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Michigan Dental Seminars

Ara Nazarian, DDS
Meth Mouth Rehab
1857 East Big Beaver Rd
Michigan Dental Center
Troy MI 48083
(248) 457-0500

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Training Course Excerpt: Comprehensive Bone and Teeth Replacement

Reconstructing Tissues Ravaged by Drug Induced Xerostomia

The material presented here represents excerpts from Dr. Nazarian's most popular implant training courses that he has presented over the years, with different implant manufacturers and surgical product distributors.

A slide show video of the protocols, products and procedures used in this treatment plan can be viewed here.

Meth Mouth Xerostomia
Catastrophic Drug Induced Deterioration

Origins of Destructive Xerostomia

The adjacent picture is representative of many advanced treatment cases that can have multiple causes but produce similar degrees of tissue degradation associated with xerostomia.

Methamphetamine abuse, cocaine abuse, medication effects and over consumption of soft drinks and energy drinks, for many patients, produce similar treatment needs.

The mirrored view of the maxilla nonetheless reflects a good amount of healthy bone within the ridge. All upper teeth are beyond repair, requiring full edentulation.

Upper Arch Damage
Maxillary View
The impact of the destructive aspects of drug induced xerostomia and severe imbalance of oral ph is most evident on the upper teeth.

Normal occlusal events operate also, accelerating the break down of teeth that undergo rapid enamel deterioration.

For this patient in particular, the loss of vertical dimension is significant and was beginning to affect normal tmj function and also created cosmetic chances in facial appearance.

Mandibular Damage
While the lower teeth "seemed" to sustain less damage, calculus and tartar accumulations were significant. Edentulation of the mandible was required.

Bone and soft tissue loss was more evident on the lower arch.

Since bone leveling and socket grafting was incorporated into the treatment plan to achieve the best opportunities for accelerated healing and tissue regeneration, minor losses of bone height would not be a significant issue.

Fast Removal of Teeth
Extraction Forceps
Dr. Nazarian uses the Physics Forceps instrument to assure efficient tooth removal that is minimally invasive, comfortable for the patient and, more importantly, eliminates the problems of extracting severely compromised tooth structures without additional breakage.

Learn more about Physics Forceps here.

Special instruments are used beforehand to sever any periodontal attachments to the tooth structures. The unique design of the forceps do not require the use of a fulcrum and gently complete the loosening of the tooth structure.

20 Minute Edentulation
32 Extractions in 20 Minutes
Removal of the loosened tooth is completed usually with finger tips.

As can be seen in the adjacent picture, the patient's remaining 32 teeth, many of which were broken to the gum line, were completely removed in 20 minutes without additional breakage or complication.

With the right combination of preparation and use of specialized instruments, what is often considered to be a time consuming edentulation protocol.... can be reduced to minutes, instead of hours.

Extractions, Bone Leveling and Socket Grafts

Once the extractions were completed, bone leveling was performed as needed to eliminate high spots in what would become the patients new bite plane, for the upper and lower jaws.

Post Op Socket Healing
Extraction Socket Healing after 3 weeks
Socket grafts were used to fill in the varying depths of each extraction socket. The use of socket grafts immediately inititiates the healing and bone regrowth process and, perhaps more importantly, assures excellent control over establishing a homogeneous plane of bone.

Waiting for extraction sockets to fill in on their own (when socket grafts are not used) can cause untimely delays in the overall treatment plan.

Immediate Denture Products

Temporary Immediate Denture Prosthetic
Temporary Immediate Dentures
Immediate dentures were fabricated to provide a comfortable pair of prosthetic teeth that enabled the patient to leave the office with comfortable teeth.

The level ridges and soft denture lining helped to optimize healing time for the bone and soft tissue grafts, along with suturing.

Graft Healing and Implant Placement

Although the manifestations of excellent healing occurred at about 3 weeks, a total of approximately 4 months was provided to assure the highest values of predictability of bone regeneration success and the needed dimensions of bone augmentation for each implant site.

Healed Maxillary Bony Ridge
Healthy Upper Bony Ridge Rehabilitation
After approximately 4 months of healing, the successfully augmented bony ridge is prepared for implant placements.

Implant selection is customized, incorporating bone tissue characteristics (width, height, porosity) at eacn proposed implant site.

No "one implant fits all" type of solution is used. Varying widths and lengths of each implant are chosen to take the best advantage each implant site can provide.

Surgical Guide
Surgical Guide
A total of eight (8) implants are selected for the upper jaw. The number and placement of each implant will provide the best opportunities for maintaining healthy bone height across the entire arch.

The use of specialized ctscan based treatment planning software assists in site and implant selection while providing the means for fabricating a surgical template as shown in the adjacent picture.

The guide fits snugly onto the patient's arch and, when appropriately secured, guide the implant drills into the locations specified on the ctscan treatment planning software. Correct location and correct depth are scientifically assured.

Surgical Guide Tools
Maxillary Implant Placement
Implant site preparation for each new root form implant consists of a series of graduated drill bit diameters that safely creates the diameter and depth needed without the danger of overheating, which can cause implant failure.

Special sleeves are used in conjunction with each drill bite diamter that assures an accurate preparation of the implant site.

Site preparation is typically different for certain locations along the bony ridge. Wider posterior implants while anterior positions typically use a narrow implant. Depth is usually a function of the ridge height at each location.

Upper Implant Selection
Maxillary Implant Placement
Notice how the molar implants are sized considerably larger in diameter, compared to those along the anterior aspect of the ridge.

Anticipated biting forces of the patient are matched to an implant design to assure against over-loading which could lead to a future failure of the implant or grafted bone.

Precision ctscan based Implant Surgical Guides are fabricated to optimize error-free placements that are more commonly associated with free-hand implant site preparation.

The mandible is similarly prepared for implant selection and placement.

Healed Lower Bony Ridge
Healthy Lower Bony Ridge Rehabilitation
The healed ridge is uniform in width and height throughout the entire span of the jawbone.

Biting forces, bone characteristics and the overall design aspects of the patient's planned fixed porcelain bridge influence implant selection.

The Surgical Guide used for the mandible is developed in the same manner as the upper guide.

Ctscan data is reviewed and assessed for selecting the best implant positioning possible in terms of diameter of the implant, height (important for avoiding hidden neural tissue) and the possible need for special angulation.

Mandibular Surgical Implant Guide
Precision Implant Placement
Eight implants are selected for placement along the ridge of bone that will provide solid support for the patient's reconstructed bite plane.

Larger implants are again selected for the posterior segments of the arch to assure optimal stimulation of bone tissue while enduring typical posterior bite pressure dynamics.

Healing caps are placed on the implants to promote healing and full osseointegration of the implants into the newly augmented bone tissue.

Lower Jaw Implants
Lower Ridge Implant Placements

Implant Osseointegration Completed

An additional 3 months of healing now completes the osseointegration of the implant placements. Healing caps are removed as well as any excess soft tissue that covered the healing caps.

Temporary impression posts are placed and adjusted on each implant site.

Temporary Prosthetics

Implant Impression Posts
Impression Posts
Acrylic temporaries are created to replace the immediate dentures and to begin the process of assessing overall bite characteristics, regaining normal dental function and to achieve the final cosmetic goals desired by the patient.

The adjacent photo shows the placement and alignment of all implant abutments. Alignment blocks are used to provide the best accuracy possible to eliminate any technical errors.

Minor errors in abutment alignment during the try-in phase of the temporaries may not become as evident as one would like. The acrylic product can mask certain types of errors by minor flexing or in the case of an unusual error, perhaps cause the bridge to crack or break.

Checking Abutment Alignment
Confirmation of Abutment Alignment
Confirming and re-confirming abutment alignment is more critical for assuring exact fit and function for the permenent bridgework.

Unusual forces that operate on the porcelain, bridge framework that have the potential of becoming telegraphed to the implants are virtually eliminated, providing the long term endurance that patients want.

Optimized Alignment

Precision Implant Dentistry
Aligned Abutments
The temporary bridges are lightly cemented into place. For this patient, gingival tinting is provided to assure a comfortable aesthetic while an extended try-in period is implemented.

The patient will have opportunities to undergo bite adjustments along with controlling the amount of vertical dimension that will be maintained or adjusted, modifying the shape and sizing of the overall smile and determining an ideal ratio of gingival tint that will best approximate a natural appearance of the bridgework.

Attention to Detail: Technical and Patient

Acrylic Bridgework
Glidewell Biotemps
The patient had been without a normally functioning bite for quite some time. As food preferences and eating behaviors slowly changed over several weeks, occlusal factors were closely monitored to assure proper distribution of biting forces across the bridgework and implants.

Cosmetic adjustments were made as necessary as the patient slowly regained "normal smile behaviors" which affected apparent tooth sizing and balance of the gingiva tinted porcelain.

Porcelain Bridgework
Porcelain Bridgework

Final Porcelain Bridgework

Close review of the two adjacent pictures reveal the structural and cosmetic changes that were made with the temporaries. The patient can now smile as broadly as he once did, without any concern for revealing that his teeth are made of porcelain.

Rather, his new teeth compete very favorably with what Mother Nature had provided years ago.

Panorex Representation: Full Mouth Reconstruction

X-ray Confirmation
The xray confirms implant placements and alignments, along with indications of excellent bone density and quality through both bony ridges.

The lower bridge is revealed to consist of elements that will distribute biting forces in a predictable fashion, thereby preventing any single implant from being overloaded.

Questions and Details: Reconstructive Dentistry Seminars

Dentists and specialists seeking post secondary training that enables their practice to incorporate leading edge dentistry concepts and technologies immediately are encouraged to contact Dr. Nazarian directly for any questions or additional requests for technical information.

Dr. Nazarian can be most easily contacted via our on-line email Contact Form. He will respond to you directly with the answers you seek to unique questions or questions about the activities of the Reconstructive Dental Institute.

Michigan Dental Seminars
Ara Nazarian, DDS Seminar Leader
1857 East Big Beaver Road
Troy MI 48083
(248) 457-0500 - Fax: (248) 457-0501

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