Case 2
“Think Ahead”
(a novel approach to site preparation in the esthetic zone.)
Steven C Duboff, D.M.D., DICOI
[email protected]
www.duboffdentistry.com
This patient presented (from his original restorative dentist) with suppuration and bleeding at the level of the gingival margin of #9. Previously, he had presented from the same general dentist with a similar issue to the adjacent maxillary central incisor, #8. At that time, #8 was extracted and conventional grafting and membrane was used for guided bone regeneration, prior to placement of an endosseous implant in that site.
Upon placing of a forceps on the crown of #9, the crown separated from the tooth and then the post was removed from the remaining root. There was a post perforation which can be seen in photo #3 where the paper point traces the path of the perforation. After removal of the tooth, the socket was curretted and laser hemostasis was performed. Energetics used were 89 J at 4 W. Once initial hemostasis was achieved, Mineross (Biohorizons) particulate graft was placed into the bed of the thermogenic clot and lightly packed. As the bleeding continued to perfuse through the graft, the laser was again taken in non-contact mode and the surface congealed.
It is important to note that there was no suturing performed; which in and of itself would lead to shrinkage of the surgical site. This alone could be the difference between the possibility of an esthetic result upon final restoration and the opposite.. As can be seen from the photos, the fibrin clot achieved within 1 day was so significant that there was no concomitant loss of tissue volume. At 3 days we see the clot healing from the outer edge of the wound towards the center of the wound. This is consistent with laser healing. As well, the patient reported no post-operative discomfort.
At 4 months we see excellent adaptation of the ridge and films show no loss of graft material despite not having either sutures or membrane applied to this area. This is a significant advance to both the clinician and the patient alike . The lack of materials needed allow for easier manipulation of the tissue without the expected morbidity. An implant fixture was then placed and appropriate time was waited prior to restoration.
We see from this approach that proper understanding of the healing moment and how to coax the tissues into their own resolution makes for a better outcome in not just routine cases, but even more-so in difficult situations in the esthetic zone. Given the complexity of both the anatomy and the bony topography in the maxillary esthetic zone, by manipulating the tissue “less “ early on, we have a better chance of an easier path toward final esthetic and functional restoration.
The utilization of the laser allows for the body to find its own physiologic healing point, rather than a traditional “cut and sew” method, which, while doable, increases the risks of post-operative discomfort and change in tissue architecture which often results in added finishing procedures.
Pre-op periapical showing post-perforation of the root.
crown off #9 due to clinical fracture.
paper point tracing path of root perforation
immediate post-op. graft in place and thermogenic clot in place.
1 day post-op. n.b. the excellent fibrin plug
3 day post-op. Fibrin retracting from outer border inwards with no loss of concomitant soft issue volume
1 month post-op n.b. – well defined soft tissue architecture.
ibid. n.b. No loss of particulate graft.
6 months post placement of second fixture.
Bicon implants placed and in proper position due to the planned grafting prior to placement.
Radiographic evidence of proper placement of restorations/implant crowns.
Final restorations. Implants in place #’s 8 and 9. n.b. the excellent soft tissue emergence profile and zone of keratinized gingiva.