Treatments

Teeth Whitening

Whitening creates a more esthetic appearance by reversing the discoloration of tooth enamel. Determining whether a patient is a candidate for whitening is largely based upon diagnosing the exact cause of the tooth discoloration. Careful clinical examination and X-rays will help determine if whitening is indicated for the strength and condition of the patient’s teeth.

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Whitening is done simply in the comfort of your own home. Patients have an initial appointment at the dental office to determine their gums are healthy, then impressions are taken and custom trays are made to fit snugly around their teeth. When the trays are picked up a couple of days later, patients are trained on how to perform the procedure. Basically, each night after thoroughly brushing their teeth, they put a small quantity of a special whitening gel into their custom trays and place them over their teeth. Then they go to sleep. In the morning they remove the trays, clean them carefully, and brush their teeth normally. This is done over a period of two to three weeks until the desired result is achieved. Although this is not a permanent treatment, annual touchups of only a few days at a time can maintain the original whitened result.


Crowns

Crowns are dental restorations otherwise known as “caps” which are coverings that fit over teeth. Some of the indications for a crown are:

  • A previously filled tooth where there now exists more filling than tooth. The existing tooth structure becomes weakened and can no longer support the filling.
  • Cracked Tooth Syndrome (CTS) – A tooth may exhibit pain with pressure, and this can be a sign of an internal fracture, usually due to a previously placed amalgam filling that expands and contracts with temperature changes. The only way to prevent the tooth from flexing is to place a crown to hold the cusps together.
  • Root canal – After root canal, teeth tend to become brittle and are more apt to fracture. These teeth need to be protected by a crown.
  • Bridges – When missing teeth are replaced with a bridge, the adjacent teeth require crowns in order to support the replacement teeth.

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Crowns strengthen and protect the remaining tooth structure and can improve the appearance of your teeth. Crowns can be made from different materials which include the full porcelain crown, laboratory-fabricated composite crown the porcelain fused-to-metal crown and the all-metal crown (gold or precious metal). Latest techniques like CAD/CAM metal free zirconium and E-max crowns are also available. You and our doctors will decide which type is appropriate, depending upon the strength requirements and esthetic concerns of the tooth involved. Fitting a crown requires at least two appointments. During your first visit, the tooth is prepared for the crown, an impression or mold is made of the tooth, and a temporary crown is placed over the prepared tooth. At the subsequent visit, the temporary crown is removed and the final crown is fitted and adjusted and cemented into place.  First Appointment: The first visit begins by giving you a local anesthetic. Depending upon the type of local anesthetic used, you can expect to be numb for one to four hours. If your anesthesia should last longer, do not be concerned. Not everyone reacts to medication in the same manner. Once you are numb, we will prepare your tooth in a very specific way in order to maximize the retention and esthetics of your new porcelain to metal crown. After the tooth is fully prepared, we proceed with the impression stage. At times, we use a thin piece of retraction cord that is placed around your tooth in order to get the impression material under the gum where the crown ends. Once the impression stage is completed , we will place a temporary (transitional ) crown on your tooth. These plastic (acrylic) restorations are placed on teeth to protect them and the gum tissues between dental visits. The temporary cementing medium used is designed to allow the easy removal of the temporary at your next scheduled visit.  Second Appointment: At that time, the temporary crown is removed and any temporary cement is cleaned from the prepared tooth. We will fit the final crown, check for accuracy, adjust for any bite discrepancies and evaluate the esthetics. If all of these factors are acceptable, the crown is cemented to your tooth. It is not unusual for the new crown to be mildly sensitive to cold temperatures for a few weeks. However, if the sensitivity is severe, does not subside, or if the bite feels uncomfortable, contact us. Further adjustments to the crown may be necessary. We hope that this brief instruction sheet will answer most of your questions regarding crowns. Following these simple guidelines will help provide you with the finest in dental care. If you have any questions regarding this or any other procedure, please contact us.


Bridges

Protect and keep badly decayed or fractured teeth while maintaining a beautiful smile.

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The Problem: – A missing tooth or teeth – Potential bite and jaw joint problems from teeth shifting to fill the space – The “sunken face” look associated with missing teeth – Desire to improve chewing ability – Desire for a more permanent solution than dentures

The Solution: A bridge is a single appliance that is generally attached to two teeth on each side of the space where a tooth is missing. An artificial tooth attached in the middle of the bridge fills in the gap where the missing tooth was. The teeth on either side of the gap are prepared for crowns (see crowns) and a highly accurate impression or mold is made of the prepared area. This mold is used to create a gold or porcelain (tooth colored) bridge in a special laboratory. The bridge is then cemented onto the prepared surface of the teeth, effectively creating the appearance of a “new” tooth.

In some instances, a resin-bonded bridge may be used. In this case, the two teeth on each side of the gap are not prepared for crowns. Instead, the bridge consists of a false tooth with metal brackets on the back of each side of the gap. The brackets are attached to the backs of the real teeth on each side.

Advantages: Unlike dentures, a fixed bridge is never removed. It is stable in the mouth and works very similar to natural teeth. By filling the gap and stopping the movement of other teeth, a fixed bridge is an excellent investment, providing better chewing ability, heading off jaw joint problems and saving money that would otherwise might be spent on future dental treatment.

Disadvantages: Fixed bridges are excellent restorations and have few disadvantages. They are highly durable, but they will eventually need to be re-cemented or replaced due to normal wear.

Alternatives: In the event that the use of a fixed bridge is not feasible, the best alternative is a dental implant.


Veneers

Porcelain laminate veneers are probably the most esthetic means of creating a more pleasing and beautiful smile. They require a minimal amount of tooth reduction (approximately 0.5 mm) and are, therefore, a more conservative restoration than a crown. Porcelain veneers allow us to alter tooth position, shape, size and color. They are not the only alternative for all esthetic abnormalities but are truly a remarkable restoration when they are the treatment of choice. Veneers are a fantastic way to fix front teeth. You can whiten your teeth, close spaces, and create a great smile. We can even do virtually instant orthodontics to straighten crooked teeth.

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Spaces between the teeth (diastemas)

  • Broken or chipped teeth · Unsightly, stained or washed out fillings · Permanently stained or discolored teeth · Misshapen or crooked teeth · Whiten dark yellow or stained teeth

Veneers are very thin and are bonded on the front of your anterior teeth. These veneers are about 0.3mm to 0.5mm in thickness but are very strong once bonded to your teeth. They have a “life like” appearance with the strength, beauty, and durability only porcelain restorations can afford. Veneers have several advantages over crowns (caps). There is no “dark line” that is sometimes seen with older front caps. They transmit light better and, therefore, have a more translucent appearance giving a natural, esthetic look. Veneers do not require the massive grinding of tooth structure that caps do, yet, they accomplish a lifelike esthetic result.

How’s it done?

After a thorough discussion with us to establish just what you wish to accomplish AND establish what can or can not be done, your first appointment usually involves some minor contouring of the front teeth and taking an impression of the teeth. The veneers are tried in, and, if satisfactory, they are bonded in place. Many times, we combine whitening with porcelain veneers to make that perfect smile. If some front teeth are already badly broken down, we can place new all porcelain crowns combined with veneering and other cosmetic techniques. Some facts you might want to know about Porcelain Veneers: Since they require approximately .5 mm of tooth reduction, porcelain veneers are NOT considered a reversible form of treatment. Between your preparation visit and the insertion visit, you can expect some sensitivity to hot and cold. This is normal and is due to the removal of a small portion of the enamel covering of the tooth. This sensitivity should disappear after the placement of your Porcelain Laminate Veneer. Your second visit, the insertion of your laminate, can be accomplished with or without local anesthetic, but typically a small amount of anesthesia is preferable. This visit is usually longer in length. The laminates are placed with a light sensitive resin which is hardened by using a white light. Once placed your laminates are very strong and will resist most of the forces placed upon them by a normal diet. Porcelain has great crushing strength but poor tensile strength. Therefore, you should avoid anything that will tend to twist the laminate. Opening pistachio nuts with your teeth, chewing on bones or jelly apples is probably not a good idea. As with most things, common sense should prevail.

Maintenance of Your New Porcelain Veneers:

The maintenance of your Porcelain Laminate Veneer is relatively simple. A few suggestions, however, are in order: Please brush and floss as you normally would to prevent oral hygiene problems. Once placed, Porcelain Laminate Veneers are typically the kindest restoration to the gum tissues that we currently have in our prosthetic armamentarium. Do not be afraid that you will damage your laminates by either flossing or brushing. Any nonabrasive tooth paste is acceptable. A good home care regimen will insure the esthetic success of your laminate restorations for years to come. Some sensitivity to hot and cold may be experienced after the placement of your veneers. This relates to the amount of enamel left on your tooth after preparation, the proximity of the nerve as well as several other factors. Some sensitivity is absolutely normal and usually dissipates after one-two weeks. If this sensitivity should remain or concern you at all, please call our office. As mentioned before, a normal diet should pose no problem at all. Please avoid anything that will tend to bend or twist the laminates.


Dental Implants

What are Dental Implants?: Dental implants are biocompatible metal anchors surgically positioned in the jaw bone underneath the gums to support an artificial crown where natural teeth are missing. They are in no way cemented or connected to remaining teeth like traditional crowns or bridges. Implants are usually made from a metal called titanium, which is readily accepted by the body. Next, the crown is laboratory-fabricated similar to natural tooth supported crowns. Accepted by the American Dental Association, dental implants have been used for many years and hundreds of thousands of them have been placed.

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How does it work?

There is a phenomenon called osseointegration, meaning that titanium is so compatible that bone actually attaches itself to the implant. The advantages include increased stability of dentures while also reducing long-term bone resorption, the ability to restore a missing tooth without altering the teeth on either side of the space.

Who needs Dental Implants?:

Anyone who is missing teeth and can benefit from a better chewing efficiency, and improved appearance or speech, is a candidate for implants. Implants can be the solution when it has become difficult or impossible to wear a removable partial or complete denture. Eligible candidates meet the following criteria: Has enough jaw bone, and dense enough bone, to secure the implants and you do not have a disease or condition that interferes with proper healing post implant surgery (i.e. uncontrolled diabetes, radiation/chemotherapy for treating cancer, or smoking depending on your surgeon’s position on this matter)

What steps must I take in obtaining dental implants?:

First, an examination and medical history review is conducted with us. Your exam may include several types of x-rays to provide essential information about the jaw bones and it’s anatomy, models of your jaws. If we determine that you are a candidate, we will align you with our implant surgeon and work together as a team. Based on the results of each of our examinations, the team will discuss all aspects of your case with you. 

What to expect during surgery?:

Stage I Surgery: Most likely done in a dental office setting, the first procedure involves placing the implant fixtures in the jaw bone under local anesthesia and a mild sedative. The integration to bone will take place as soon as healing progresses, and the implant fixtures should be firmly anchored to bone within four to six months. Some cases will require bone grafting to assure that the implant anchor is completely secured in bone.

Stage II Surgery: After healing is completed, the second stage surgery is completed under local anesthesia.The implants residing under the gums at this point are exposed for access by the surgeon, so we, the restorative dentists, can place a crown on them. This is a minor surgery.  When your gum tissues have completely healed after Stage II surgery, you are ready to visit us and begin construction of your new crown(s). We will make impressions of your mouth, bite registrations of the way your jaws bite together, then the impressions are used to reproduce your jaws/teeth while you are gone. Based on these models, your crowns will be fabricated. It may take as few as two or possibly several appointments depending on the complexity of your case.


Esthetics

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White (Composite) fillings

When most people think of a “filling”, they imagine an item made out of some sort of material, either metal or plastic that is placed directly in a hole in a tooth, carved to resemble the original shape of the tooth, and then allowed to harden inside the hole to restore the form and function of the tooth. Of course, it also must relieve the pain associated with the cavity. In fact, these “direct” restorations, though far and away the most common types due to their lower cost are only one half of the equation.

Another type of restoration, less common due to their much higher cost, are called “indirect” restorations. These “fillings” justify their expense by being more durable (in other words, properly cared for, they should last longer than regular indirect restorations), and also more esthetic (better looking because they are actually built by a laboratory technician on a lab bench without the difficulties imposed by the time constraint and the poor access the dentist faces working in a patient’s mouth).  Indirect fillings, made in a dental laboratory, are known as inlays and onlays.

Indirect fillings used to be more common when gold and ivory were the principal dental materials.  With the advent of porcelain laboratory produced restorations, most dentists today prefer the superior strength and esthetics of “full coverage” of the tooth in the form of crowns or veneers rather than simply filling cavities with laboratory processed gold or porcelain fillings.

The types of direct fillings

There are three major types of direct filling materials; silver amalgam, composite (combination of glass/porcelain particles in a plastic matrix) and temporary filling materials. (There are also three major types of indirect filling material; gold, fused porcelain and composite.) (There is an indirect form of composite which some dentists use.)

Resin Composite fillings (sometimes called “porcelain” fillings)

Composite fillings are what people think of when they say “white fillings” or “porcelain fillings”. We call them tooth colored fillings to distinguish them from amalgam, gold and temporary filling materials. There are a number of different formulations of composite filling, but the type most commonly used today is made of microscopic glass, or porcelain particles of varying shapes and sizes (depending on the intended use) embedded in a matrix of acrylic. The glass particles account for between 60% and 80% of the bulk of these materials, so these restorations could more properly be called porcelain fillings. The glass particles give the composite restoration their color (and their stiffness in the unset state). The acrylic is the plastic matrix that holds the glass particles together. Most composite restorations today are “light cured” which means that the acrylic remains fluid until a very bright light is shined on it causing it to harden. Light curing allows the dentist time to work with the material, building and shaping it correctly, and when ready, to harden it immediately with the light. The light curing also makes for a more color stable restoration. The new tooth colored composite restorations do not get yellow or brown with age as the older ones did. The before and after images of the tooth above are impressive, but do not tell the whole story.  In fact, a tooth that is built in more than 50% restorative material is inherently weak and should be prepared for a crown. This does not mean that all badly damaged teeth should be crowned immediately. In fact the decay in this one was quite deep.  Deep decay places the nerve in jeopardy, so a plain filling may serve as a good intermediate restoration to test whether the nerve will die before a final crown is placed on the tooth. The porcelain particles also give the restoration a great deal of resistance to wear. Amalgam fillings will probably always wear less than composite restorations, however the recent advances in particle formulation and shape have made the newest posterior composites quite competitive for filling back teeth. Five to seven years is average. Composites are even stronger than amalgams in shear strength which makes them better for overlaying large biting areas.

Composite fillings have been used in front teeth for years, but only recently has the technology in composite formulation improved enough to allow their common use in back teeth. Prior to acrylic/glass composites, other types of composites were used in areas where esthetics was important. This is why even in the early twentieth century people were not forced to have silver amalgam fillings in their front teeth. However, even in the 1980’s the technology had not yet advanced enough to allow the routine use of composite to restore chewing areas of the back teeth.

Composite resins are still not as popular with dentists for repairing back teeth as old-fashioned amalgam. In fact, only about 25% of dentists currently use them routinely for restoring posterior teeth.  The reasons for this are that they are not as wear resistant as amalgam restorations, they are more technique sensitive than amalgam, and there is a tendency for more prolonged tooth sensitivity to cold after the restoration is done.  On the other hand, as the materials continue to improve, they have become tougher and more wear resistant while improvements in placement technique have reduced cold sensitivity.  However, the greater difficulty in placing these restorations remains a deterrent for many dentists, and continues to keep the cost of the service higher than for an a comparable amalgam restoration.

Post operative discomfort after  fillings (why they sometimes cause prolonged sensitivity to cold or pressure)

When any type of filling is done on a tooth, some sensitivity to cold and pressure is normal.  This often lasts for as much as a month after the filling is done.  The amount of post operative discomfort associated with any given filling depends on the depth and extent of the cavity preparation which in turn depends upon the depth and extent of the original area of decay or of the old filling which is to be replaced. 

In many instances the living nerve in the tooth is not especially healthy at the time the filling is done, and the trauma caused by removal of the decay or the old filling can push the nerve over the edge causing an irreversible pulpitis (inflammation of the nerve) which will lead to the eventual death of the nerve.  Situations in which the nerve of the tooth remains exquisitely sensitive to cold, or hurts spontaneously without an external stimulus may have a dieing nerve, and the only solution to this problem is either to perform a root canal treatment or extraction on the tooth. 

A second problem that can cause prolonged sensitivity to cold or pressure on a recently filled tooth is hyperocclusion.  This is a technical term that means that the filling is simply too “high” and strikes the opposing teeth with too much force when the patient closes his mouth.  This can cause very severe sensitivity to cold and sensitivity to pressure, especially pressure applied to the side of the tooth. This is a very common problem because the patient is generally numb when the dentist carves the top of the tooth.  The patient may not be closing into his normal bite and the dentist may miss a high spot.  The solution to this problem is to return to the dentist for an occlusal adjustment, which means that the dentist determines what spots on the tooth are high and grinds them down.

Finally, removal of an old filling or decay may reveal a crack in the floor of the cavity preparation. This can lead to cracked tooth syndrome which means that the tooth hurts whenever pressure is applied to one or more cusps (points) of the tooth.  Cracked teeth happen all the time in dentistry, and they are one of our most challenging diagnostic problems.  The sudden appearance of cracked tooth syndrome does not mean that the dentist did something wrong. It is generally due to a pre existing crack which suddenly allowed the tooth segments to spring apart when the old filling was removed, or when the dentist cut a new surface in order to remove decay.  The management and prognosis for cracked teeth is complex and I urge you to read the page I have provided to explain it.

Temporary filling materials

When a patient presents at my office with pain attributable to a cavity, we sometimes place a temporary filling in the tooth and reappoint the patient for a final permanent filling at another visit. Sometimes, this is done in order to save time, especially if we have slipped the emergency patient between two regularly scheduled patients. Sometimes it is done in order to save money.

Temporaries are the least expensive (and most temporary) way to fill a tooth. Temporary fillings can be done quickly, because they are usually inserted without any of the time consuming rituals associated with a permanent filling. The patient is anesthetized, the decay removed and the temporary filling is mixed and inserted, generally simply by pushing it into the cavity preparation with a gloved finger. The patient bites into it while it is still soft in order to adjust the height, and the patient leaves the office without even waiting for a final set on the material. In a phrase, a temporary is “fast and cheap’.

There is another reason that may indicate that a temporary is the best way to treat the patient, even if time or money is not an issue. Temporary fillings are different from permanent amalgam or composite fillings because they are “sedative” fillings. This means that they tend to soothe an inflamed nerve in a tooth, and may make the difference between the tooth needing a root canal (or an extraction), or simply filling the tooth later on, after the nerve has calmed down. Sometimes a temporary filling is the best course to relieve pain.

Temporary fillings are made of two major components: Oil of clove (eugenol), which has been used for centuries to relieve toothaches, and Zinc Oxide which is an excellent disinfectant. The oil and oxide mix together to make a stiff paste that eventually hardens into a waterproof substance which soothes the nerve of the tooth and kills germs while protecting the cavity like a hard band aid. Zinc Oxide and Eugenol is not very durable, and it wears away after just a few weeks, but it works to relieve pain, calm the nerve and protect the tooth until an appointment can be made to get it filled permanently.

Never plan to keep a temporary filling more than 6 months. They are not meant to last that long, and while the eugenol lulls the patient into a false sense of security, the restoration wears rapidly and begins to leak. If you wait too long, the nerve could die, the temporary filling will wear away, the tooth will decay further, and then you will need a root canal or extraction.


Endodontics

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These kind of dental procedures work ‘deep below’: root canal therapy and minor surgery belongs here, all of these are done in order to save a tooth that might soon be beyond repair. With the help of our well trained and experienced dentists, you can be sure that everything possible will be done in order to save your teeth. Up-to-date techniques (electronic apex measuring, endodontic machinery systems) help to reach the best possible result.