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Hi folks: Well I did this osseous case yesterday and made a few mistakes, one of which I didnt realize til the patient left and I looked at the photos.
FIrst off, this lady is 75 years old and fractured a canine crown off at the gingiva . THe lateral has a crown as does the premolar.
I had not met the lady but my associate had seen her and rightly decided that there wasnt enough tooth structure remaining to replace the crown but with osseous recontouring we would create enough.
Alternatives could have included an extraction of the root and 3 unit bridge or implant. Positives of trying to retain the tooth included better flossing than a bridge and less cost and time than an implant. Others may have chosen one of the other treatment plans.
I had another colleague in watching the procedure so I was a little distracted when doing this but all the same here are the results.
First off I know that the canine will be longer than the other teeth at the gingiva and in addition that there will be recession on the adjacent crowns.
I used a 80 degree tip to remove some tissue first so the flap wouldnt go back to where it was before. I used 30 Hz and 100 mj for the soft tissue.
Then we elevated the flap. I had broken my chisel tip (large tears flowing now) the day before so I had to use the soft tissue tip (pointed ) to cut the flap and releasing incisions. The flap was raised and at this point I forgot to take a bunch of photos, but the final photo shows the bone removed and the flap replaced. For bone I used 30 Hz and 160 mj with water and a 80 degree 600 micron tip.
I tried to use the Argon to tissue weld but the tissue was too wide apart and it couldnt be reapproximated. I wonder whether its the tip that cuts a cleaner flap or settings I used.
Anyways I should have placed one more suture in the tissue but didnt see it til afterwards so I hope it will heal.
LIke I said , some you win, some you dont , and I think I could have done a better job with this one but time will tell.
Fire away with suggestions as I am trying to improve my technique. I want to get some smaller instruments and smaller suture as well……….it looks horrible under the scope, reminds me of tug of war rope.
Cya
Glenn
Glenn,
Like David, I also usually do my incision a little differently. I’d split the papilla between 9/10 and also 10/11 and angle outward as I went more cervically(apically?) so the base of the flap is wider than the top.This keeps the flap with a very good vascular supply. You also then have the choice of suturing across the labial as you did or going interproximally. I think this way, recession on the adjacent teeth shouldn’t be much of a concern.
You definitely had some tough choices regarding esthetics and ginigval levels. I’m guessing since the tooth fractured and there appears that there used to be a pretty large restoration, that the canal was pretty calcified,pt age, and endo /post/core (with the crown lengthening) wasn’t a good option?
Wouldn’t we all have a chance at being master dentists if we could see and discuss the things we see in everyone’s post pictures, before we actually did the procedures?
Thanks for posting, Glenn- I know that after 20 years I find its easy to find myself running on auto-pilot in the office and due to your generosity in sharing, I know that there will be so much more for me to consciously think about before tackling the next fractured tooth that walks in my office.
Glenn,
I am setting at home on the couch after reviewing Ron’s web site and I noticed that no cases have been posted since you’ve taken a time out. I am thinking I really should drive down to the office and see if I have something to post. Got to give you some break. Well I couldn’t remember if I had anything worth posting so I turned on the tube instead. Ten minutes later I get a call. Fractured off #21 at the gum line and she is in panic mode. So now I have something to post!!!
I want to get the excuses out of the way from the start.
1. This is after-hours and I am working alone. Have not done that in years!
2. I did not take as many photos’ as I would have liked. Again sort of tough to do by your self. Plus she has a 4 mo kid with her.I did numb the patient as she is blond and 40 Y/O and is always tough to work on.
You have to trust me on the perio probe. I did use it. Just can not hold it, retract and take the photo all at the same time. The pocketing was 1mm all the way around. I took off a tad more then 2mm of gingival all the way around. 2.75 W 55w/65a. This did well on the outer edge of the facial, the distal and the lingual. The mesial and the facial next to the tooth did not work well at all. I dropped back to .5W 7w/11a and this did not work well. The tissue was different in this area, more inflamed and granular. I used the laser smile at 2W continuous and finished the tissue reduction. Then I reduced the bone another 3mm at 2.5W 14w/25a with the G-6 tip..
Now things are becoming fun. The picture I did not get was the bloody mess. Talk about bleed. She has a problem with clotting and tonight was not the exception. I packed the cord to help. I left it until after cementation. You will see it in the photos. The rest is just simple core, prep and temp.
Ok, now I can go home!
DAvid