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Einstein implant case to completion


From: Fred Barnett
To: ROOTS
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
PA lesion
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

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