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Einstein implant case to completion
From: Fred Barnett
Sent: Friday, January 23, 2009 7:12 AM
Subject: [roots] Einstein Fracture and apico #19
Einstein Case du jour.......Fred
30 male, non-contrib health hx
Pulpal DX: previously tx
PA: CPP with symptoms
May 08 - retreated complete - two visit Ca(OH)2, symptoms
resolved after first visit
Nov 08 - recall appointment - some bone fill - pt asympomatic,
no probing (WOW a real recall!)
Jan 09 - Pt becomes swollen, x-ray reveals (bottom left,
second page of photos) furcal bone loss and widening of
Today - probed under anesthesia before flap, couldn't find
anything significant. Flapped case and probed furcation
to 12mm. Looked for fracture, couldn't find one.
(Hindsight - should have looked longer and harder).
Continued with the apico. Before filling with MTA,
re-evaluated Furcal area and was able to identify fracture.
Then....I ran a sharp explorer into the fracture....
pieces seemed to separate. Restained and then I sat the
patient up and had the implant talk - Jared
Fred: not only you teach superior endo, the photography of
your residents is also top notch!
question: Is there a protocol in your program for staining
the coronal portion of the tooth (supra-osseous) looking
for fractures as depicted in this case, prior to making the
window for apico? - ahmad
That is a terrific question.....We probed under anesthesia
and did not get anything above a 4mm. Elevated the flap
and saw some granulation tissue...re-probed, and got to
the apex. We did not see the fracture, interestingly
enough, although we suspected one. When we removed the
granluation tissue at the mesial root apex, it appeared
that there was a possible crack. We then stained the
furca area...did not really see anything definitive.
Retroprepped, re-stained the furca area, and now we saw
a very thin line. We ran an explorer along that line,
re-stained, and there it was.
We completed the surgery, filled the defect with a mixture
of tetracycline and Puros, membrane, and then sutured.
This was done to help the healing as this will be an
extraction in maybe 12 weeks. I dragged a periodontist
into my clinic for advice, and we followed his recommendation.
These damn cracks are hard to see, even with direct scope
vision - Fred
What was the rational for incorporating tetracycline into
the mix. I know there are those who do so, but I am
unaware of any evidence based rational for doing so.
Most I know have stopped doing this, citing foreign body
reactions and material remaining as an inclusion.
Remember terra cortil? - gary
Our periodontists advised this due to the antiobiotic
component and anti-collagenase properties - Fred
I bet Gary's right. The theoretical construct that
anti-collagenase properties provide a true clinically
predictable benefit is very similar to the theoretical
contsruct that the increased growth factors added with
PRP or Fibrin glue will improve clinical outcome.
It's a nice inductive inference but it really hasn't
been borne out with true clinical testing - Terry
Prp is certainly another controversy. There is little question
it helps early soft tissue healing, but there is conflicting
information as to how much effect it has on bone, and after
6 weeks several studies are hard pressed to show a difference
with healing rates. I have all the stuff in my surgical
operatory, but I havenít fired it up, frankly Iíd have to go
back and review the procedures, in well over a year. but
there are people who swear by it, and others who swear at it.
Quick story on a local prosthodontist who I wonít name but
Fred probably would know here in philly. before I did my first
teeth in an hour case, I attended a live surgery case being
offered locally. It was sponsored by nobel, couple of other
companies, and Harvest, the leading prp centrifuge company.
We had lecture presentation in the a.m., probably a full hour
espousing the merits of prp, with lots of the corporate slides
being presented, and talking about the importance of prp.
Afternoon roles around, and a select few of us who had paid a
premium adjourn to the surgical operatory for the real deal.
The harvest unit is sitting off to one side, and it remained
there throughout the procedure, never used, no prp during the
procedure, guy doesnít even mention it. Apparently a case
of do as I say, not as I do. Just as well. Entire procedure
turns into what those of you with military background may have
described as a fuster cluck if you catch my meaning, and what
I take away from the surgery is what not to do the following
week with my case - gary