Forums › Laser Treatment Tips and Techniques › Soft Tissue Procedures › Partial bone fill
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Robert Gregg DDSSpectatorHey all,
Treated this patient of a GP dentist friend of mine here locally (went to high school together).
Patient originally had the following findings:
— 66 year old male
— non smoker
— good health
— retired blue collar
— not lots of $$Clinical
— Class III mobility
— Suppuration
— BOPMB = 13
CB = 3
DB = 13DP = 13
CP = 9
MP = 8Total of 59 mm of pocket/probe depths
[img]https://www.laserdentistryforum.com/attachments/upload/RobertpostPreOp.JPG[/img]
<br />
4.0 watts, 20 Hz, 650 microseconds for <u>625 Joules</u> = <b>10.59 J/mm pocket depth</b></p>
<p>[img]https://www.laserdentistryforum.com/attachments/upload/Robert3MoPostOp.JPG[/img]</p>
<p>— Class < I mobility<br />
— No Suppuration<br />
— No BOP</p>
<p>MB = 9 (+5mm)<br />
CB = 3 (=/- 0 mm)<br />
DB = 3 (+10mm)</p>
<p>DP = 9 (+5mm)<br />
CP = 4 (+5mm)<br />
MP = 6 (+2mm)</p>
<p>Total of 34 mm of pocket/probe depths = average of 25mm probe depth improvement.</p>
<p>
What would you do NOW??</p>
<p>Bob</p>
<p>P.S. Going to Florida to get some lobsters…….be back next week.</p>
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Glenn van AsSpectatorWow ……..I looked at the original film and immediately thought fracture.
I would do it again and see whether you get more bone fill.
WOnderful result.
Glenn
AnonymousGuestBob,
Double digit pocket=multiple tx.Possible accessory canals on distal where gutta percha ends
Since you got good fill on the distal, I wonder how much a factor the open contact on the mesial is? Something driving those teeth apart?
Not any easy choices, are there?
Have a great trip!
PatricioSpectatorBob,
I would go with a retreatment wondering if some laser bone stimulation would help. I would include a protocol of topical biocidal irritant to eliminate any reinfection from the top down. Since at a 6 mm plus depth there is likely residual biofilm I would consider a periodontal appliance to maintain 24 hour tissue contact with the biocidal. Food trap? Poor oral hygiene on the mesial?
Pat
Robert Gregg DDSSpectatorHey Guys,
Thanks for the feedback. I needed some thoughts on this one!
Ron–Giving it right back to me–very funny, and probably right. So you and Gleen agree–take a second shot at it.
I guess I shouldn’t assume there is a fracture there even though it looks probable, huh?
I like Pat’s idea of retreatment. Internally, there may be a better chance at an MTA repair too.
I thought about raising a flap and taking a peak with the microscope, but that doesn’t address Ron’s observation of the short fill, or Pat’s comment about microbes.
I think I’ll call my friend and suggest an RCT retreat, and repair of any fracture with MTA–along with a second treatment of the perio defect. He was agreeable to me flapping and peaking and repairing……
Thanks for the suggestions, I needed the different perspectives.
Muchas gracias,
Bob
PS Ron–I went to Destin and the Ocean Club and had tha surf n’ turf with fried florida lobster…….Yep, it was as good as you and I remembered!!!
AnonymousGuestQUOTEQuote: from Robert Gregg DDS on 2:41 pm on Aug. 19, 2003PS Ron–I went to Destin and the Ocean Club and had tha surf n’ turf with fried florida lobster…….Yep, it was as good as you and I remembered!!!
Good thing I don’t hang out w/ you and Ron K too often, I’d weigh 400 pounds!
dkimmelSpectatorBob, anyone around with a perioscope? Nicer then flapping!
David
ASISpectatorHi Fellows,
That’s the beauty of this forum as new perspectives are gained upon sharing. Great work everyone!
Andrew
Dave RodrickSpectatorI would check occlusion (lateral interferences may be excessive) I saw Robert Barr in Vancouver at the World Congress of Microdentistry last weekend and he showed a case similar to this where he troughed with his waterlase and cleaned root surface and place Emdogain followed by synthetic bone (your choice) and then covered in with Barricade. It looked like a reasonably atruamatic way to treat this area.
Kenneth LukSpectatorDave,
Do you mean that there was no flap opened ;and that the emdogain was only injected into the pocket ?
I think Bob would have relieved the tooth from occlusion in the LPT as the last stage of LPT is to adjust the problemetic teeth from occlusal trauma. The abutment , however, seems to be carry quite a lot of pontics. Is there only one molar abutment at the other end of the bridge?
Cash may be a problem for the patient but I’d suggest implant bridge to replace the three pontics.( bone quality looks ok ) Sectioning the bridge and polishing the abutment crowns. He may agree.
What about redoing the laser procedure with addition of Atridox ?
Ken
(Edited by Kenneth Luk at 9:16 pm on Aug. 20, 2003)
Dave RodrickSpectatorKen – Thats right. It’s a closed flap procedure with Emdogain. Emdogain inhibits epithelial cells and prevents epithelial growth into the defect. It also initiates a natural process that mimics (biomimicry) that of tooth development. Bone formation starts along the root surface and the defect is gradually filled with new alveolar bone.
Dave
Robert Gregg DDSSpectatorHi Dave and Andrew,
Yes, Andrew, the occlusion was aggresively adjusted at the treatment appointment. Also, there is only one molar abutment distal to the tooth.
I like your idea Andrew to remove and place single impants, but financial considerations have removed that from consideration. Sectioning the bridge and making new crowns (perhaps) and a partial is more likely what he can afford…..and that’s even a stretch.
Dave, we have tried Emdogain over the years in a method you describe. It works fine, but not any better than a stable fibrin clot, and it may not work as well.
I used to use it a lot, and one has to have patience to leave the area alone for 9 to 12 months before any sign of improvement takes place. Haven’t used it for some years now.
The stable fibrin clot that is obtained using the correct laser & parameters prevents epithelial migration, bacterial contamination, contains platlet rich plasma (PRP), stem cells, bone morphogenic proteins–in essence all the precursor and nutrient cells needed for regeneration, but without the need for a foreign material injected into the defect. Plus, it costs less than Emdogain.;) One also doesn’t need a bone graft material or a tissue barricade, as the patient’s own fibrin does it all….
[img]https://www.laserdentistryforum.com/attachments/upload/Markpoach2B.JPG[/img]
This is the complete thread:
http://www.rwebstudio.com/cgi-bin/ikonboard/topic.cgi?forum=24&topic=54
Andrew, we actually did a laser vs. Atridox comparison. Atridox was very disappointing compared to using a pulsed Nd:YAG (1.064 nm). And I think we have tried everything that’s been available (and then some) into the defect at one time or another. We simply get a much better tissue response with Fr Nd:YAD than when we put something into the defect.
Thanks for all the ideas and feedback. This has been great!
Bob
Dave RodrickSpectatorBob,
Thanks for your insight on Emdogain. What do you think about the use of the perioscope (Dentalview) to meticulously remove as much subgingival calculus as possible. Roger Stambaugh (a periodontist in Santa Monica, CA) is getting great results (usually 6-18 months later) using the perioscope to find and remove calculus with a H2R Diamond tip from Satelec. You can also identify root fractures, subgingival decay and root anomalies.
Take Care,
Dave
Robert Gregg DDSSpectatorHi Dave,
Sure, Why not?
I think it is a great idea for going back in to find areas that are not responding, or to definitively S/RP in a closed procedure in the first place.
I’m wondering if using an intense pulse from an Nd:YAG and once rendering the calculus aseptic, that once it is gram negative free we need to remove every speck of rogue calculus? After all, what is germ free calculus but calcium phosphate. Perio studies show that attachement can crawl over, through, above calculus that is germ free. But how to get germ free?
I’ve met and spoken with Dr. Stambaugh about our laser pocket therapy and he feels–as do I–that the light in both technologies is having an effect on healing that can’t be attributed to the removal of calculus alone. What that effect is, still needs to be determined.
Just my 2 cents.
Bob
Alfred WyattSpectatorBob
Just a thought after reading your last post. Could the bacteria we’re dealing with deep in the sulcus possibly be photophobic? Just curious.Alfred Wyatt
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