Silicon Valley Surgical Arts, Inc. & San Francisco

Effects of E-cigarettes and progression long-term smoking

In the dental implant world we know that smoking is detrimental to the success rates of implants.  Some go as far as not placing implants in active smokers.  Well, now we have to contend with e-cigarettes.  Some of the early research on E-cigarettes is showing that even this once thought “benign” habit is actually more detrimental to our health.

If you have any teenager that use E-cigarettes, please have them quit NOW!  Otherwise you may be looking at a long-term smoker when they become older.

See the research below.   This was one of the top 10 articles in JAMA (Journal of the American Medical Association) in 2016.


Bone Grafting…Whaaaaaat?



Everyday, we have patients that question the need for bone grafting.  So what is bone grafting and why is it necessary?  The main goal of bone grafting an extraction site, its to converse the architecture of the jaw bone and the soft-tissue aka “gums or gingiva” that covers it.  There are numerous studies that show, when a tooth is extracted without bone grafting there is an natural loss of the bone, leading to what we surgeons refers to as a “bony defect”.  As expected, when “the bone goes, so does the soft-tissue”, meaning that when the bone is lost, so is the soft-tissue that is supported by the underlying bone.  The bone loss and the subsequent change in the soft tissue can lead to a bony defect that can prevent a patient from replacing the missing tooth with an implant.  We typically see bony defects when the tooth is extracted without bone grafting, which is the reason why it is highly recommended to have bone grafting at the time of extraction in order to conserve as much bone as possible.  (DO NOT let anyone extract your toothin the esthetic zone without bone grafting).  Bone grafting will only help to support the over-lying soft-tissue and reduce the chance of have a bony defect.  The following case demonstrates this phenomenon.

This is a 32 years old gentleman that was referred to us for an emergency extraction of an infected tooth #7.

With arrow

He had previously had facial trauma as a teenager, when lead to the “tooth dying”, meaning that the root canal or the internal portion of the tooth died – forcing the patient to have a root canal as a teenager.  Fast forward…two decades later, the root canal failed leading to a major infection in his jaw bone – See X-ray.Preop PA 3-11-2016

The endodontist attempted to retreat the root canal but in the process discovered that the root portion of the tooth was fractured and that it could not be saved.  Extraction was recommended.  We obtained a CBCT to see if there was any possibility of placing an “immediate implant”, which means extraction and a placement of an implant in the same visit.  Unfortunately, as you can see below, even with the longest 18mm implant there was not enough bone at the depth of the extraction site to obtain primary stability of the implant.



Hence we had to do this case in two separate surgeries / stages: Stage I. Extraction + bone grafting.  Stage II. Return 4-6 month later for guided implant placement using a surgical guide with a prefabricated temporary crown.

Prior to the extraction of the tooth we have the patient’s general dentist fabricate an “Essix” retainer, which is one of two types of retainer to replace missing teeth.  This retainer in particular is best since it is off the soft tissue and extraction site and does not apply pressure on the soft tissue.  This retainer is best for the immediate postop period as the soft tissue is healing which is about 6-8 weeks.  After the soft tissue is healed the patient can wear a traditional “Stay-plate”, which rests on the soft-tissue underneath.

Essix Retainer




Hence, we extracted the tooth atraumatically with periotomes, then performed a bone grafting procedure to prepare the site for eventual implant placement.  See the photos below

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4 weeks later :

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10 weeks later:

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Now the site is ready for guided implant placement with a prefabricated temporary crown using the Anatomage surgical guide.  More to come on this case….stay tuned!

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How to avoid getting a dental implant?

One simple answer: Fluoride.

Below is an informational sheet on water Fluoridation and how it has been one of the more successful public health measures since 1945,



Dr. Massoomi at the Anatomage Users group mtg 2016 in San Francisco


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What does it mean to guide?  Does your surgeon “guide” your surgeries?  Please make sure to ask your surgeon how do they do their implants, do they have a surgical guide?  Is their treatment plan based on 3D CBCT imaging.

Check out what Anatomage has been doing for the past few year.  Dr. Massoomi was one  of the featured speaker on this new technology at the 2016 User Group Meeting.  He has helped them develop some the latest approached in oral surgery in order to improve patient outcomes.


BMP is better in alveolar ridge augmentation then sinus floor augmentation



In a recent article in the JOMS (J Oral & Maxillofacial Surgery 74:928-939, 2016) Dr. Kelly and their team performed a Meta analysis of articles from 1980 -2014 and discovered that recombinant human bone morphogenic protein-2 (rhBMP-2) is much better at increasing bone height in alveolar ridge augmentation, then in sinus floor augmentation procedures.

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A case for Fixed hybrid prosthesis vs. the removable overdenture

A recent study published in the journal “Clinical Oral Implant Research” gives more weight to a fixed hybrid prosthesis (typically supported by a minimum of 4 implants) vs. the traditional removable overdenture (supported by 2 implants only).  According to Kremer et al  in an article titled “Mandibular bone resorption pattern with implant overdentures”, they show that despite having an overdenture, resorption still continues to occur in the posterior mandible due to a lack of dental implant.

Below is a schematic of what happens to the jaw bone in the mandible when you compare a full lower denture versus an overdenture.  This lends more evidence to the benefits of a fixed hybrid prosthesis that is supported by more implants, even in the posterior mandible, resulting in bone preservation due to stimulation of the bone by the dental implants.

Resorption differnces between full denture versus implant overdenture

Below are panorex x-rays of:

1.) patient with two implant and wears a removable overdenture

Dr Massoomi overdenture with Markings

2.) Hybrid prosthesis supported by 5 implants and stays “fixed” to the jaw and does not need to be removed.

Dr Massoomi All on 5 fixed hybrid


Mini Implants anyone?


Dr Massoomi 3i MDI Mini Dental implants

Every wonder why we have never placed mini dental implants in our practice OR why have we stopped teaching the use of these implants at the University of Pacific Dental school a few years ego?

Well, as of March 1, 2016; this product has been discontinued.

3M letter on ESPE MDI mini dental implant discontinuation 3-1-2016

Obviously, these mini-implants are cheaper; so when I have patients that request us to place these implants due to financial reason, I always ask: “Why place these mini implants when there are perfectly good, traditional implants that have decades of data behind them?”  These mini-implants have been shown to have problems, such as fracturing during use.  The most common reason I see patients with these implants are for the removal of these broken mini-implants…creating more damage to the jaw bone.

We stick to the traditional implants.

Avoid the mini-implants.

Open contacts adjacent to dental implant restorations?

Open contacts adjacent to restored implants, as early as 3 months post restoration?  How is this possible.

Dr Massoomi open contact

In the most recent edition of the JADA, Dr. Gary Greenstein and his team, examined 5 studies in which the investigators looked the incidence of open contacts after implant restorations are inserted next to a natural tooth.

Results:  An interproximal gap developed 34% to 66% of the time after an implant restoration was inserted next to a natural tooth.  This event occurred as early as 3 months after prosthetic rehabilitation, usually on the mesial aspect of a restoration!

Conclusions.  Normal bite forces cause tooth movement and the implant acts like an ankylosed tooth.

Here is the link for the actual article:

Immediate implants and labial bone in the maxilla

A great article in the most recent edition of JADA.  A must read!

We always obtain CBCT in these esthetic zone of the maxilla for this precise reason.  What is the condition of the labial bone (the bone in front of the teeth) in immediate maxillary implant cases.?


  • Maxillary central incisors are 2.37 more likely to have labial bone perforation (LBP), than canines
  • Maxillary teeth with Sagittal Root Position (SRP) in class I were 4.9 times more likely to have Labial Bone Perforation (LBP)

CONCLUSION: beware of SRP class I!

We are starting to see more and more SRP class IV cases in patients that have undergone Invisalign treatment by non-orthodontist, whom prior to the initiation of the Invisalign did not fully assess the patients anatomy in 3D using CBCT.  The teeth were literally move outside of the bony housing.  See 3rd picture below.


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E Cigarettes – The tobacco industry’s latest threat to oral health

We often have patients that need to replace their missing teeth with implants.  Unfortunately, if you are an active smoker, research shows that it can lead to implant failure or non-integration.

For some patients, in order to quit smoking, E-cigarettes have been marketed as the better alternative.  Well in the most recent edition of the Sept JADA 2015 (Journal of the American Dental Association) there was a great commentary by Dr. Tomar about E-cigarettes.

I think everyone should ready this article to get a sense for whats really behind this E-cigarette push.

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