Mastication Miracle

Or How Al Got His Teeth Back
(continued)



SECOND INSTALLMENT

Preliminaries

In case you landed directly on this page and would like to start at the beginning, you can call all the way back to:

The Tooth Fairy's Evil Twin—Or How Al Got a Denture Plate.

If you would like to merely start at the begining of the implant stage you can go to:

Mastication Miracle—Or How Al Got His Teeth Back.



Reconnoissance

Thursday February 21, 2008

Once again I sat down with my book reader, while waiting out in the dentist's lobby area. Phileas Fogg had long since made it back to England, arriving only seconds before the 80 days ran out on his wager at the appointed meeting location. I was now reading Hans Brinker or the Silver Skates and enjoying a very interesting description of a group of boys skating around Holland on a mission of exploration. It is the kind of book you wished they still wrote today for young people.

I went to the dentist for a follow up visit. On the way back to the dental chair there was a brief stop in the x-ray alcove to get another panoramic view of my teeth. (I am very glad that they have gone to digital x-ray detectors instead of film. All of the x-rays I have absorbed for this entire procedure probably wouldn't add up to one panoramic shot done on film.)

"Ah, back to my old stomping grounds," I sighed as I sat in the same chair I had spent so many hours in the week before. My dentist chuckled at that as he came in. He said that he had a lady come in for an implant this week and as he was getting set for that he was hit with the thought, "Hey, this is only one implant." I think I changed his life. Knee-Slap Laugh

When he looked at the x-rays he was very pleased with how things had been progressing. There is some visible filling in already, including over the top of the small intrusion into my sinus made by the left front implant.

The tissue around the implant surfaces has also filled in, and the one implant on my lower jaw, that was up a bit above the gum line in order to line it up with my teeth (that was the only one of the implants drilled into a location that had lost its tooth earlier than July last year, and the bone had receded because of it) is now nearly covered with gum tissue. I was originally worried about that one rubbing my tongue raw because the metal felt odd there. Now my tongue actually touches gum and not metal.

I learned some things that day about bones. He said that on the top 6 implants he had only drilled into brand new bone, bone that had grown only since July when my teeth were pulled. Bone in the jaw area is very resilient and it just fills right in when a hole is made in it. He commented many times during the procedure that my bone was very solid, and very hard, and now I found that it was all less than a year old. He was quite happy to find that the bone is that way, because the implants should set up wonderfully well in that bone. And the fact that it grew in so fast and hard bodes well for the success of this process. Thumbs Up!

The second thing, and more surprising, was what I learned about the two additional implants that I have yet to get, and have been avoiding thinking about as I try and pull myself out of the hole the first batch put me into. They are going to be doing a "Sinus Lift" for each of the two remaining implants.

  1. A cut will be made to create a flap in my gum tissue to the side of the bone of my upper jaw, at the location of the intended implant. They will cut a small "doorway" in the bone, to get access to the sinus membrane.

    When you have a tooth pulled in the upper jaw, a great deal of the bone between where the tooth had been and the sinus above it disappears over time. The sinus comes down to only a short distant from where all the chewing should be going on. It can be a quarter of an inch or less. It doesn't leave any room for an implant to go in.


  2. They will "tease" the membrane away from the bone, and push it upwards and out of the way, lifting it far enough to create a large enough cavity between it and the bone to allow the insertion of "simulated bone," which is pushed into place, sort of like foam insulation is put into a house, forced into a vacant cavity. It will be inserted and that will hold the sinus membrane away from the old bone.


  3. The bone doorway that was cut will be allowed to reseat itself, and the flap of skin will be put back in place. (My guess is that a stitch or two may come into play here.)


  4. A period of time may or may not be required at this point before the actual implant is placed. It depends upon whether the bone that is already there is thick enough to hold an implant in place while things stabilize. If there is enough bone, then they do the implant. Otherwise they wait several months for enough new bone to grow to hold it. (That will of course require another several months after the implant is placed before it will be able to be used. That would mean 6 months would pass before I could actually have teeth placed on those implants.)
This is the coolest thing I learned during the visit. The simulated bone they are putting in is what my dentist called a "scaffolding" for the healing process. Just like happens with petrification, the simulated bone will all be replaced by new real bone! The simulated bone will just provide room and incentive to grow. As the new bone grows in the simulated bone will be absorbed and washed away. At the end of the process it will be just like a tooth had recently been pulled, and the jaw healed up, just like happened with my upper teeth. I had worried that I would be walking around with two "blocks of concrete" in my jaw for the rest of my life holding these two last implants in place—and they both will be supporting molars! I now feel much better about that part of the procedure than I did before. After getting back home I did some research on the materials that they use for this procedure and I found that the material that dentists use for this procedure that most closely matches the way the dentist described it is Hydroxyapatite. Hydroxyapatite is just calcium, which is a big part of bones naturally. It should be a very safe thing to use, and with the way my bones grew after my extractions, I have very high hopes for these "sinus lift" procedures.

I still felt traumatized a bit from that first procedure and wasn't really ready to even think about doing another one so soon, but we scheduled it for a week and a half in the future. I will try to be ready for it.

The Day Before

Monday March 10, 2008

I was spending the day with the apprehension of what was coming the next day never too far behind my level of consciousness. How would it go? Would it be more or less traumatic than installing the first 7 implants had been? Would I have to fight off on infection afterwards? Mainly, how tough would that session be in the chair? I didn't know, and it left me with some anxiety. But at this point, I just couldn't back out. I was half way across the bridge and the section I had just crossed over had collapsed behind me. Pressing forward was the only real option it seemed.

Dotti and I had discussed getting out and doing an errand or to, but finally we decided to just relax and stay at home. About 4 PM the phone rang. It was my dentist, and he asked how I was doing. I lied a bit and said I was fine. Physically I was okay and that is what he wanted to know about really.

He then got down to the real reason he called, "I have some instructions for you." For him to have called this late in the game with this information leads me to believe that he was given these instructions himself from the "mentor" dentist whom he had said would be at the procedure. Normally, my dentist is very thoughtful and would have called me earlier in the day to let me know these things were required if he had known they were coming. I could be wrong, but I think that was the case.

What he wanted me to do was to pick up a prescription that he was going to call in for me for Amoxicillin and then to take one of them before going to bed, and then to take another one in the morning before coming in to the office for the procedure. He wanted to get my immune system running full tilt before we got started and that way, hopefully, infection could be averted right up front. He also wanted me to buy some Sudafed, in case it would be needed. He didn't explain what would make it become necessary, he just gave the suggestion that I should buy some. Lastly, he told me to take 800 mg of Ibuprofen before retiring for the night and then to take 800 mg more before coming in for the procedure. At this point I asked him to wait a moment and grabbed a pen and some paper to write on. I didn't want to miss anything if there were more. However, that pretty well took care of the To Do list he had for me and he said he would see me tomorrow.

Well, so much for relaxing for the rest of the evening. We got ready to go and hopped into the car and headed off to the drug store. It is right next to a department store and we decided that since we were out, we would drop by the department store and walk around a little for some relaxation and a bit of exercise.

We pulled into the drive-thru at the pharmacy and the pharmacist, whose English was not very good, told us that the prescription was called in to the wrong branch and we would have to drive 5 miles north to pick it up. Fortunately I don't believe in evil omens or this would have been a something to worry about. Soon we were off on our 10-mile round trip excursion to find the pharmacy. There was another one of the chain about half way there and I mistakenly turned in there before Dotti pointed out that it was the wrong one still. So, I turned around had headed out once more. The potential omens were mounting it seemed, but luck was finally a lady to us and we found that the distant branch of our normal pharmacy did indeed hold my prescription.

With the Amoxicillin in hand we drove back to the department store. We were already set to walk around it and we were not going to let a bureaucratic goof stop us. After walking around a while, we drove home and then settled in to rest up for the next day's "festivities." I took my Amoxicillin and my ibuprofen and could do no more.

My eyes grew heavy at 9 PM;
I made my way to bed--
With visions of chairs, cuts, and drilling,
stuck in my weary head.


D-Day


Tuesday March 11, 2008

Rise and Shine


When I woke up it was 5:45 PM and I still 6 hours to wait. I answered some e-mail and waited for the hammer to fall. I had been playing around with a problem that a very good friend had sent me The Monte Hall Puzzle and I was just was wiping the egg off my face from blowing the answer, before heading into the dentist's office.

When I arrived at the office the attractive and efficient receptionist made me feel welcome and let me know that I was all checked in and they would be coming for me soon. Dotti visited with all the ladies in the front office area, while I paced the floor waiting. Yes, I was a bit anxious. This was something more than what I did before, even though I had been told that it would probably take less time than my last procedure did. Still, visions of what they were about to do were running through my head.

Dotti arranged to get my prescription for pain meds so she could have it filled for me while I was having the work done. She headed out and wished me luck and soon I was headed back to the same chair I had spent so many wonderful hours in over 3 weeks before. I was introduced to the expert who would be assisting in the procedure and he assured me that I had made the right choice in what I was doing, and he referred to it as "hitting a homerun." At the moment it felt more like being a practice ball and the heavy hitters were about to take a swing at me.

I have to say that I was running on adrenaline at that point in time, and when they had taken my blood pressure it was up 20 points on the high end to around 140/90, and they asked if I were nervous or anxious. I didn't reply "As nervous as a long tailed cat in a room full of rocking chairs," but it would have been correct. Instead, I merely told them that I was not surprised to see my pressure go up the way I was feeling. I was pretty nervous. They had no problem proceeding at that point.

I had a moment before we started where my dentist was alone with me and he asked if I had any questions about what they were going to do. At this point I gave him a quick rundown on what I was expecting.

(Side view with the front of the mouth to the right.)

I have included some computer drawings I did, which I hope will help to convey what was in my head as I was talking.

To begin with where these implants were going to be placed had a very thin bone (during the procedure I found out that it was about 3mm) along the bottom where they had to drill in and mount it. So, more bone had to be created. The sinus was down on the floor of the bone and had to be lifted up out of the way to make room for the new bone and of course the implant.

(Looking forward on the right side or backward on the left, end on.)
The gum and bone would be cut and and a door opened in the side wall, allowing access to the sinus membrane which would have to be moved out of the way.

Side view again, showing the proposed completed work in red. Note the new bone and the implant.


(Side View)
I was a little unclear on exactly what shape and size the incision would take. As it turned out, it was about an inch and a quarter long front to back, cut along the bottom of the gum line, and then there were two side incisions upwards to complete the cut. It reminded me of the flap on my old Cracker Jack dress blue uniforms in the Navy, but upside down.

(Side view)
Once the flap was lifted out of the way they could then have access to the bone where they could drill into the wall. During the procedure I heard them discussing the fact that the bottom of their cut had to be above the floor of the bone ridge, giving a clear path of motion for it.

(Side view)
I am not sure of the size of the cut they made for the "trap door" but I am assuming it was something like this. They would have to punch through the bone but not cut into the sinus membrane, which was a touchy part of the operation.

(End on View)
Once the entry was created they would use their tools to move the sinus upwards and out of the way. The sinus adheres to the floor of the bone and so it has to be worked free from that and this is a point where a puncture can occur in the sinus membrane. Once the membrane is worked loose the trap door is raised to become the new floor for the sinus. (I had originally assumed that they pulled the trapdoor closed again when they were done but the dentist pointed out that would not be possible after the new bone was added. Good point. )

(End on View)
I told him that I thought they would then pack in the simulated bone, and if possible then would drill out the path for the implant and mount it. As it turned out they packed it part way full, sort of like this (red is the simulated bone) and then drilled out a hole for the implant. Fortunately the bone floor was thick enough to support an implant during the healing stages so they could put it in.

(Side view)
Once the hole was cut in the floor of the bone the implant would be mounted just like had been done on the earlier ones that had been installed. A small pilot hole would be drilled and then a larger hole and then the implant would be screwed in with a torque ratchet wrench until properly snug.

(End on View)
The final goal was to to have the implant in place, the trapdoor up and horizontal, forming a new floor for the sinus, and the space below filled with simulated bone around the implant, which would be mounted in the bone floor.

(Side view)
When all was done I would have my final implants placed that would be the right distance to support 3 teeth on two implants and the flap of gum would be stitched back in place to hold everything together.

(End on View)
The gum would be used to hold things together as it heals. In a way it would be like an extraction from the side, where the "socket" is all filled in with simulated bone and covered with gum.

I know that they expect it to be about 3 months before the bone will have grown in to replace the simulated bone and for things to be set up enough to place teeth. What I don't know is how the area will feel in that area of my mouth at various points along the way. Will it soon become unnoticeable, toughening up quickly as I have found extraction sockets tend to do? I hope so.

I found that, unlike with my other implants, the flap of skin would be completely covering these final two implants and they would remain hidden, until they are ready for the next step. I wasn't up to looking past this point yet. Right now I was focused on the upcoming ordeal.

Care For a Lift, Sir?


The sinus lift procedure could now begin, and things settled down into the general order that all would take. The expert dentist sat on the right and his assistant moved into the chair at the left. He had brought along his own assistant for the procedure which turned out to be a good thing, because the two of them had a rapport that allowed them to work well together.

She suggested that I uncross my ankles and let my shoulders relax back into the chair I found those suggestions to be very helpful. She also made sure that my nitrous oxide flow was right and the one time I asked to have it adjusted she made sure that it was right where I wanted it. She was an excellent dental assistant who had obviously been doing it for a long time.

The dentist was new to this office and the chair controls were different from what he was used to, and it took a bit to get the chair and the patient (hmm that would be me ) placed to his liking. Once that was done I said, "Well, now the hard part is done." He chuckled.

I could tell that this guy knew his business all the way along. He placed his shots in just the right place and I never had to ask for any additional shots throughout. He explained to my dentist what he was doing at each step along the way. (At some point it became clear that my dentist was doing this entirely for the first time, and I was the practice dummy. Actually, that was not a problem at all for me. I knew that there would be an expert right there throughout in case he got into trouble. Also, it would an opportunity to help future dental patients as this very good dentist was able to expand his knowledge base and add a new tool to his kit that would no doubt come in handy in the future.)

Another advantage of this situation was that I got to be privy to an expert description of what was going on as it it was happening. Unfortunately, my "dental-ese" is a bit weak and a number of the terms scooted right over my head, but most of it was pretty easy to follow.

I got to hear how thick my gum wall tissue was and how the scalpel could be easily dulled by scraping bone and that having a back up scalpel was a very good idea.

Soon he began what felt like scraping. He said, "A lot of pressure here." I had visions of a putty knife working on a stubborn bit of paint on the wall as he rubbed forcefully against the bone surface. I don't know if it was the N2O or not, but I did feel pretty detached about it at this time. I assume he was working under the gum tissue to separate it off and then to create a good drilling surface for the trapdoor, but that is just a guess.

It came time for the drill at last and it had a different pitch to it than any other dental drill I have come in contact with. It was not so much when it spun up, but when it came in contact with the bone that suddenly I was introduced to the most irksome high pitched squeal that I was thinking of listening to someone rub a blackboard with chalk incorrectly, or using his fingernails along the surface, and having a chill run down my spine.

For a moment I wondered if this was going to become intolerable, but then I got around the corner as it were, and I started to acclimate to the sound. It was not pleasant of course, but it became less and less of an issue and I was able to mentally move on.

To make sure that he didn't just punch through and make a hole in my sinus membrane he stopped at various points along the way and tested the trapdoor to see if it were showing signs of being free to move.

It also sounded like he had used some device to shine light through the bone to determine where the floor of the bone was at so he could drill above it. I was not outside looking in, so I have no really clear idea what he used for that but whatever it was, it didn't take long for him to set is spot and start drilling.

Once the trap door was cut in the bone, he set to working the membrane free from the top of the bone floor. (It was about here that he gave the verdict that I did have enough bone in the floor to place an implant on this day and I gave a thumbs up. )

He mentioned the fact that he had borrowed this toolkit he was using from another local dentist and his kit was in Salt Lake, where he calls home. So, from time to time he would comment on wishing he had this tool or that, but that what was there was adequate to the task. At one point he commented on how a respected dentist had gone to the standard dental tool shelf and come up with a tool that was normally used for something else but that was very useful during this procedure. (It was little snippets like that made this an interesting procedure beyond the normal.)

He pointed out that the sinus membrane had to be worked free all the way to the back wall so that the trap door didn't pinch it and cause problems later. And once he was happy with the "movement" of the sinus membrane he had his assistant mix up some of the simulated bone. He drew off some blood from my mouth to add to the mix and then started putting the mixture into the cavity he had created. He said that he was going to use about 3 cc of the mixture. He said that some dentists use 5 cc but he felt that 2 to 3 might work better.

He put in a starting amount into the cavity, enough to hold the sinus up out of the way and broke out the drill again. He cut in the pilot hole and pointed out that the drill didn't have to run in all the way since there was no bone on the other side of the floor. The drill made quick work of it and he had the second bit through in no time and was placing the implant.

Unfortunately the threads didn't bite in at first because the hole was a bit small. The small hole is good to make sure the implant is snugly held, but it has to be big enough to allow the implant to bite in. So, he got a larger bit and hit the hole opening with it, just to spread out the opening a touch, and then tried the implant again. This time it caught, and screwed right in.

Next he set to packing in the rest of the simulated bone mix. I could feel him make contact with the implant as he was working and it seemed weird. It was like having someone reach into your abdomen and scratch from the inside.

He got to a point where he wanted to run a quick check on what he was doing. So, we stopped and they put the digital sensor into my mouth and an x-ray was shot. The site looked good but he wanted to add in just a bit more of the mix to make it perfect. So, I was rotated back into the business position of the chair and he put more into the cavity, and at last it was time to close!

When he was working on closing up he mentioned that it was going to be "a challenge to close, at least at first." That enigmatic statement only worried me for a moment because he said no more about it and finished closing up soon afterwards.

The sutures were left with the ends dangling. I assumed at the time that these loose ends would be trimmed but at it turned out, they were left that way. This led to some confusion later in the day as you shall see.

Everything was cleared out of the way and I was soon on my feet and paying a visit to the restroom. I had risen slowly, just to make sure that I would not grow dizzy, but I was okay. It was 1:37 PM and I was about half way through. I debated with myself as to how long the the second procedure would take and whether I was really halfway or not. My dentist would be doing the second one and he was learning. I knew he would be meticulous and accurate in what he did. So, it could take longer, since this was his first time. On the other hand, he didn't have to teach someone else as he went along, and it could take the same or less time.

I had been very happy to have not even noticed the pictures being taken along the way. In fact during the first procedure I don't know that pictures actually were taken. But, while I did notice a flash once or twice during the second half, having a dentist shoot the camera was far easier because he knew just what was wanted and there was no stopping.

Back in the chair things got underway again. My dentist took over, along with his assistant. The expert was looking over his shoulder the whole way and from time to time my dentist would ask a question, or stop and have the expert check his work. Also, the expert would drop a suggestion along the way, or describe alternate approaches that might be considered another time.

Things progressed and other than the talking back and forth, and a slightly different feel of the way the tools were applied, we moved forward pretty much the same. The incision was made, the gum tissue was worked loose and raised, the positioning for the drilling was established, and the high pitched squeal of the drill was started.

The expert described the proper technique for getting through the bone, as to where to apply the cutting force and the level of force required to avoid cutting through into the sinus membrane, and then how to wiggle the trapdoor best to get it free.

The only place where trouble was encountered was with separating the sinus membrane from the floor. At this point there was what the expert called "a step" where the bone surface was not even and getting the tool to work over that step was apparently difficult.

He worked around a bone intrusion and finally got the membrane to come loose, but not before a small hole was punched into the membrane. So, and additional step was added here as the expert talked my dentist through applying a patch to the hole.

They had some material that was designed just for this situation. In listening I picked up the fact that it had an adhesive quality that would stick to the membrane once placed. They jointly worked on getting just the right size of patch cut, and then my dentist maneuvered it through the hole in the bone. He had to bend it just right and once through, position it right over the tear.

It really didn't take to long and soon he was back at moving the trap door up into place and packing in some of the simulated bone. The drilling and the implant placement went smoothly and more of the mix was packed in to fill the cavity before the x-ray was taken.

There was some area forward and toward the top that could use some more, and so it was back down for my chair and things continued on. Soon the packing was done and it was time to close.

The second procedure had taken longer and the anesthetic was starting to wear off. When he began to put a suture at the bottom of the gum it felt pretty live. So, he stopped and gave me a bit more anesthetic to allow placement of the sutures. I remember having the impression that the sutures seemed to be a bit of a challenge to get completed but finally the end was reached.

 

(To be continued...)