Bill: I have a case now which was my first case in the office that I did osseous surgery on. In that case I literally ablated the tissue and bone between the papillae of the maxillary lateral and canine so that I could get the margins placed on solid tooth.

I am embarrassed that I did the case that way , but its done.

I saw him last week and it was one year or so after this was done and the crowns looked great (remarkable but true).

I will phone him and get him back for some photos for you.

I am glad that you come here to learn. I dont mind constructive criticism, as you have levelled at me before at DT. I showed the case which has healed fine.

It is there for you to see.

In addition Danny asked me privately to comment on the osseous cases.

First off, most of them are not cases that I would have done in my office at present as the bone was too much for me to take off with the laser.

2nd off, I will tell you that the tips of the DeLight laser can be either 400 , 600 micron, and the chisel tip which I have shown is much much bigger than that and the footprint of this gives you a nice cut on bone.

I have shied away from closed crown lengthening because of what Danny and others have said for all but very simple cases.

In closing, I will say that osseous with the laser for bone removal in an open flap environment shouldnt even be discussed as a viable alternative to traditional methods……..IT IS …..PERIOD.

There are some advantages in my opinion to the laser…..

1. Non contact, quieter in the DeLight case than a turbine.
2. Water spray has much less splatter than with a handpiece.
3. It is slower than a bur but you can be very precise in your bone removal , flaking of bone that covers a follicle predictablely without risk of damage to the follicle or tooth underneath.

Some can claim th at periotomes and other assorted chisels can do the same thing (these are the same people who have never even used the laser!!), and that is fine.

All I am saying is that the laser does work on bone, safely and precisely and if you use it open flap there is no reason it cannot be used as an adjunct to traditional methods and in some instances I suspect it will become the treatment of choice.

I will try to post some of my follow up cases and their healing, one of the difficulties for me is that I have two scopes in my treatment areas and none in my hygiene areas yet (but it is coming) so its not as easy for me to take the pictures postoperatively with the same magnification as in my operatories.

Take care……….

Glenn

I wanted to jump in here for a couple of reasons. One, because, like Bill, I stepped on some toes when I first posted and can feel his pain.

Also, because I think I represent an entire segment of dentists out there who can easily fall into Bill’s category of “morons”. I know I’ve placed my share of restorations that have violated biologic width principles and some have come back to haunt me. Most haven’t. We’ve all seen what I call “amazing dentistry” — the crowns that fit like socks on a rooster but have no perio or decay. Fortunately, some peoples’ systems can tolerate some incredible insults. Most can’t.

Twenty-plus years ago in dental school, the term “biologic width” wasn’t discussed at any great length. I can’t even recall its being mentioned, and I don’t think that’s because I slept through the lecture.

Consequently, many of us start our careers with only the rudiments from school and are thrown into the profession with little knowledge of how to perform complicated dentistry successfully.

Maybe I’m deluding myself, but I think I represent an entire segment of garden variety dentists who do generally nice work on a regular basis. We’re not into gnathology, TMD treatments or perio surgery. Total occlusal reconstruction we simply don’t do. But we do very nice restorations and do them every day. We don’t contribute articles to journals or travel to seminars to teach others.

We coach little league or soccer, teach Sunday School and read novels for relaxation rather than JADA. Our patients generally like us and trust us to take care of them as we would our own families. We’re reluctant to buy the latest and greatest gizmos and use our patients as guinea pigs.

We start our practices, raise our families and struggle to squeeze mandatory CE into our schedules. In the blink of an eye, two decades have passed and we’re still drillin’, fillin’ and billin’. It works. It pays the bills. It gives me time to raise my family and have hobbies, which is why I chose the profession in the first place.

I admit that with some shame, because I thought I’d always be on the cutting edge of dentistry and would never allow myself to turn into one of those “old coots” who still practices how he was taught eons ago.

>sigh<

Anyway, I’m playing catch-up big time. Now that my kids are gone, it’s time to learn new techniques and new treatment modalities. The concept of biologic width and how to fine tune what I already do right is a great adjunct to my personal “continuing education”.

As was mentioned, in the real world, patients will often accept a crown, hesitate if it involves RCT as well and will probably opt for extraction if you mention the cost of crown lengthening.

I, for one, was anxious to start closed crown lengthening procedures with the information garnered from the laser sales pitches. After digesting the great posts here from Glenn, Danny, Ron and others, I’ve come to the conclusion that I need to seriously consider open procedures rather than closed.

I have a LOT of work ahead of me. Not unlike dental school, it’s a do-it-yourself project. I don’t even know where to incise for such a procedure; I’m sure even that has changed over the years. But I’ll learn. I’ll ask questions, try some things and, like others before me, fail occasionally. But I’ll succeed more often than fail, and my patients will be be beneficiaries of my technical improvements, even though they’ll probably be unaware.

I’m a good dentist — not great, just good. And that’s OK. I may even be a moron, and I won’t argue that. Heck, it’s much better than some other things I’ve been called. However, sometimes we morons do things because we haven’t taken the time to learn how to do things better than we were taught.

Bill, here’s a challenge for you: Take a moron to lunch. If you see somebody continually abusing biologic principles, maybe a friendly conversation would open his eyes to a concept that he never learned. Just a thought…

— Don

Yes, Danny, you’ve made a believer of me. Before your challenge to closed CL, I thought it was just an easy procedure that could be whipped off just prior to completing a post & core and crown prep — and sometimes can, but not without completely visualizing the width of bone available and the resulting contour of bone after the procedure. Without your input, I’d have tripped along merrily, probably making circumferential ruts in bone around every CL tooth.

I’ve seen you go from being somewhat adversarial toward lasers for CL to being accepting — so long as biologic principles are followed. I commend you for being open to new paradigms of treatment ( I just HAD to use that word!)

I’m looking forward to learning more from all of you.

(I also apologize for the length of my last post. I had no idea I was so long-winded! Oops.)

— Don

I’m looking forward to the response. Could you add some pictures or diagrams to illustrate your flap design in such a case? Thanks, Dan.

Kelly

Here is a case I did today. It was done Closed flap CL.

THere was decay under the gold crown which needed removal and there was alot of decay under the buccal. I used the erbium for soft tissue and bone (1mm or so) and ran out of time before I could get the impression.

I will follow the case up.

I like the clarity of these pics shot with the new camera setup and with a little time I figure the pics of mine will be improved.

Hope you like it and I didnt get a chance to take a pic of the provisional crown in place.

Take care and cya in a week when I am back from Salt Lake City………cya

Glenn

Hi Hack…….thanks for your interest in the case. You know what these are the tough cases when they occur because honestly you know there is decay under the crown but really you have no idea how extensive it is.

I was faced with a tough decision………flap the case and perhaps run the risk of opening up the furcation on a patient who has previously gotten decay under a gold margin and doesnt have the best OH

I could have done Dannys Root reshaping but the decay was quite deep into the tooth so that again presents problems because there is pulpal blushing as it is due to the proximity of the decay.

I chose to place a temporary after really removing tissue and a very little amount of bone strictly on the MB of the tooth.

It wasnt interproximal and I used a curette afterwards to try and smooth out any ledges.

I will follow this case so that you may see how the healing occurs. I have done this 5 times on cases just like this.

One hasnt healed (temp crown broke off in addition and tooth was extracted).

Other 4 have healed…….

Hack, you are always courteous to me. If you had a GP who referred to you, would you ask him to place a temp in this case and refer to you for osseous , how would you handle this case.

I will show you the results as they come in.

Glenn

Anyone able to direct me to Danny’s pictures for his case presentation???

TIA Cam