Perio/Restorative Case and LASERS???

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August 22, 2003 at 3:33 pm #3363 Reply

Swpmn
Spectator

57 yo male presents for opinion on periodontal and restorative needs. Patient concerned with “red gums” on maxillary anteriors and wants missing teeth replaced. He has an aversion to periodontal flap reflection/sutures and also does not want to undergo implant surgeries.

He has hypertension and benign prostate enlargement. Past history of hepatitis A and basal cell carcinoma. Medications include Cardura and Proscar. He quit smoking in 1999 after 30 years and denies alcohol abuse.

Patient has had crepitus/clicking of temporomandibular joints for thirty years but no discomfort. Normal maximum opening with discomfort after long dental procedures. Large tori can be seen throughout the mouth. Severe marginal gingivitis is noted in the photo, particulary around fixed restorations. There is localized Type II(4-5mm pocketing) periodontitis noted on teeth #5,6,11,13,20,21,27 and 28. One 6mm pocket was found on #21 disto-lingual.

Tooth #14 has a periapical lesion and #19 a near pulpal carious lesion on the distal. There are provisional crowns on teeth #5,11,13 and 14 and a lost provisional on #2. From the patient interview, it appears he has not undergone any initial periodontal therapy, e.g. root planing/scaling.

The patient is receptive to replacement of all existing restorations and missing teeth with conventional fixed crown and bridgework. Finances are not a concern – flap surgery is a big concern. My initial direction will be to provisionalize the entire mouth and commence scaling and root planing – I have not promised the patient that his mouth can be restored without flap surgery, only that we will begin initial therapy and see how things progress.

What would YOU do??? Help me think of other diagnostic procedures, e.g. osseous “sounding” to measure biologic width?

Could laser therapy benefit this patient? If so, what procedures/wavelengths do you think should be utilized?

Hammers include:

Electric handpieces, 4.5X loupes with headlamp, ultrasonic scalers, diode laser 810nm, erbium lasers 2780 and 2940 nm, scalpels and sutures.

Thanks for your help,

Al

[img]https://www.laserdentistryforum.com/attachments/upload/williamsa082203-1.JPG[/img]

[img]https://www.laserdentistryforum.com/attachments/upload/williamsa082203-2.JPG[/img]

August 22, 2003 at 4:47 pm #10550 Reply

Robert Gregg DDS
Spectator

Gosh Al,

There’s still room in our September Bootcamp…..:cheesy:

This is the kind of case we use LANAP for:

1. LANAP – one time laser treatment FM.
2. Temp C&B (FM)
3. Wait 9 -12 months for new attachment.
4. Retreat endos while waiting.
5. C&B restore with confidence.

I love these cases………”Will that be cash, check or credit card.”

Bob

August 23, 2003 at 12:11 am #10547 Reply

ASI
Spectator

Hi Al,

You have likely considered the following:
1. Panoramic radiograph
2. Study casts with necessary wax up
3. Occusal analysis
4. Pulp testing

I am particularly concerned about his occlusion aside from the perio therapy. Is the midline off by that much or just in that photo? Cervical abrasion or abfraction to tooth #22 and #26 along with incisal wear to most of the lower anteriors may be indicative of unfavorable occulsal function.

Just a few thoughts from the info so far…

Andrew

August 23, 2003 at 3:36 am #10546 Reply

whitertth
Spectator

Anterior inflamed tissue is most likely due to ill fitting crowns….provisionalize, scale root plane, periostat, and if u need laser therapy( i think here any wavelength will work) …Once u s/rp I think tissue will normalize…I agree with Andrew , the wear is a concern on the lower canine and occlusion, especially good solid posterior contacts as well as anterior guidance must be established.. Looks like u will be opening vertical here… so try and get it close as possible with provisionals…Good luck

August 23, 2003 at 3:54 am #10544 Reply

dkimmel
Spectator

Al, Not wanting to go under the knife is a concern. He is setting limits on his treatment. Do you think it is a matter of trust? That once you get working on him, he would come around.
If you think that this is going to be a big issue I would not place him in full mouth temps. Rather replace the temps that are lost or in poor shape. Deal with the endo and caries. Place him in a splint adjust occlusion as needed. Take him through scalings and use the diode retreating and backing out. [Perioscope use if you got one. ] Then reevaluate his concerns. It looks like you can take care of the biologic width problem without a flap if you place him in temps. #2 can also be CL without a flap. #21 could be more a problem but looks like an occlusial situation. The splint should help. A bit concerned about the span of the bridge that would need to be placed.
Hope that helps
David

August 23, 2003 at 6:11 pm #10551 Reply

Swpmn
Spectator

QUOTE

There’s still room in our September Bootcamp…..:cheesy:

Boy did I know that one was coming!!!!!

Thanks for all the help/suggestions guys!!!! Yes, Andrew, the midline is way off and occlusion is of great concern. As you can see, the crowns on #7 through 10 are all-porcelain – as Ron said I suspect they are poorly fitting or there is a cement problem and also probably biologic width violation. Dave, I feel confident the patient will allow me to reflect a flap should it become necessary.

See midline, sorry shot is not dead on:

[img]https://www.laserdentistryforum.com/attachments/upload/williamsa082303-1.JPG[/img]

Thanks again,

Al

August 26, 2003 at 12:45 pm #10545 Reply

marc andre gagnon
Spectator

hi folks
In a case like that, we do curettage with diode 980 at 6 watts pulse mode with a fiber of 400um.
Following that curettage we do irrigation with chlorexidine and fluoride.
For the next week we ask patients to brush with oxyfresh and rince 3 times a day with oxyfresh mouthrinse.
We do post op appointment 2 weeks later and do laser curettage where we have inflammation of the gums and continue with oxyfresh.

August 26, 2003 at 5:53 pm #10548 Reply

Glenn van As
Spectator

Great idea Marc, but if the margins are inflamed due to infringement of biologic width or poor fitting margins (overhangs) the likelihood of resolution of the inflammation is poor in my opinion.

SOmetimes a flap and either/or osseous recontouring and removal of overhangs and replacement with temps provides the best alternative to healing.

If the gingivitis is due to other situations than restorative margins , I think your idea is excellent.

As an alternative you can try this approach and if it doesnt work go to the more comprehensive treatment.

Glenn

August 27, 2003 at 12:25 am #10549 Reply

Kenneth Luk
Spectator

Hi ,
The lack of posterior support on the right would be difficult to tackle with lost of alveolar ridge. GBR/ implants? OR partial denture?
Occlusion would be difficult to stabilse.
The occlusal surfaces of crowns on the lower right premolars and molars looked heavily adjusted against the upper ones to fit into occlusion. Over built upper premolar and molar crowns on occlusals and height?
Ken
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