The Troublesome Tooth - Boulder Implant Dentistry

The Troublesome Tooth

As a child, Barbara had had a root canal done on her upper right front tooth, tooth #8. Over the years, Barbara had several dental crowns on that tooth but never really liked how they looked. For 45 years, the tooth did not cause any pain until one day she began having pain and pressure especially when chewing. This is when she first sought treatment from Dr. Adler. Based upon the exam, x-rays, and prior history of a root canal, Dr. Adler recommended that Barbara have an apicoectomy.

Dr. Adler's Patient Excited with Her New Smile:



An apicoectomy is usually performed after a tooth has had at least one root canal but continues to develop infections. Root canals are very complex, with many small branches off the main canal. Sometimes, even after root canal treatment, infected debris can remain in those branches and possibly prevent healing or cause re-infection later. During Barbara’s apicoectomy, the root tip was accessed directly through the bone instead of up through the tooth as in a root canal treatment. The root tip, or apex, was removed along with the infected tissue. A filling was then placed to seal the end of the root and a suture is placed to close the access opening. In order to stabilize the tooth, Barbara then had an all porcelain crown and carbon fiber post placed.

For a year after the apicoectomy, the tooth was symptom free but unfortunately the tooth became infected again forming an abscess. A tooth or root abscess is pus enclosed in the tissue of the jaw bone at the tip of an infected tooth that usually originates from a bacterial infection that has accumulated in the soft pulp of the tooth. If left untreated, an abscess can continue to grow and may become large enough to perforate bone and extend into the soft tissue. It will continue to follow the path of least resistance and spread either internally or externally which can lead to severe complications. Dr. Adler performed another apicoectomy in an effort to save the tooth hoping that it was another root tip infection. During the procedure, Dr. Adler saw a fracture in the tooth that extending from tip to crown and it was determined that the tooth could not be saved due to the vertical root fracture.

Patient After Extraction of the Infected Tooth:



Dental Patient After Tooth Extraction is Fully Healed:



The tooth was extracted and a bone graft, allograft, was placed by Dr. Cheri Brown to help replace the bone that had been lost due to the abscess. Dr. Cheri Brown, a Boulder Colorado periodontist, works with Dr. Adler at Adler Cosmetic & Family Dentistry. A removable temporary partial, custom made prior to the appointment, was fitted so that Barbara was able to leave the office without a gap in her smile while she continued to heal. While the graft was healing, Dr. Adler was able to perform guided tissue recontouring. Guided tissue recontouring reshapes the gum around the tooth giving a more aesthetic look. This was done for Barbara by slowing adding material to tooth on the temporary partial where it presses against the gum line. Overtime the tissue is gently formed into the desired shape to better match the other teeth.

Dentistry Patient's Dental Implant as it is Healing:



Once the graft had healed and become stable, Dr. Brown placed the titanium implant. The implant was placed during a surgical procedure, directly into the jawbone and under the gums. The implant with a healing cap attached was then allowed to heal for four to six months so that the bone will grow around the implant and "osseo-integrate". Dr. Brown later placed a soft tissue graft because Barbara needed more connective tissue to support the implant. After six months of healing, Dr. Adler placed a zirconium implant post, also known as an abutment, that connected to the implant. The post was made of zirconium to allow for ideal translucency once the all porcelain crown was place about a month later. So today, Barbara is no longer bothered by that troublesome tooth and she looks great.

Dr. Adler's Patient Excited with Her New Smile:





For more infomation about dental restorations contact Boulder dentist Dr. Michael Adler, DDS.

Cracked Tooth Syndrome: The Hidden Fracture

You are having frequent but sometimes intermittent pain, discomfort, and sensitivity in your tooth. The cause of the pain is not visible to the naked eye and does not show up on the dental x-rays. You are beginning to wonder if the pain is all in your head until the doctor tells you that you have cracked tooth syndrome.

Illustration of the Progression of a Cracked Tooth:


Cracked tooth syndrome describes the recurring pain, discomfort, and/or sensitivity that is caused by an incomplete fracture or crack in a tooth. The fracture involved is often difficult to detect and may be completely invisible to the naked eye and may not appear on dental x-rays. A cracked tooth can be caused several different ways. Clenching and grinding teeth can weaken them causing fractures. Teeth that have undergone root canal treatment and are not restored after treatment with large fillings can cause your teeth to lose strength, making them brittle. Every day your teeth endure a tremendous amount of pressure from biting and chewing, so if you bite down on something hard like a popcorn kernel, the force can cause the tooth to fracture, especially if it is weakened.

Treatment of a fractured tooth usually depends on the location of the fracture as well as the extent of the damage. If only the outer enamel is cracked then we remove the affected portion and restore the tooth with a crown or onlay to stabilize it and protect it from further damage. If the crack extends into the underlying dentin or pulp layers then more extensive treatment may be required, such as a root canal, before a final restoration can be placed to stabilize the tooth. In some rare instances, a crack will extend all the way through the tooth and under the bone. In these extreme cases, there is no way to restore the tooth and we have no other option but to extract it. Fortunately, most cracked teeth can be saved. The key is early detection and appropriate treatment. Since diagnosis is often based on patient symptoms, it is very important to tell your dentist of any pain or discomfort you have been experiencing as soon as you have it.

Cracked Tooth as the Fracture is Uncovered:


Dr. Craig Beyer a Boulder lasik eye surgeon of the Beyer Laser Center is a good example of a those rare cases where a fracture extends through the tooth. Dr. Beyer came to Dr. Adler complaining of that he was having pain when he was biting down. Based upon the symptoms Dr. Beyer described, photographs, and x-rays, Dr. Adler determined that Dr. Beyer had a fractured tooth and recommended a crown. The tooth was prepped and fitted with an all porcelain Cerec crown. The fracture became even more apparent once the tooth had been prepped for the crown and had decay indicator placed on the tooth. Decay indicator is a dye that helps make decay more visible, it can also be used to see tooth fractures because the dye will run along the crack. Interoral pictures allow the doctor to get an up-close look at the teeth allowing him to see cracks that might otherwise be missed. If the fracture had been an oblique fracture, extending into the enamel or dentin but not the pulp layers, as was first assumed then the crown would have solved the problem. Unfortunately, Dr. Beyer continued to have symptoms of pain. Dr. Adler then performed a root canal believing that the fracture extended into the pulp of the tooth. During the root canal procedure, Dr. Adler saw that fractured propagated through the tooth and that the root canal would not be sufficient treatment to save the tooth. Since the fracture extended through the tooth splitting it, the tooth could not be saved and had to be extracted and replaced with a titanium implant.

Bill is a common example of cracked tooth syndrome. Bill had been having sensitivity with a tooth on his upper left side for about one year whenever he would bite down but didn’t think much of it since it only hurt when he bit down and wasn’t a constant pain. After mentioning to the dental hygienist at his cleaning that he was having this continuous problem, the doctor diagnosed a fracture in the tooth. An old filling was removed from the tooth and a decay indicator was placed on the tooth in order to see the extent of the fracture. The decay indicator along with the interoral pictures allowed Dr. Adler to see that the fracture, an oblique fracture, extended across and into the tooth but had probably not yet entered the pulp chamber. Dr. Adler placed an all porcelain Cerec crown on the tooth to stabilize and to help prevent the fracture from propagating further through the tooth. The crown also kept the fracture from expanding and contracting which can increase the pain or sensitivity that a patient experiences. Since the crown was placed, Bill has been symptom free.


Cracked Tooth Once Fracture is Fully Uncovered:


For more information contact Boulder Dentist, Dr. Michael Adler, DDS by visiting his website or calling 303-449-1119.

Complete Cosmetic Dentistry Makeover - Case Study

Sarah came to our office in need of a complete mouth makeover. She was having muscle spasms on her right side, felt like her bite was off, and had TMJ pain. In addition, she was complaining of jaw pain and pain when chewing. Sarah was concerned about having healthy teeth and gums and a comfortable bite.

Dr. Adler saw that Sarah had several problems that needed to be addressed. Her upper arch had crowding, wear, and large silver fillings that needed to be replaced to avoid fracturing the teeth. Her lower arch had cavities, wear, and crowding. She also had alignment issues, variations in gum height and tooth shade, a deep bite, and her midline was off center. The wear, deep bite, alignment issues, and off center midline concerned Dr. Adler because these along with her symptoms of neck and jaw pain are often signs of TMD (temporal mandibular disorder).

Before Pictures:





Just as house needs a level foundation, your mouth also needs a level foundation called the plane of occlusion to work properly. When the plane of occlusion is properly aligned with the forces of occlusion (your bite force) then the forces are evenly transferred through the maxilla (upper jaw) to the rest of the cranial bones of the skull. If this alignment is off, then the force is not evenly distributed and can cause muscle strain, headaches, and the body becomes unhealthy due to the constant stress. If muscles must strain to get your teeth together you set up a muscle vs. tooth war in your mouth. If your muscles win, you have rapid tooth wear. If your teeth win, you have muscle tension and stress along with headaches and other TMD problems, or worse you will experience a combination of both. Sarah showed a combination of both wear and jaw pain with headaches.

Sarah’s treatment began by doing a K7 evaluation. This involves taking diagnostic cast so we have an accurate model of her mouth and bite. The K7 produces scans that measure the muscles, range of motion, and joint noise among other things. EMG or electromyography measures the muscles at rest and during function-clench. CMS (computerized mandibular scan) measures joint function, habitual freeway space, swallowing, and range of motion. Sonography measures joint sounds. TENS or Transcutaneous Neural Stimulation relaxes the muscles in the face and neck to find their true resting state and establish the occlusion at that position. Material is then placed in the patient’s mouth to capture that ideal position, known as the bite registration. Sarah’s scans showed dramatic improvement when preformed with the bite in place. The bite registration was used in Dr. Adler’s study of her bite and was used by the laboratory to fabricate a fixed orthotic that was bonded to her lower teeth to establish that ideal position. The orthotic was worn and adjusted for several months and gave Sarah a good trial run for how her bite would feel after permanent restoration was completed. The orthotic temporarily alleviated pain symptoms associated with TMD and ensured that her neuromuscular occlusion was correct before undergoing more advanced treatment.

Fixed Appliance Photo:



Sarah underwent a very dramatic change the day she came in and had all of her teeth prepared for restoration. Every tooth was fitted for all porcelain crowns. The procedure was completed in a single day, thereby reducing the number of visits the patient needed to make and insuring the correct bite. Due to the extensive nature of the case, the crowns were sent to a lab for fabrication. The lab is then able to custom craft the entire mouth instead of trying to piece together and match the teeth had they been done separately over a period of time. The lab will insure that her smile is not only aesthetically beautiful but also functional and in the proper bite. Although Sarah will not have her final restorations for a few more weeks, even just her temporaries show the remarkable change that she has undergone.

After Temps Photo:



Stay tuned for postings and pictures of Sarah’s astonishing smile makeover.