Forums › Laser Treatment Tips and Techniques › Soft Tissue Procedures › How to proceed?
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ELLIOT ROGOFFSpectatorPatient had apico done by Oral Surgeon and the results are not want we wanted. He is in a real pickel and wants me to help him. Thought of doing some ablation with the CO2 to thin out tissue and then make some temps for four all porcelain crowns. Will do some givgivalplasty with the Diode prior to finals. Any suggestions and can it be done.
dkimmelSpectatorHere are the pictures.
So what do you tink?
David
Dan MelkerSpectatorNot all is lost and in fact you could end up with beautiful result:
1. frenectomy with laser.
2. provisionals placed on existing crowns.
3. You are dealing with Altered Active or Passive Eruption, great news! The teeth need to be crown lengthened. By doing the proper technique with a flap you will be able to do away with the black triangles.
4. When was the apico undertaken? This will dictate when the procedures should be undertaken.
5. In my opinion a flap will need to be reflected to see underlying osseous for correction. That is only my opinion.
6. Being careful with frenectomy will be critical so as not to lose any more papilla between 8 and 9.
Not to worry, this case can be one of your finest!
thanks,
Danny
Glenn van AsSpectatorI agree with Danny on this one….osseous if the probings are as I expect at 2-3mm. What were the probings.
The frenectomy is good idea as well and temps of course for long term.
Danny, I think the bone is quite bulbous here, or is it the tissue or both.
I think that open flap osseous can help reduce the bone, but if the tissue is also bulbous or is most of the problem, then the erbium laser with a chisel tip can be wonderful for shaving the tissue down.
First off I would remove the crowns and have lab fabricatecd temporaries.
Do the frenectomy before raising the flap, then I think that I would do the osseous by flapped of course, in this case to visualize the bone. No way to do this one closed flap, no way at all with the bulbous nature.
After healing if the tissue still is bulbous the erbium yag with a chisel tip could help shave or plane the excess tissue back. I love the erbium for this. Nothing I know does it as well as this laser does it.
I think that once the tissue has healed then the margins can be refined on the temps ( you may even need a second set once the osseous is all healed) and then the final crowns can be made.
What do you think??
Good treatment planning Danny , I like it.
Glenn
Dan MelkerSpectatorGlenn,
I would love to see your handling of bulbous tissue. With a scalpel it s—s and can have a fair amount of discomfort. ( some use burs to do the samething which also s—s)
This is a case that looks worse than it is because of the papilla loss. We are saved by the AAE. since the teeth can be lengthened.
Thanks,
Danny
Glenn van AsSpectatorDanny: I will show you a case if I have time ( I am swamped right now preparing for a lecture at Nash Institute and then in Costa Rica starting next wednesday) where I used the erbium for ovate pontic.
The thought process is similar in that you can selectively shave with a chisel tip the tissue, its amazing really and you can create a shape while shaving the tissue down.
The same could be done here with this tissue if its soft tissue bulbous in nature. Of course I think like you that alot of it is bony in nature and that needs to be altered first but what is wonderful is when you want to shave or thin the tissue down the erbium is by far the best laser and best tool that I have ever used.
I mean this honestly, the diodes and nd yags are tough because the laser is so small in terms of diameter of the tip and it doesnt shave the tissue.
The erbium is wonderful and for ovate pontic it is unreal.
The same could be done with shaving tissue down that was too thick.
Now whether it would grow back or not is a whole other story but things like hyperplasia to drugs, or tissue that is thicker are wonderfully thinned by the erbium with a chisel tip.
If I have time I will post a case or two but I am swamped.
Gotta go
Good stuff and see I am not against open flap, this case calls for it for sure.
Glenn
ELLIOT ROGOFFSpectatorSorry for now getting back to all. I had the patient return for some post-op photo opportunities and I will b try to show them. I didn’t receive too many opinions the first time around but what the heck here goes.
ELLIOT ROGOFFSpectatorEnclosed are the pictures again for the case How to proceed from July 2004
(Edited by ELLIOT ROGOFF at 12:16 am on Sep. 23, 2004)
dkimmelSpectator
There you go Elliot. I had to degrade the image as it was too large a file.
DAvid
jetsfanSpectatorElliot,
Beautiful result! Patient must be quite pleased.
Only question is how high is the smile line? My concern is the gingival height discrepancy on #10.Robert
ELLIOT ROGOFFSpectatorThank you very much for the kind words. If I told you how long I have been trying to share this with everyone, the tissue would have receeded more. The smile line is a concern and the patient does understand the need for grafting in the 10 areas and also the need for cosmetic reshaping of the 8 and 9. There has been much discussion on the need for a surgical open procedure or the vaporization and frenectomy procedure I have done. Who’s to say, well I guess Biology and time will tell, but I wanted to show the before and after pictures to stimulate some discussion. Again thanks for the kind words. PS if the Jets quarterback stays healthy you have a good shot. I still love Joe Willie.
Dan MelkerSpectatorElliot,
As you and I have become friends it is great to see your willingness to share cases.
I think as I told you that a closer look at #10 is interesting in the sense that the CEJ is apical to #8 and #9. There is only minimal root showing.
The key here is to find out where the CEJ’s are on #8 and #9. Crown lengthening of these teeth is the key to the case since you will be able to sculpt the tissue creating a very cosmetic result.
The worries about #10 are unjustified until you see the CEJ’s of #8 and #9. You will have to do minor correction but the outcome should be great!
Think Biology of the bone CEJ’s and soft tissue!
Danny
Do not ignore 6,7 and 11 in order to create ideal symmetry.(Edited by Dan Melker at 7:10 pm on Sep. 24, 2004)
Glenn van AsSpectatorDanny, these kind of professional posts and education are WONDERFUL.
It is of great help for you to aid us in looking at tissue.
It is weird how our focus as laser dentists change from looking at the incisal edge on veneer cases to the whole tooth and often my first glance is at the Gingival Heights of COntour.
Its because we now have a tool to help us in shaving or recontouring tissue that we start to look at these areas more critically.
I learn alot from these kinds of posts and I really think that courteous professional posts like this with your insight into periodontal concerns can help us ALL become better dentists.
Thanks for the nice post.
Glenn
jetsfanSpectatorRon,
Sorry for the extra work. I hope you can delete that las t post of mine with the oversized photos.Glen,
here’s one from your playbook. Orthodontist wants #7, #10 bonded, on this 15 y/o girl, to proportional size to other teeth. The teeth were in the altered passive mode. Recontoured without encroaching on BW, then bonded. Mother was thrilled, 15 y/o, well… try to get a reaction.
Robert.
Glenn van AsSpectatorHi Robert: neat case and really nice photos. What were the probing measurements on the lateral. Do you think there will be rebound ( I have had this happen to me a few times), and do you think you will need osseous.
What kind of retainer is it (ie Hawley with finger springs to prevent movement of the laterals??)
What settings did you use with the laser and what tips.
Cool stuff.
Glenn
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