the site to drain any fluids/pus that might have formed.  Once again he gave me injections Novacaine to numb the surgical site. Upon inspection he declared that the implants were doing well and that I did not have an abscess, there was no fluid to drain, but I did have a "cellulitis" which he explained as an infection in the skin of the gums, which, however, did not extend into the bone. He thoroughly cleaned the area with sterile water to flush away all the "anaerobic" (bad) microbes and placed new stitches to reclose the gum tissue over the surgical  site. Finally he prescribed an antibiotic to prevent any new anaerobic pathogens from recolonizing the site and causing another infection. It is important to always ask the surgeon what are the most common problems you may encounter after the surgery (any surgery). Post operative infection is probably the most frequent one of them.

May 19, 2000

    The painful swelling began to recede the very next day under the influence of the powerful antibiotic that Dr. Ned had prescribed (Clindamycin, 150 mg, two tabs, 4x/day for 5 days). He had placed in a special kind of suture (mattress suture) which made it impossible for me to remove. A small piece of it, however, remained exposed to my tongue and despite my attempts to refrain from touching it my tongue seemed  to want to "mate" with it at every possible moment. It was an irritating love affair from start to finish for me. It ended on May 19, when I returned to Dr. Nix at the hospital dental clinic where he removed the mattress suture causing me a few more twinges of pain in the process. He declared that the surgical site looked healthy and requested/demanded that I return in two weeks to evaluate the area again.

Preparation of the implant site for the abutment and the crown:
  
On July 28, about 14 weeks after the implant was surgically emplaced, I returned to the hospital dental center to continue  onto the next step ie., having the teeth built on the implants.The procedure took about 45 minutes.  Following local anesthesia my temporary bridge was removed revealing the now healed gums covering the implants. (See the pic.)  The new chief resident oral surgeon, Dr. Ronan Gold lifted the gum to gain access to the implants now covered by a "healing caps." (See the pic.) He screwed them out with a miniature "screwdriver" and replaced them with "healing abutments/cuffs." (See the pic.) Healing abutments are used to reshape the gum so that the new tooth can have a properly shaped outline into which the tooth can be seated when it is fitted onto the "abutment" which the dentist fits into the implant. (The tooth is made on an abutment ("post") which is screwed into the implant/fixture.) (See the Pic).   A Panoramic X-ray was taken to verify the  straightness of implants. (See the pic of the x-ray.)  A new temporary bridge was bonded on with crazy glue. (See the Pic.) Dr. Ted sends new molds and X-ray to the Dr. he has chosen to do the teeth on the implants.

The steps the dentist takes to fabricate the crown(s) that will be screwed onto the fixtures:
        Make a mold of the patients  teeth with replicas of the fixtures embedded in it:
   
Prior to my August 11th appointment with the prosthodontist I ordered the parts from the implant company that he was going to need to  in order to continue with the fabrication of the two artificial teeth/crowns that had to built on the  implanted fixtures. My prosthodontist *** is very unique since he is one of a few dentists in the country who can create the crowns that he provides i.e., he does not need a laboratory to fire his porcelain creations.
     He removed my temporary crown and the "healing abutment" from the fixture and attached a new  piece to the fixture called "fixture impression coping" (FIC).  Then he made/took an impression of my teeth with the FIC in place. Then  he detached  the FIC from the fixture, and once again replaced the healing abutment and the temporary bridge. I left the office.
    He then put the FIC in the impression, attached still another thingy called the "fixture replica"  to the FIC and "poured up" the impression to create the mold of my upper teeth.
     
Fabricate the Abutments/posts that the crowns are made on:
The result of this step is the creation of a mold/model of my teeth (a model that mimics my teeth including the presence of the two implant fixtures that were emplaced).
(See the pic of model the dentist uses to make the crowns.)  In essence, he must fist create a mimic of the crown of the tooth which he then can properly shape in the same way that a dentist does when he prepares/shapes your teeth for crown/jacket. It is called a dental "abutment". It is upon the abutment that he shapes the new crown, which he will then glaze/fire in a small dental furnace.
    When  I returned  a week later on July 18, Dr. Arguelles by then had sculpted the abutment/supporting base on which he was going to fabricate an all-porcelain crown. So he  removed my temporary bridge and the healing caps.  Then he tightly screwed the abutments he had sculpted on to the fixtures to see if they fit right and seated correctly onto the fixtures/implants (on which he was going to make the all-porcelain crowns). 
(See the pic of the sculpted abutments temporarily screwed on.) Now he had before him what the dentist  creates when he prepares real teeth for crowns.    
   
Prepare the porcelain crowns using the abutments as the infrastructure and cement them on the abutments:
Finally, he fitted  the temporary crowns he had made during the previous week onto the abutments.
(See the pic of the temporary crowns in place.) He did cement them on as they fit rather precisely.
    On September 7th, at the final visit, he removed the temporary crowns. Then he tried-in/fitted-on the all-porcelain crowns he had fabricated in his lab. When he saw they fitted well, and was certain that the color match and shade were precisely correct he took an X-ray to make certain the abutments were seated correctly on the fixtures/implants.
(See the pic of the X-ray showing abutments sitting straight on the fixtures.) Then he used a special instrument to tighten the screws that held the abutment on to the fixture.  This procedure is critical since it assures the "marriage" of the abutment to the fixture is precise. 
    Finally, he cemented the permanent porcelain crowns on to the abutments and  lightly sanded some teeth on certain spots to make certain my lower teeth could slide across my upper teeth without interfering with each other when I moved my jaw forward and back and to the right and left.
    My treatment, begun on January 7 and completed on October 7th, had taken exactly eight months with barely a week of unnecessary delay. It takes me about 16-28 months to complete the treatment of a patient with braces so you can imagine that I am a VERY PATIENT man. Nevertheless, I assure you, the day my work was finished I was a VERY HAPPY person.
(See pic of Dr. Ted with work completed.)   

A
problem encountered with a porcelain crown
   
About ten days after the crowns were permanently cemented on to their abutments, I began to feel something slightly scratchy high up on one of the new crowns. A glance in the mirror showed that there was a small chip (about the size of this (e)) at the rim of the crown where it abutted the gum. Here is what had happened: Think of a crown as a glass... the kind you use for champagne. Try and imagine that  glass tapering to a razor edge as it rises to the top. You can imagine how fragile it might be even though it is made of glass.  It would require only a slight touch to shatter the edge.  When you chew you put forces on your teeth/crown. Simply biting into a food must have put a force on the crown that stressed it at the rim resulting in a chip. The underlying abutment is white-colored and my gum is very high so that it does not show even when I make a big smile. I reported the  problem to Dr. Arguelles. I will leave it alone for now.
    On November 15, some weeks after the first chip in the front of the tooth occurred, it chipped again,
this time in the back, where my tongue seemed to want to constantly touch ("frantic tongue") its sharp edgy surface. Consequently, on December 1st, I returned to my dentist, who removed the fractured permanent crown revealing the sculpted abutment of the implant. He reshaped the abutment somewhat and placed on  it a temporary crown. One week later on December 8th, he cemented on new permanent  crown with an enhanced color match compared to the original he had first placed.
(See pics of the abutment of the implant, the temporary crown and the new permanent crown.)   

Ted Rothstein, DDS, PhD
Specialist in Orthodontics for Adults and Kids
35 Remsen St.
Brooklyn, NY 11201
718 852 1551 fax 718 852 1894

**Specialists in Oral Surgery, Park Slope, Brooklyn:
    Dr. Paul Baker and Dr. Frank Chionchio
    805 Union St.
    718 398 1969
   
Email:ParkSlopeOMS@aol.com
    http://www.parkslopeoralsurgery.com/

*** Dr. Orthelo Arguelles
      185 Prospect Ave. S.W
      Brooklyn, NY 11218
      718 435 7777

Synopsis of procedure:
   
Appointment with dentist who makes referral to Oral Surgeon. 30 minutes
    Appointment with Oral Surgeon for Consultation evaluation. 30 minutes
    Appointment with Oral Surgeon for molds and x-rays. 30 minutes
    ? May be special appointment with X-ray lab for special and expensive x-ray. 45 minutes
    If natural tooth must be removed appointment with general dentist or oral surgeon to remove it. 30 minutes   
    If natural tooth had to be removed then allow three months for bone to heal.
    Appointment with Oral Surgeon to Implant fixture. 60 minutes
    Appointment with dentist for temporary bridge to fill in space while waiting for healing.
    Allow three to four months for fixture and bone to heal around each other.   
    Appointment with Oral Surgeon to add healing abutment onto fixture. 30 minutes
    ? Appointment with general dentist to rebond temporary bridge? 30 minutes.
    Appointment with general dentist to make molds of your teeth. 30 minutes.
    Appointment with general dentist to try in the crowns. 15 minutes.
    Appointment with general dentist to cement the crowns. 30 minutes.
    Appointment with general dentist to check the work done for cosmetics, function and gum health. 30 minutes.
    Typical number of months to complete the treatment for an implant and crown from the day
         you have a tooth removed:  6-12 months. 
    Range of fees for implantation of fixture: $1,200-$1,900/fixture
    Range of fees for fabrication of crowns: $900-$1600/tooth
    Success rate: 95%

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