I wasn't planning on documenting my tooth extraction and implant, but the images Dr. Ghotanian took and the CAT scan are so awesome that I feel compelled to share. Also, I've gotten appreciative emails about blood clot page, which gets visited even more than my home page. Apparently people either like read the experience of somebody who has gone through a similar procedure to theirs, or they find medical images fascinating.

Warning: Gruesome. Some of the images below are a bit gruesome. If they're not gruesome enough for you, you can click on them to see higher-resolution versions.

Short Version

I had my right front tooth extracted. Now I have an implant around which my bone is healing for the next few months. After that, I'll have a shiny new tooth. [Todo: fill in short version after you have a shiny new tooth]

Long Version

For several years my right front tooth ("crazy number eight") would sometimes ache at the root, and a few years ago I noticed that there was some inflammation of the gum above the tooth (not directly above; a bit higher). My dentist at the time said it was a fistula and said it would be a good idea for me to go someplace else to check it out, but I didn't.

Diagnosis and plan

The fistula manifested itself as a little bubble on the gum above the tooth. When this picture was taken, it wasn't very pronounced; I'd been on antibiotics for a few days.

In this x-ray, you can see that there's some resorption of the root, and some damage to the bone surrounding the root.

More recently when the tooth started bothering me, I went to my current dentist's office to check it out. They said that there was significant resorption of the root and that I would probably have to get the tooth extracted. They also helped me set up an appointment with the endodontist, who would be able to determine whether the tooth could be saved with a root canal. He said that he didn't think he could do it well; if he did a root canal, he figured it would keep getting infected. Instead, he recommended I get the tooth extracted and get an implant to replace it.

Random tangential complaint: communicating with the endodontist was pretty slow, though I did eventually get the important information out of him. He tried to simplify his explanations, despite the fact that (a) I obviously didn't mind medical terminology and wanted more details (he'd say "what you call a 'fistula' older people would call a 'gum boil'" and procede to use "gum boil" exclusively) and (b) his simplification amounted to repeatedly drawing a parallel with other parts of the body, as if nobody without a dental degree could understand the concept of an infection in part of the the mouth. He stabbed the fistula with a toothpick (or something) without warning.

Why extract it if it wasn't bothering me too much? Because the tooth was getting infected, and the infection was eating away at the bone surrounding the root of the tooth. Since that bone is what supports an implant, the likelihood of success of an implant would drop off if I didn't do it soon.

Why an implant instead of a bridge? Every dentist I talked to about this problem would look at my x-rays, and then promptly ask if I'd had some trauma to the tooth. I didn't, as far as I know. But if there was some trauma to the tooth, it may have affected adjacent teeth as well. A bridge would require shaving down the adjacent teeth a bit, and then those teeth would have to bear the load of the missing tooth. If they already had some damage, that would be a bad idea. Anyway, my upper right canine (number 6) is way out of line (see pictures below), so stressing tooth number 7 isn't a good idea.

So I set up an appointment with Dr. Rene Ghotanian to make a plan for what to do. After a quick review, it seemed like the extraction/implant approach was the only reasonable way to go. But to make sure we had a good understanding of the extent of the bone damage and the shape of the fistula, Dr. G asked me to go to a nearby dental imaging place to get a CAT scan (I'm also a "Dr. G", but for the duration of this page, "Dr. G" will refer to Rene Ghotanian). Aside from that, the CAT scan also (a) was really awesome, and (b) showed that my wisdom teeth were really close to my mandibular nerve. This meant that so long as they aren't causing any problems, it's best to leave my wisdom teeth alone, since extracting them risks permanently damaging the nerve. Incidentally, several months earlier, Dr. G had given me the same advice about my wisdom teeth, but without the extra knowledge about their proximity to the mandibular nerve.

Dr. G did an awesome job of explaining everything I wanted to know. I'm sure he goes through the same spiel about extractions and implants quite often, but it's a really good spiel and it's quite engaging.

Ordinarily (e.g. for a molar), the extraction/implant plan would be roughly as follows.

Extract the tooth and do a bone graft (i.e. pack the hole with bits of bone harvested from a cadaver). Then wait about 4 months for the bone to be assimilated.
Drill a hole in the bone and insert the implant. Then wait another 4 months for the bone to grow on the implant. The implant is made so that it has very large surface area, so there's a lot for the bone to grab on to.
Measure the stability of the implant to determine if it can support the abutment and crown. This is done by attaching a "smart peg" to the implant and then magnetically vibrating it; by measuring its resonance frequency (I think), you can tell how well attached to the bone it is.

In my case, Dr. G said that he would do an "atraumatic extraction", some way of extracting the tooth while minimizing damage to the surrounding bone. Then he would drill into the bone and insert the implant immediately, and then do the bone graft. That way, the whole thing should be done in half the time. Since the bone in front of my tooth seemed pretty damaged, he also said he'd lift up the gum to do the extraction/implant/graft, then put a collagen membrane over the graft. I assume this is because it's not desirable to have the bone graft supported directly by the gum.

Dr. G said that they could take a mold of my teeth before hand and have a false tooth that attaches to the roof of my mouth ready the day of the extraction, but he recommended that they do some kind of a mold of the tooth after it had been extracted and have it ready the next day. The idea being that they could do it more accurately that way, and get a better fit.

Big surgery day

My appointment was 9am, Monday July 2. I'd started antibiotics (500mg amoxicillin 3/day for 28 doses) the previous Thursday, and taken an 800mg ibuprofen with some cereal that morning. A couple of people had emergencies (broken crowns, I think), so we got started a bit late.

Instead of the temporary tooth that attaches to the roof of the mouth, Dr. G said he wanted to try a different kind of temporary which is supported by the surrounding teeth. This is supposed to be more comfortable, and since it doesn't touch the gums or the roof of the mouth, it's supposed to interfere less with the healing. So we took a couple of imprints of my upper teeth (good thing too; it turned out that the first mold broke when it was being removed from the imprint.)

The shots of local anesthetic were uncomfortable, similar to what I'd gotten before when I'd get a filling. After I was numb, we got started. Dr. G made a couple of incisions in my gum and lifted it up (I didn't feel any pain).

Extracting the tooth seemed pretty straightforward. It came out after a bit of yanking it around. Dr. G said that the bone was much less damaged than the CAT scan suggested. In particular, I he expected the bit of bone in front of the tooth to come out with the tooth, but it didn't.




Now that the gum is lifted up, you can see the fistula much more clearly.	After the tooth is removed, the little sac of infection is still there! Luckily, the bit of bone just above the tooth didn't break during the extraction.	You can see that the root of the tooth has been eaten up by the infection.

Some of the bone had turned into slimy granulated tissue because of the infection. Dr. G scraped it out with a little serrated spoon tool. This part was uncomfortable; it felt like a more intense version of the pain that led me to get the fistula checked out in the first place. Then he drilled a shallow hole in the bone and inserted a pin. They took a quick x-ray to check that the angle of the hole was correct (it was). He finished drilling the hole (also uncomfortable) and threaded the implant. I was surprised by how thick the implant was ... it was something like 4.5mm thick, and 14mm long. He mostly used a drill tool, but did the last bit of threading of the implant by hand with a torsion wrench (still uncomfortable). He told me that at the end, he needed to apply 25-30 N*cm of torque, which means that the bone is already grabbing on to the implant very well. They actually forgot to do the smart peg measurement, but Dr. G said that given the torque, he was sure it would have registered something like 70 arbitrary units, where 20 is the minimum required to consider the implant a success.


It's pretty cool that you can see the implant through the little window in the bone.

Then he packed in the bone graft around the implant. I was surprised that the bone being added was more yellow than white. He then added the collagen membrane and sutured me up. The anesthetic was wearing off at this point, so I could feel when the sutures were being inserted on the palate side.


Bone packed around the implant.	Collagen membrane.	All sutured up.

Finally, we had to take care of the temporary tooth. Dr. G got a cast of my teeth, as it would be sold in stores. In other words, it was a cast that was encased in clear plastic. The interesting part was the plastic. He cut out the bit corresponding to the nearby teeth. I could snap that over my teeth, except that I was now missing one tooth. In place of that tooth, Dr. G added some composite material. Looks pretty good! He said that I should wear it when I want to look extra pretty, but that it's better to leave it off otherwise.


The picture of me wearing the temporary tooth on the right was actually taken 2 weeks later.

The bill for the day: $3,095. My insurance only covered the extraction, but not the implant, bone graft, or collagen membrane. When I was leaving the office, I was given a gift bag with a neat tea cup and some earl grey tea from Bird Pick (very tasty!). It also had a sweet hand-written note commending me on tolerating a difficult procedure and inviting me to relax. Dr. G's office seems to have pleasant patient interactions down to a science. I even got a follow up phone call from Dr. G the next morning to make sure everything is going okay.

Random observations after surgery

The anesthetic wore off pretty soon after I got home. I kept some ice on my upper lip for half an hour to minimize swelling, and I regularly took the 800mg ibuprofen I'd been proscribed. Surprisingly, I experienced almost no pain or soreness. I was able to get back to doing math over skype the same day. I eased off the ibuprofen, and completely stopped taking it after two days or so, with no negative consequences. I never took any of the Vicodin I'd been proscribed (Dr. G said he didn't expect I would have to).

The sutures proved to be really annoying. I find it difficult to avoid poking at the knots with my tongue, trying to push them out of the way somehow. The result is that my tongue ends up stabbed sore by the little ends, making it more eager than ever to get them out of the way so that they don't bother it. Half the time I've worn the temporary tooth, it was to create a barrier between my tongue and the sutures. The knots that are constantly in contact with the inside of my upper lip are completely unnoticable, though I think they're smaller. It's possible that moving all the knots to the outside could only have happened at the expense of not being able to wear the temporary tooth. If I could travel back in time and be given this option, I would take it.

I thought my saliva had gotten slimier, but I'm now quite sure the slime was being produced by the wound. I'm not sure what role this sliminess served in the healing process. I did notice a definite peak in slime production about a day before I finished the antibiotics (~4 days after the surgery).

Overall, I'm impressed by how quickly stuff in the mouth heals up. I'm writing this 9 days after surgery, and it feels like the gums have just about completely healed (though there's probably a lot that happens after the wound feels better).

2 weeks later. The red marks on the gums are from the scissors used to remove the sutures earlier in the day.

July 12-13 (10 days after surgery) I noticed that the sutures that go under the gums to the palate side have become significantly looser. As far as I can tell, they haven't cut through any gum tissue anywhere, so either the sutures have become longer, or the gums have reduced in size. Either way, the benefit is that the knots are now free enough to move away from my tongue. I did have a bit of pain in the area (probably from playing around with the newly-mobile knots), so I took some ibuprofen. I called Dr. G to ask if it's okay for me to remove the loose sutures myself (yes). He said that the slack came from the fact that the gums grew, moving the insertion points of the sutures.

After 2 weeks, I came in to get the rest of the sutures taken out, and so that Dr. G could check that everything was going well. He said that it looks like I'm healing up beautifully. Now we wait another 3.5 months or so.

Future

This part hasn't happened yet.