Glenn,
What are the do’s and don’t for troughing on the facial? I have been a little reluctent to trough this area and risk recession and possible margin exposure where I did not want it.
Pat

Any chance we could see a VERTICAL BWX?

Here’s what I’d try:

First of all, I’d do NO pre-surgical root planing, etc.  Pre-surgical (phase 1) root planing could cause the tissue to firm up and shrink.  It would also cause the immunilogical factors that are present in high amounts to diminish (by becoming temporarily more healthy).  This means that the tissue would be more difficult to manage if it had shrunk and become more fibrous.  And you WANT all those immunilocial factors present in mega amounts when you do regeneration. (learned this from Bill Becker himself)

Some sort of temporary splint — even if you had to put a glass fiber ribbon splint on both the buccal and lingual, with the idea that with success, you can remove.  Keep it away from the gingival area.

I currently don’t use the laser when I do these.  But it certainly couldn’t hurt (possible biostimulation?).

I’d do a great endo.  I personally think this is a must.  With this much bone loss, there has got to be some endo problem via lateral canals — lotsa literature to back this us — esp. by Selzer (sp?).  They’ve shown that even when you get a normal pulp response to EPT and thermal tests, when there is this much bone loss, there are virtually ALWAYS areas of ischemia in the areas of the lateral canals.

I’d flap the area, root plane WITH ZEZA ULTRASONIC CURETTES (this is important in my opinion), absolutely impeccable debridement of the boney defect with the same ultrasonic curettes, taking away a little layer of bone.  Just be sure to ONLY use the ‘root planing’ inserts, and NOT the surgical inserts.  The ‘surgical’ ultrasonic curette inserts are WAY too aggressive, even for the debridement of the osseous defect (which is what they’re meant for).  Just use the ‘root planing’ ultrasonic curette inserts for both root planing and osseous defect debridement.

And yes, do de-epithelialize the internal of the flap, but don’t get all that aggressive — you don’t wanna impair circulation in the flap.

OH, by the way, very important — when you give anesthetic, be sure you use 1:50,000 epi at least 25 minutes prior to your incision.  And be sure you give it both buccally and palatally adjacent to the root.  This will give you good hemostasis, and that is important in this procedure.

So after your GREAT root planing, GREAT debridement of the defect, and de-epithelialization of the internal of the flap, treat the roots with PrefGel (by Biora — the Emdogain people) for 2 minutes.  Literature says you could use citric or even phosphoric acid, but in much shorter times.  I disagree.  Citric acid will denature proteins, and I don’t like that idea.  And phosphoric stimulates bleeding — not good with this technique.

Rinse well.  At this time you should have virtually no bleeding.

Inject the Emdogain gel into the defect, onto the prepared root surfaces and to the internal of the flap.  Then place your graft material (I’ll discuss below)to fill the defect and close with matress sutures (you don’t want the suture material going through the graft material.  I suture with GoreTex sutures.  You need to get primary closure.

If I get EXCELLENT primary closure, I usually don’t put on packing.  But if the closure is not as ‘sealed’ as I’d really like, then I place packing.

The graft material.  I specifically like the Pepgen P-15.  Consider this — we know that DFDBA (Demineralized Freeze-dried Bone Allograft) will hasten bone regeneration to a degree.  It’s been found that only one out of 3,000 proteins in DFDBA is responsible for this enhancement of bone regeneration.  And that protein?  Yep, it’s ‘P-15’.  Obviously a product that is saturated with pure P-15 is a big plus — studies of this are totally awesome.

But P-15 is dense as all get-out — and this would prevent in-growth of blood vessels and bone percurser cells.  So I mix DFDBA and Pepgen P-15 in about a 50-50 mix.  The DFDBA will resorb very quickly and is very spongey — thus allowing rapid ingrowth.  And the Pepgen P-15 will accelerate attraction of these cells.

I first mix them together when dry (much easier to get a homogenious mix when dry).  Then I hydrate with sterile water — I personally mix just a ‘pinch’ of tetracycline in with the water first.  

Place the tetracycline in some sterile water (or saline) — just a VERY LITTLE (we don’t want the HCl in the tetracycline to give us much acidity).  It should give the water only a very slight hint of ‘yellow’ if you only put the slightest bit in.  Let the solids settle to the bottom and suck up the top of the water in a syringe and squirt that into the graft mixture to start the hydration.  I do this right before I make my flap.  The material should hydrate for a minimum of 15 minutes.

And don’t ‘float’ the graft mix with this water.  Once the DFDBA absorbs the water, you want it rather dry (barely moist).

I don’t use a membrane.  The Emdogain enhances acellular cementum formation, which in turn forces fiber generation, and that in turn forces bone generation.  And the graft material then enhances the ‘fill in’ of the bone between the teeth.   If you use ONLY Emdogain, you sometimes get only a thin coating of bone forming on the root surface, with no bone inbetween — this is still good, but I’d prefer bone right straight across.

Emdogain has been found to prevent epithelial down-growth, so I don’t use a membrane.  Pepgen P-15 has also been shown to prevent epithelial downgrowth, but this may not apply when mixed with DFDBA (don’t really know)

I then place the patient on Peridex rinse as well as Doxycycline 100mg bid for 2 weeks.

When I say that these patients have no post-op pain, I mean they have NO post-op pain.  It’s weird!!  You haven’t ‘recontoured’ bone.  You haven’t place irritating membranes.  And I truly think there’s something about the Emdogain that virtually tells the tissues that nothing has been done.  

So far, every single patient, without exception, has said they didn’t even need to take Advil or Tylenol!  I kid you not!

GTR membranes always seemed to work very well in my hands, yet this technique has results that are even better.

So yes, if the patient wants to ‘try’ to save the tooth, I’d say OK, and THIS is the technique and approach I’d use.

How ’bout that vertical BWX?

Rod

(Edited by Rod at 12:39 am on Jan. 25, 2003)

PS…if you haven’t done so already, I have replaced using a scalpal for incisions. I use the T-4 tip with about 1W 13%air, 11%water, and have had success with very little bleeding whatsoever, and a great “playing field” in which to work in during flap surgeries. The tissue approximates back excellently, BUT DON’T use too much wattage. Low powers are so effective, especially with the T-4 tip, which seems to exude much more energy per pulse than the G series tips. Just a PS.
Mark

Nice results Glenn–

Some people are just naturals!

Notice that Glenn left some room for the tissue to receed a little, should it need to do so. If no recession, then he can always touch it up later. That’s a good idea with CW or gated pulsed lasers.

Notice Glenn doesn’t have any epithelial peeling or coagulated tissue beyond his laser margin. That a “cool” wound.

Also, Glenn didn’t burn or char-up the tissue (black), indicating he didn’t overheat the soft tissue thus he’s not likely to get recession.

Some remarks to answer Pat:

1. Direct fiber away from soft tissue you wish to leave behind. Don’t point up into the sulcus.
2. Don’t count on water to cool–it can be deceiving like getting a sunburn on a cloudy day. 810-1064nm wavelength transmits right through water. Use air to cool. Water spray is OK, then air dry.
3. Don’t let water “pool”.
4. Watch for “tan” tissue changes indicating that the tissue is getting HOT.
5. Stop if you are seeing epithelial peeling. The tissue is too hot and will go away.

Bob

Pat,
These are valid questions. I usually always use the 5.5-6W defocused (at 10mm away), 90%air, 73%water. I know that this weekend in Dana Point, Stu Rosenberg will be discussing 2 other methods he uses with the Waterlase in our afternoon hands on seminar. I think he will discuss the way you do it, a la Dr. Chen, and then I know Bill Grieder has another way he will discuss. I, like you, am interested in learning other methods. I DO have GREAT success so far the way I am doing this, so who knows. Glenn, what do you do with your Er?
Mark

Diode Trough 1.0W CW Used the air to cool -thanks for the tip ,Bob!
My real question has to do with the fracture on the distal (that is a base on the occlusal , not amalgam -still learning to control the flash on the camera). I was able to put the finish line for the FGC cervical to where I could see the fracture end. What is the consensus for the crack- leave alone , laser etch & seal , or chase the crack?