Watching, Waiting And Rewards May Come Your Way, An Implant Someday!

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This case goes on to about 250 Doc’s that have taken my courses and we share cases. Many of you would watch wait argue over literature and some would even consider extraction and an implant. The statements made to me are we don’t want to lose bone on #19 for a future implant so why not take the tooth out now. That is a f—–n fact as I have been told that in person by a Diplomat of the AAP. Sorry for the childish explanations but this case was discussed with GP’s not as surgically sharp as Periodontists. Yes I am jaded about the all we care about is implants attitude of many and yes I mean Periodontists. And as one of my good friends on this site said if it is not about implants don’t expect a discussion.

Have a great weekend,

Danny

I am going to discuss this case photo by photo. We all wonder about a little recession. Treat or watch? Particularly on molars. Another thought is what is the greatest cause of loss of molars and we all know furcation involvement.

Picture 1- Benign with just a little recession but no AG.
Picture 2- Upon reflection of the tissue a furcation involvement is present which is to be expected based on J of Perio 2003 and location of furcations from CEJ’s.
Picture 3- Reflection of periosteum to do proper osseous.
Picture 4- Barreled in furcation and osseous.
Picture 5- Submarginal graft placed.

[photographs redacted?]

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Danny,

In my opinion, taking the tooth out will insure bone loss not prevent it.

Chuck

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Danny,

I do not think that there is much debate about treatment options for this case.
In my humble opinion, removing such a tooth for implant placement would probably be open to a case of assault and battery???????
The only debate is what design of muco-gingival augmentation would one individual over another choose, but the diagnosis of a muco-gingival defect, and treatment with gingival augmentation is clearly the correct ethical and moral approach. Calibrated monitoring for changes would also be considered acceptable and implementation of treatment when changes are seen, is an alternative approach.
The only risk for this tooth is to ensure that the patient is aware of root surface plaque control in order to avoid cervical decay!
Enjoy the summer and the week-end.

Very best wishes,

Colin

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Danny,

I agree. Periodontal disease is not a disease of titanium deficiency!

Kenny

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It appears that this case is one of an early furcaction problem in a patient with thick biotype and a thick band of keratinized tissue. Cleaning and modifying the root makes sense. But why does putting more gingiva on this tooth make sense? There was no deficiency and there is no evidence to suggest that abundant gingiva is any better than adequate gingiva, especially in an unrestored tooth or without orthodontics.

It is very offensive to hear this tooth should be extracted. But I find it equally disturbing to see a gingival graft done too. Isn’t that why we apically position tissue?

Jeff

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Each to his own. Over a span of 37 years I have found plain and simple a patient can never have too much connective tissue bound down and attached. I cannot remember the last time I did an apically repositioned flap to gain AG. In fact I find that when I did them over time I did not get the result I wanted. In my hands that is. If all was well why did the patient have recession, bone loss and the start of a furcation involvement? My take on adding connective tissue is at VERY worst you added the best type of tissue to prevent future loss of bone etc. BTW, notice the teeth are not longer, old school thinking in my humble opinion and the only way I got away with that was NOT to do an apically repositioned flap but instead add connective tissue. Down here in Clearwater Florida my patients don’t like long teeth so doing apically positioned flaps in not in my vocabulary. Let’s go further Jeff, when doing APF you expose more interproximal bone generally speaking. I am really against doing that. I am talking now say perio-restorative cases where the interproximal is exposed. I shoot for primary closure to avoid as much secondary healing as possible. Less discomfort etc. I’ll stop here because you have every right to do surgery the way you want as do I. To me though apically repositioned flaps to gain AG just doesn’t fly. Remember that is only my opinion but my surgical documentation of 37 years backs up that in my hands. Try not to get too disturbed though. I don’t do implants and 95% of the teeth treated this way that are still in recall are still in the patients mouth. Probably 95% is low. I could bore you with teeth that would be extracted today for implants that are present 30 years but all pretty much have an abundance of attached connective tissue that was added. suggestion go back and look at your apically repositioned flaps 10 years later provided you documented the case initially to see where they stand. I do as I have documented 99% of all cases I have ever done. May change the way you think when you see your failures. My my case they are pretty much what I did wrong and not the patient.

Have a great day,

Danny

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How does one know the quality of the tissue until he or she passes a blade through it. This tissue was paper thin. You can’t thickness by a photo. How much longer would this tooth have been with an apically repositioned flap? End result of my surgery a shorter tooth. My choice of surgery and as I said everyone has their choice.

Danny

[photographs redacted?]

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Do nothing seems more reasonable than ext and implant.

All the best,

John

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Ok, you don’t like apically positioned flaps, then regenerate this shallow furcation. Hat make the most sense to me. Still can’t rationalize a sub marginal free Gingival graft for the treatment of periodontitis.

Jeff

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Now we are really separating treatment thoughts but you regenerate and I’ll simply remove the furcation and be done with it forever, J of Perio 2004? talked about breakdown of regenerated furcations at 5 years. As far as treatment of periodontistis and gingival grafting now we are even farther apart. The beauty of connective tissue is DENSE THICK CONNECTIVE TISSUE with very little VASCULARITY. Ideal to decrease the ability of bacteria to violate such tissue and get to the underlying periodontium. Those that went to BU will tell you when doing treatment plans KRAMER would go nuts if AG was not discussed and abundance was not recommended. Jeff, please remember whatever works for you is great!

Danny

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