Surgical Therapy - Phase II
Mr. J presented for periodontal surgery, the following areas have been chosen for treatment. Maxillary anterior teeth #8 and #9 present with PFM crowns and have vertical bone loss with visible recession. Maxillary posterior teeth 14 & 16, present with vertical bone loss on the distal and mesial of both teeth. Tooth number 16 has also started to supra erupt since there is no opposing tooth on the bottom (#17). Tooth number 15 was extracted after radiographs were taken due to an infection. Present radiographs shows severe bone loss on the mesial and distal of this tooth. Mandibular lower anterior tooth is present with horizontal and vertical bone loss, root resorption and class three mobility with depression. Tooth number 25 is not present and the area of #25 has some horizontal bone loss. Tooth numbers 30 and 31 are not present this area is being restored to provide function, prevent occlusal migration of counteract teeth, and prevent more bone loss. Due to the absence of teeth #25, #30 and #31, the biting force on the remaining teeth have changed, increasing pressure on the jaw joints, teeth shifting, and risk for periodontal disease. The fact that Mr. J continues to use tobacco, his healing during this process will be delayed unlike a nonsmoker who has the potential for a faster healing process.Smoking leaves Mr. J with an increased amount of periodontal pathogens present in his mouth
Surgery Phase
The type of surgery recommended for Mr. J will be a flap for access or Widman flap surgery will be done on the maxillary anterior for access of tooth numbers 8 & 9. An allograft bone graft will be done is this area to try and restore an adequate bone level that is in line with the rest of the arch. Allograft grafting material is decalcified material from the same species to prevent rejection, with the bioresorbable membrane performed at the first appointment.
A Widman flap will also be done on the posterior maxillary teeth 14, 16 and lower anteriors (area of 24& 25). Extraction of tooth numbers 14, 16 and 24 will be done at this time. Since there was severe bone loss in the area of tooth number 15 and surrounding area and also the lower anteriors, additional allograft bone grafting material will be place at these areas after extraction to reestablish a more natural looking bone contour. Since both the lower anteriors and upper posterior molar regions suffered from a good amount of bone loss, implants will not be place at this time in order to insure a positive osteogenesis of the treated areas. This will help to promote a successful build of height and width of the bone placed.After grafting of the selected areas is complete a special collagen membrane is placed to protect and promote reparative healing. Sutures will be placed in order to hold the tissue together during healing. Since recession was prevalent in the areas of 8 and 9 a coronal positioning of the flap may be recommended by using a combination of interrupted and sling sutures. Periodontal dressing will be placed to aid in the placement of sutures and the healing of tissue. Specially made dentures can be constructed during this the time of healing for the patient.
A follow up appointment will be made to assure the progression of the healing process. Successful healing of tissue can wake up to a few weeks or more and bone graft can take between a 4-6 months. Once the healing time has passed and healing is complete, the patients next visit will be for the placement of standard dental implants for the upper right posterior regions and lower anteriors. The lower left region will benefit more from the mini implants. Since there has been some bone loss to the area but the remaining bone is healthy and dense bone this would be the best option for this area to avoid any complications. The initial osteotomy sites are established by drilling and increasing diameters for the placement of the implant body. Then the implant body is placed in the bone slightly above the crest of the bone. The gingival should be secured over the implant and left undisturbed to allow for osseointegration of the implant body and the bone for a period of 3-6 months in promotion of the healing process. Again special constructed dental wear can be worn at this time of healing.
Proper home care instructions should be given to the patient during the entire surgical treatment. Proper removal of unwarranted bacteria and biofilm will play a key role and the success of these surgical procedures. Upon maintenance visits radiographs should be taken to insure no bone loss or tissue damage is being done. During the second step/ next visit, the implant is uncovered and the abutment post is attached. One more time the gingiva is allowed to heal around the abutment post. Finally, the dental crown is attached to the abutment post.
Before the surgery, nutritional counseling and smoking cessation would be discussed with the patient as well as telling the patient how proper nutrition and smoking can affect the mouth and delay healing. We will discuss the importance of any alcoholic beverages must be avoided 12 hours prior to surgery and to eat a healthy breakfast while staying hydrated. We will state that Mr. J’s diabetes must be under control and evaluated by primary physician for the safety and health during the dental treatment. The patient would be informed that any Aspirin-containing drugs should be discontinued for 7 days prior to surgery and Ibuprofen-type (Motrin/Advil) drugs should be discontinued 2-3 days prior to surgery. Lastly, we will discuss oral hygiene instructions with Mr. J to brush his teeth and rinse with recommended oral rinse.
After the surgery, instructions for care of sutures and/or periodontal dressings will be discussed with Mr. J such as eating a soft diet until the sutures and dressings have been removed. Instructions for prescriptions of antibiotics for pain that the dentist has prescribed for Mr. J. The dentist will most likely have the patient use 0.12% chlorhexidine mouth rinse twice daily to promote the healing process. Oral hygiene instructions will be discussed with patient thoroughly. We will once again remind Mr. J the importance of staying away from any alcoholic beverages for atleast 48 hours after the dental procedure as well as no smoking no matter what. It is important that we remind the patient of how smoking will affect his mouth and delay the healing process. We will let the patient know to come back for his evaluation appointment in about 1-2 weeks and then 3-4 weeks later.
ADA codes
D6010 Surgical placement of Implant body
D6066 Implant porcelain fused to metal
D4263 Bone Replacement Graft
D4266 Bioresorbable membrane material
D1320 Tobacco counseling for the control and prevention of oral disease
D1310 Nutritional counseling for the control of dental disease
D1330 Oral hygiene instructions
D4275 Soft tissue allograft
D7140 Extraction, erupted tooth or exposed root
D4240 Gingival flap procedure,
Surgery Phase
The type of surgery recommended for Mr. J will be a flap for access or Widman flap surgery will be done on the maxillary anterior for access of tooth numbers 8 & 9. An allograft bone graft will be done is this area to try and restore an adequate bone level that is in line with the rest of the arch. Allograft grafting material is decalcified material from the same species to prevent rejection, with the bioresorbable membrane performed at the first appointment.
A Widman flap will also be done on the posterior maxillary teeth 14, 16 and lower anteriors (area of 24& 25). Extraction of tooth numbers 14, 16 and 24 will be done at this time. Since there was severe bone loss in the area of tooth number 15 and surrounding area and also the lower anteriors, additional allograft bone grafting material will be place at these areas after extraction to reestablish a more natural looking bone contour. Since both the lower anteriors and upper posterior molar regions suffered from a good amount of bone loss, implants will not be place at this time in order to insure a positive osteogenesis of the treated areas. This will help to promote a successful build of height and width of the bone placed.After grafting of the selected areas is complete a special collagen membrane is placed to protect and promote reparative healing. Sutures will be placed in order to hold the tissue together during healing. Since recession was prevalent in the areas of 8 and 9 a coronal positioning of the flap may be recommended by using a combination of interrupted and sling sutures. Periodontal dressing will be placed to aid in the placement of sutures and the healing of tissue. Specially made dentures can be constructed during this the time of healing for the patient.
A follow up appointment will be made to assure the progression of the healing process. Successful healing of tissue can wake up to a few weeks or more and bone graft can take between a 4-6 months. Once the healing time has passed and healing is complete, the patients next visit will be for the placement of standard dental implants for the upper right posterior regions and lower anteriors. The lower left region will benefit more from the mini implants. Since there has been some bone loss to the area but the remaining bone is healthy and dense bone this would be the best option for this area to avoid any complications. The initial osteotomy sites are established by drilling and increasing diameters for the placement of the implant body. Then the implant body is placed in the bone slightly above the crest of the bone. The gingival should be secured over the implant and left undisturbed to allow for osseointegration of the implant body and the bone for a period of 3-6 months in promotion of the healing process. Again special constructed dental wear can be worn at this time of healing.
Proper home care instructions should be given to the patient during the entire surgical treatment. Proper removal of unwarranted bacteria and biofilm will play a key role and the success of these surgical procedures. Upon maintenance visits radiographs should be taken to insure no bone loss or tissue damage is being done. During the second step/ next visit, the implant is uncovered and the abutment post is attached. One more time the gingiva is allowed to heal around the abutment post. Finally, the dental crown is attached to the abutment post.
Before the surgery, nutritional counseling and smoking cessation would be discussed with the patient as well as telling the patient how proper nutrition and smoking can affect the mouth and delay healing. We will discuss the importance of any alcoholic beverages must be avoided 12 hours prior to surgery and to eat a healthy breakfast while staying hydrated. We will state that Mr. J’s diabetes must be under control and evaluated by primary physician for the safety and health during the dental treatment. The patient would be informed that any Aspirin-containing drugs should be discontinued for 7 days prior to surgery and Ibuprofen-type (Motrin/Advil) drugs should be discontinued 2-3 days prior to surgery. Lastly, we will discuss oral hygiene instructions with Mr. J to brush his teeth and rinse with recommended oral rinse.
After the surgery, instructions for care of sutures and/or periodontal dressings will be discussed with Mr. J such as eating a soft diet until the sutures and dressings have been removed. Instructions for prescriptions of antibiotics for pain that the dentist has prescribed for Mr. J. The dentist will most likely have the patient use 0.12% chlorhexidine mouth rinse twice daily to promote the healing process. Oral hygiene instructions will be discussed with patient thoroughly. We will once again remind Mr. J the importance of staying away from any alcoholic beverages for atleast 48 hours after the dental procedure as well as no smoking no matter what. It is important that we remind the patient of how smoking will affect his mouth and delay the healing process. We will let the patient know to come back for his evaluation appointment in about 1-2 weeks and then 3-4 weeks later.
ADA codes
D6010 Surgical placement of Implant body
D6066 Implant porcelain fused to metal
D4263 Bone Replacement Graft
D4266 Bioresorbable membrane material
D1320 Tobacco counseling for the control and prevention of oral disease
D1310 Nutritional counseling for the control of dental disease
D1330 Oral hygiene instructions
D4275 Soft tissue allograft
D7140 Extraction, erupted tooth or exposed root
D4240 Gingival flap procedure,