At long last, the series of dental procedures to replace my baby tooth have completed.  Last Wednesday, I went in for the final appointment where the dentist set the crown (the artificial tooth) onto the implant. 

About 3 weeks before, I went in to get fitted for the crown.  Unexpectedly, this turned out to be one of the more unpleasant parts of the process.  The main part of this process was taking wax impressions of my teeth that a lab would then be able to manufacture a properly fitting crown.  To do this, they stuck a fairly large wad of the wax impression material into my mouth, had me bite down, and then I had to keep it in place for about 10 minutes or so until it set.

They started off by taking the impression of my upper teeth (the implant is on the bottom).  This was kind of uncomfortable, but not too exceptionally bad.  The worst part was that the wax had a very slight, strangely spicy flavor to it and I found that it kind of burned my lip a bit while it was in place.  While waiting for the impression to set, the staff left me alone in the room and went off to gather supplies and/or tend to other patients.  For some reason, I kind of felt oddly self-conscious during that time.

After the upper impression was completed, they next took a couple X-rays to verify the exact angle and positioning of the implant.  I thought it was interesting, and encouraging, that while reviewing the X-ray, the dentist spontaneously exclaimed that the oral surgeon is “a master”.  Apparently, the implant was very precisely and cleanly positioned, creating a pretty ideal situation for the placement of the crown.

Next, the dentist removed the “healing cap” that had been placed into the implant.  This was actually the first that I had realized that the metal disk-shaped piece that had been in place was actually temporary.  It made a lot of sense, but it was something that I had somehow simply overlooked or misunderstood during the previous appointments.  This cleared up something I had really been wondering about, which was how the crown was going to fit over this disk, which seemed to extend a bit too far past the edge of my other teeth.

Once the healing cap was removed, he placed a fairly large metal piece into the implant that was used as part of the measurement process for the impression of the lower teeth.  I’m not really entirely sure what this actually was, but it was the part that was especially unpleasant.  The reason for this is that the big metal piece prevented me from fully closing my mouth or from putting my teeth together.  This had to remain in place until they completed the impression, which was done in a fairly similar manner to the upper one.

The lower impression was especially rough as it had the same basic problems as the upper one, plus the added discomfort from the metal piece.  At the end of the waiting period while the wax set, the hygienist came in and removed the impression, having to do some maneuvering to pull it out around the metal part that was in the implant.  The dentist then came in and immediately asked her how she got it out without removing the other part first.  He then examined the impression and confirmed that it had been ruined and would have to be redone!  As much as I disliked having to repeat that part of the process, I admit that I actually felt kind of sorry for the hygienist, who both seemed to feel really guilty about the whole thing and also had to endure a pretty strong scolding from the dentist.

Fortunately, for that replacement impression, the dentist came in and removed the impression material himself (after taking out the other instrument) and this one was fine.  The healing cap was put back in after that to keep something in place until the actual crown came back from the lab.  The dentist then pulled out a set of color samples that he matched up to my existing teeth in order to determine the correct shade.  It was actually a tad troubling to discover how yellow my teeth actually are when viewing the color outside my mouth that way, but I guess that comes with age.  The dentist did ask if I had any intention of ever getting my teeth bleached as a factor in deciding whether to go with a somewhat lighter shade.  I decided that wasn’t something I was probably going to ever do, so I went with the exact match.

They told me that it would take about 2 weeks for the crown to come back from the lab and made an appropriate follow-up appointment.  A few days later, they called and told me that the lab had called and said that they would need another week.  Coincidentally, I already had a long-standing appointment scheduled for that week for my six-month cleaning.  They were able to go ahead and schedule me for the appointment slot right after that one to put the crown on.  This worked out well from a scheduling/convenience standpoint, although it resulted in about 2 1/2 hours spent in the dentist’s chair, which is something of an endurance test.

They did the cleaning first, which was very routine, and then moved me to a different examination/procedure room for the crown placement.  The dentist came in and explained that they are usually able to do these without any anesthetic, but he did warn that there can sometimes be some discomfort as the shunt is screwed into the implant.  The reason for this is that the shunt is somewhat thicker than the healing cap, which can cause a bit of pressure due to the compression of the gum tissue.  He said that some anesthetic could be used if I started having enough discomfort to indicate a need, but it never bothered me enough to be necessary.

The process was never especially uncomfortable, but it was fairly time consuming.  The dentist fairly repeatedly had to place the crown on, take various measurements of how the bite lined up, and then remove it and trim it down a bit before trying again.  The measurements were done using small strips of marking paper that would leave guide marks on the crown. The trimming of the crown was done using a dental drill, but thankfully it was all done on the counter and not in my mouth. 

Once he had the sizing correct, he took the crown into another room to polish it up.  I presume this was basically to take away any roughness that was left behind from the trimming process.  He then came in and mixed up some special dental cement that would be used to hold the crown in place.  Once the crown had been cemented in, I then had to bite down on a small Styrofoam cylinder for a few minutes to let the cement harden.  The dentist then gave me a few instructions about how to properly clean the area around the implant/crown and also warned me to be particularly careful during the first 24-hours until the cement fully set.

After about 8 months without a tooth in that spot, having one there again is taking some getting used to.  Initially, I was feeling a bit of pressure against the adjacent teeth and the gums, almost as if I had something stuck between my teeth. That feeling pretty much went away by the next day, probably as the gums and teeth adjusted to having a tooth there again.  The other part that I really have to get used to is that the new tooth is full-sized.  I’ve always had the smaller baby tooth in that spot, so the bigger tooth is a definite change.  Finally, the crown is pretty much completely smooth without the ridges that are typical across the top of a real tooth.  Over the last few days, I’ve had to keep periodically reminding myself that this is normal and doesn’t mean that I have something stuck to my tooth.

The only thing that still is really unresolved at this point is how much all of this is going to cost.  Despite the fact that several months have passed since the implant was done, I still haven’t heard back a final determination of how much the insurance is going to pay and how much I’m going to owe.  It seems that the oral surgeon’s office is being exceptionally patient about that, although I suppose that they are probably used to this process taking a long time.  After the crown was put on, the dentist indicated that they were still waiting for a response from the insurance company on that work as well and that they would bill me once they new the correct amount.

Obviously, this has been a pretty long and difficult ordeal, but I do think I am way better off with this implant than I would have been going with something more routine like a bridge.  Aesthetically, the implant and crown looks pretty much just like a real tooth and, once I get used to the few quirks, I think it will pretty much feel like one as well.

I am way past due in getting around to writing the next part of this story.  As you might recall from the first 2 parts, I had one baby tooth that I had never lost as a child due to the permanent tooth never coming in.  Back in April, the tooth started bothering me and the dentist informed me that it was going to have to come out.  I had it extracted in early-May.

On August 22, I had oral surgery to put in a dental implant, the first part of the process of replacing the lost tooth with an artificial one.  This was the most invasive, and only surgical, part of the procedure.  The surgery involved the insertion of a titanium artificial root into the jawbone through an incision at the gap where the extracted tooth used to be.  Once the surgery has fully healed and the oral surgeon confirms that the bone has fused appropriately with the implant, my regular dentist will be able to affix a crown to the root, completing the process of replacing the lost tooth.

After I had the tooth extracted in late May, I had to wait a minimum of 6 or 7 weeks to allow it to fully heal before proceeding with the implant.  That timing pretty much ran right into a vacation that we had planned for the end of June as well as the July 4th holiday, so I ended up deciding to just put up with the gap in my teeth for a bit longer.  I finally contacted the oral surgeon’s office and set up an appointment for a consultation at the end of May.

The oral surgeon that I went to specializes in implant procedures.  I think that might be the only thing he does, although I’m not entirely certain.  Dental implants are expensive and generally considered by insurance companies to be an "elective" procedure (more on that later), so there actually was kind of a salesmanship element to the consultation.  I even felt a bit like I had been to a luxury dental office, with such amenities as bottled water offered while waiting for the dentist and even sunglasses provided during the exam to shade by eyes from the examination light.

After the examination, the oral surgeon told me that I was a good candidate for the procedure and spent a little time going over the procedure in more detail.  One key topic that he brought up in this discussion was the available options for anesthesia for the surgery.  He indicated that general anesthesia wasn’t usually needed for this (I’m not entirely sure, but I don’t think he even offers that as an option), but he did pretty strongly recommend the use of an oral sedative during the surgery in order to help me to relax and also to help to avoid movement during the procedure.

I then met briefly with a member of the office staff who went over some of the financial details of the procedure with me.  She indicated a cost of a little over $2000 for the implant.  Many dental insurance plans apparently do not cover implants, considering them to be fully optional, cosmetic procedures, even though they are now widely considered to keep the gums/jawbone much stronger and are also longer lasting than dental bridges.  Fortunately, my insurance does cover about 50% of the cost, although apparently it is 50% of what the insurance company thinks the cost should be rather than 50% of what the oral surgeon actually charges (and the patient has to make up the difference).  There are also annual maximums that come into play.  As of the time that I’m writing this, my insurance company still hasn’t finished processing the claim and I don’t yet know how much they will cover.

After the financial discussion, we then scheduled the appointment for the procedure.  I decided that I wanted to have it done on a Friday, which would then give me a couple days to recover without having to take more than one day off from work.  We initially scheduled an appointment for the next Friday after the consultation, but they called the next day and let me know that the office staff had incorrectly recorded the itinerary for an upcoming vacation the oral surgeon was taking and would have to push it back a couple weeks.  The August 22 appointment was the next available Friday.  I wasn’t entirely thrilled that the only time available was 7:30am, but I still took the appointment since the only alternatives were to either switch to another day of the week or put the procedure off for almost another month.

A few days before the procedure, the oral surgeon called in four prescriptions to my pharmacy.  These were the sedative (triazolam), a strong pain reliever (Hydrocodone), a prescription-strength version of Ibuprofen, and an antiseptic mouth rinse (which tasted awful…) that I was to use twice a day for the next two weeks.  The Hydrocodone was intended for use as needed during the first couple days after the procedure while the Ibuprofen was to be taken on a regular schedule for the first several days to help reduce inflammation.  I was generally impressed that they called in all the prescriptions ahead of time, preventing the need to get them filled in the time shortly after the surgery.  Of course, the prescription for the sedative had to be filled ahead of time, so it was pretty obvious to take care of the others at the same time.

On the morning of the procedure, I was supposed to take the sedative approximately one hour before the appointment time.  With morning rush hour, that was roughly the amount of time we thought it was best to allow to get there, so I took the pills right before leaving home.  As you might expect, I wasn’t allowed to drive because of the sedative, so my wife took me to the appointment.  During the drive over there, I really didn’t notice that the sedative was affecting me at all, which surprised me a bit.  I did know it was working as soon as I tried to get out of the car, though.  I basically couldn’t stand up on my own power and I ended up having to pretty much hang on to my wife’s arm in order to make it into the dentist’s office.

I don’t actually remember very much of the procedure itself. I have some very vague recollections, mostly of the early steps, such as the injection for numbing the area. I don’t know if I actually fell asleep, but I certainly wasn’t very aware. I recall being surprised at how quickly it went and then more surprised when my wife told me the procedure took over an hour.  I also have pretty much no memory of the drive home, so that further indicates how out of it I was.  I do vaguely remember them going over the care instructions with me after the surgery, but was so out of it that the information didn’t sink in.  In fact, I finally got around to reading through the instruction sheet the next day and realized that I hadn’t really done a very good job of following them, particularly when it came to the procedures for cleaning the teeth on that side and such.

After arriving home, I promptly went up to the bedroom and fell asleep for a couple hours.  There really was no bleeding at all (unlike my experience after the extraction) and the anesthetic had me numb enough that I wasn’t in any pain.  I did take doses of the pain medication before falling asleep in order to help head off pain as the anesthetic wore off. 

A couple hours later, my wife came upstairs to let me know that she was going to head out to Wendy’s to get lunch for her and our son.  She mainly wanted to check to see if I wanted her to bring me back a Frosty, figuring the ice cream would feel good after the dental procedure.  She was pretty surprised when my answer was “yes”, but I then added “and also bring me a bacon cheeseburger”.  At that point, I still wasn’t feeling any pain, but I had managed to work up a pretty big appetite.  I did have to cut up the burger into small bite-sized pieces, but I otherwise had no trouble eating it and, in fact, I was so hungry that I almost inhaled it.

I never really had any serious pain from the surgery, although I think a lot of that was thanks to the fairly strong medication that was provided.  The dentist’s office pretty strongly encouraged me to be proactive with the pain medication, at least for the first couple days in order to minimize any discomfort.  For this reason, I took the Hydrocodone at the minimum intervals throughout the weekend, although I did switch to only using it at night once I went back to work on Monday.  I did have some occasional aching in the jaw, but that never became too awfully bad. 

The stitches were really the biggest source of post-surgery discomfort.  For one thing, they had essentially thread them between some of the adjoining teeth in order to hold them in place and that did irritate the gums quite a bit.  I also had a really hard time keeping my tongue off of the stitches and the looser strings became pretty stiff.  I went back to the office to have the stitches removed on the Wednesday after the surgery (5 days after) and that was definitely a big relief.

I don’t think I’ve really said much about the implant itself.  With the crown not having yet been attached, it feels very much like I have a big metal screw in the gap where the tooth used to be.  The surface of the implant is a flat, circular piece of metal with a threaded hole in the middle.  The last part of the process will be the placement into that threaded hole of a metal shaft to which a crown will be cemented.  This part will be completed by my regular dentist.

At about the 8 week mark after the procedure, I had a follow-up appointment with the oral surgeon.  At this appointment, an X-ray was taken to confirm that the implant is properly placed and that the bone has healed correctly around it.  He also used an instrument to verify the strength of the implant and that it will properly hold the shaft/crown.  All that checked out, so I am now clear to schedule the appointment for what will hopefully be the final part of this story.

The tooth is gone now. Rather than simply pulling it, as I had expected, the dentist ended up essentially pulverizing it last Wednesday afternoon. Apparently, it wasn’t as easy a tooth to remove as had been hoped or expected.

As a bit of a preface, this ended up being my family’s week for unpleasant dental procedures. My wife had learned a couple months ago that she needed to have her wisdom teeth removed and, coincidentally, that was scheduled for last Saturday, just 4 days before the extraction of my baby tooth. Since she only had two wisdom teeth that needed to come in (the lower ones never came in), she decided to have the procedure done with just local anesthetic instead of being put to sleep for it. When she got there, the oral surgeon immediately asked her if she wanted to re-consider that, which obviously wasn’t a good sign. She decided to go through with it, though, and when she came out she immediately told me it was one of the most miserably painful experiences she remembered.

Since my baby tooth extraction was scheduled to be done only using a local, her experience obviously made me very nervous. I even called the dentist’s office on Monday and asked them to advise on what I should do. They still recommended sticking with the local and essentially said that this should be a much easier experience. When I had my own wisdom teeth out around 12 years ago, one of them was removed using only a local (it was something of an emergency as it had become infected) and the other two were removed while I used a combination of laughing gas and valium. I didn’t remember either procedure being overwhelmingly bad, so I decided to stick with the original plan this time as well.

The first thing that the dentist told me on Wednesday was that he was going to use a lot of the local anesthetic and that I shouldn’t really feel anything at all during the extraction. To his credit, this turned out to be pretty much accurate, even when the extraction did turn out to be a bit more difficult than expected. The amount of anesthetic used was by far the most I ever remember receiving for a dental procedure, with the dentist even having to stop to refill the dispenser at one point. He applied it at several different locations in my mouth and I was overall pretty thoroughly numb. My dentist has an excellent bedside manner and pretty regularly double checked during the procedure to make sure that I was ok and not feeling any pain.

Initially, the dentist tried to just pretty directly pull the tooth out. He loosened it a bit using a sharp tool and then used the “wiggle and pull” technique (as my wife called it last weekend) to try and get the tooth out. While the anesthetic kept it from really hurting, this was a bit unpleasant as it involved quite a it of pressure and I could even feel and hear some popping as it was pulling loose. The tooth just wouldn’t let go, though, and he couldn’t get it to come out that way. At that point, he switched over to the dental drill, which he used to essentially break the tooth apart. At one point, a chunk of the tooth even flew out and hit the assisting hygienist in the face. Fortunately, she was wearing a face mask so it didn’t cause any damage.

He explained to me that the tooth was angled towards the bone, which had caused the root to be somewhat fused into place. That was why it required quite a bit of extra effort to get it out. After it was all out, the dentist had an X-ray taken to ensure that there weren’t any fragments left in. This may actually have been the most difficult part of the procedure as I found it very difficult to bite down on the mouthpiece when I was both numb and generally irritated from the procedure. They had to try a couple times before I was able to suppress the gag instinct enough to get the picture taken. Fortunately, it did show that the tooth was fully removed at that point.

I didn’t try to go back to work after the extraction on Wednesday and, instead, ended up sleeping through a lot of the afternoon. The numbness didn’t really start to wear off until late in the day, so I didn’t have much discomfort then. The biggest problem was that I was supposed to bite down on gauze until bleeding fully stopped, but I did quit a bit before that as it was really causing me to gag. Fortunately, the clot still seemed to form ok despite that. I have had a fair amount of soreness in both my jaw and in the gums around where the tooth was, although I’ve been able to control it with Advil and haven’t had to fill the pain medication prescription the dentist gave me. I’m writing this on Saturday (3 days after the extraction) and I’m still a bit sore today.

One of the tougher problems this week has been trying to come up with things to eat that are sufficiently soft and easy to eat. Wednesday evening, my wife went over to the grocery store and picked up some deli roast beef and chicken, which I was able to eat pretty easily, but not in a sandwich. For that first night, the instructions I was given said not to eat anything hot, so that is why cold cuts were an obvious choice. At lunch on Thursday, I tried getting a burger and fries from McDonalds and those did end up being a bit tough to eat. Looking for something softer, we ended up fixing scrambled eggs and toaster waffles for dinner that night. Yesterday, I decided to go over and try a new Yoshinoya (a fast food chain featuring Japanese food) that had opened near my office and the beef bowl with rice turned out to be pretty easy to eat. Last night, I ended up getting French Toast at Denny’s for dinner and I had soup for lunch this afternoon. I think I’m getting to the point where I hopefully can start eating somewhat more solid food, though, which is good since we have reservations for a Mother’s Day brunch buffet tomorrow.

At the end of the appointment on Wednesday, they gave me the formal referral to the oral surgeon for getting the implant. The dentist said that I need to wait 4-6 weeks for the extraction to fully heal before the implant can be done. I actually have a vacation scheduled in about 6 weeks, so I don’t know if I will end up having to delay the procedure until after that. I likely will call next week and at least set up the initial consultation on it. I do hope that the big gap in my teeth doesn’t drive me completely nuts between now and the time that I get the implant in place. At least it is far enough back that it isn’t visible.

When I was a child, a routine dental exam revealed that one of my baby teeth did not show any signs of a permanent tooth growing beneath it.  The dentist explained that without a permanent tooth coming in, I would not lose the baby tooth in the normal manner and that the baby tooth would hopefully last for a pretty long time.  On the other hand, he did acknowledge that baby teeth obviously aren’t intended to last a lifetime and that, sooner-or-later, it would begin to break down and have to be removed.  This was back in the late 1970s.  Over the subsequent years, I’ve had two different fillings put in the tooth in order to help strengthen it but, otherwise, it has largely served as an odd conversation piece during visits to new dentists.

A few weeks ago, I started to notice that the area around that tooth was becoming sensitive.  Touching the jaw-line around the location of that tooth causes a jolt of pain, focused around the spot where the baby tooth meets the gum.  It hasn’t yet given me any kind of continuous pain and, usually, it hasn’t really been too much of a problem while eating. I was obviously concerned that the discomfort was an indication that the tooth was failing and put off a visit to the dentist for a few weeks on the faint hope that the problem would just go away.  Earlier this week, I finally decided that it wasn’t going to clear up (and it was also getting a bit worse), so Thursday I did go to see the dentist.

The dentist did confirm what I was afraid of.  The tooth is finally breaking down and now will need to come out.  His recommendation is to replace it with an implant, which is an artificial root that is put in by an oral surgeon and then can be used as the support for a crown.  The implant is a titanium rod that the oral surgeon basically screws into the jawbone through an incision made in the gum.  I hope that is more fun than it sounds but I somehow doubt that it will be.  On the positive side, the dentist assured me that the use of a crown with the implant is pretty much indistinguishable from a real tooth in look, feeling, and function.

At Thursday’s appointment, they took an X-ray and the dentist did a short exam to confirm the problem.  They then took a huge number of photos.  I find it interesting how much high-tech digital technology is now involved in dentistry.  They now have monitors at the dental chairs and all the photos and X-rays are immediately transferred to a computer (running Windows XP…) and displayed right away.  At the beginning of the appointment, the hygienist took several digital photos of the tooth in addition to the X-ray.  They have a tiny digital camera at the end of a wand (similar to the electric toothbrushes they use for cleanings) making it easy to take the close-up photos.  For some reason, I found it really funny that every time she took a photo, an old-fashioned camera shutter sound played loudly from the computer behind me.

After the diagnosis and determination that an implant was going to be needed, the dentist then took a whole bunch of photos of my teeth using a Nikon digital SLR camera.  The camera had a very large, presumably specialized lens that was also fitted with a number of lights, which I would imagine were needed to get anything recognizable in the photos.  Presumably this was intended to fully document my mouth to help with getting the right sizing and coloring of the implant and crown.  The whole thing felt rather weird, though.  I’m not an extraordinarily comfortable photographic subject under good conditions, so it felt really strange having someone snap all these close-ups of my mouth, often with a metal instrument (the doctor called it a "lip retractor") holding my mouth wide opened.

Finally, to better inform me on the implant, they showed me a short video about it.  This was obviously produced by the manufacturer and was hosted by a doctor who was apparently one of the designers of the procedure.  The whole thing was kind of cheesy and I was a bit amused how he kept explaining all the potential side effects or complications with statements to the effect of "we are ethically obligated to inform you of this, but it very rarely ever happens." Fortunately, it did sound like most of the risks were pretty minor and included the typical "risk of infection" that is there with any surgical procedure as well as potential impacts to bite, speech, appearance, etc. any of which could easily be corrected.

The video also went over the alternative treatments that were available.  Ever since I first learned about this tooth, I remember being told that eventually a "bridge" would be needed to replace the tooth.  Doing a little research online, I found that implants started becoming generally available in the early 1980s (not that long after I first found out about my tooth), but I suspect that they have probably become much more common and routine in recent years.  A bridge is a much more destructive approach where the dentist files down the teeth on either side of the gap and then fits crowns over both.  The artificial tooth is then attached to and anchored in place by those two crowns.  Obviously, the big disadvantage of this is that it requires otherwise perfectly good teeth to be damaged and crowned.  The implant process leaves the other teeth alone.

The next step of this process will be the extraction of the baby tooth, which is scheduled for Wednesday, May 7th.  They mentioned that they would call me if an appointment opens up that would allow it to be done sooner, but I admit that I’m not in that big a rush.  I’m sure I’d be more anxious if I were in more continuous pain, but right now I simply find this to be something I dread more than welcome.  I know I need to get it done, though.

In addition to doing the extraction at the May 7th appointment, the doctor said that they would take the necessary measurements and impressions to prepare for the implant procedure.  They also will give me all the remaining information that I need at that appointment to get the surgery scheduled.  I’m not sure how long it will end up being between the two procedures.  Fortunately, the tooth is towards the back, so I shouldn’t look too much like a clumsy hockey player during that time.

Look for the next installment of this story shortly after May 7th!