From: Terry Pannkuk
To: ROOTS
Sent: Thursday, February 18, 2010 3:42 AM
Subject: [roots] Cracked Tooth Pneumatized Sinus Implant

This was an interesting case to take before and after CT's on.  I decided to flap the case due to the
CBCT data showing some irregular bone contours and cratering.  I doubt I could have been as accurate
with the placement if I had chosen to do this flapless. I had to direct the osteotomy precisely along
the bone in the regenerated previous socket.  A wider platform than 4.3 would have probably blown out
all the available native bone requiring grafting and a riskier outcome.   I wouldn't have dreamt of
doing this as an immediate replacement.

It was a tough decision for the patient to decide between doing the endo with build up versus
extraction implant.  We outlined all the pro and cons ahead of time.  The referring dentist was not
enthusiastic about putting a crown on the broken down bicuspid with this patient being a heavy bruxer.
A different patient and a different referring dentist may have decided to save the tooth.
Borderline call - Terry






Terry, terrific precion with placement!!!... just exactly like in your planning
(or was that plannig done after placement? LOL!)

Did you use any condensers to infracture sinus floor and lift it up? Why 4.3 platform (why not narrower?)
Do you plan on soft tissue augmentation later on? -  Dmitri

A regular platform NBC fit fine.  A narrow platform NBC is known to be weak with a history of breaking.
Would you want to put a weak fixture in this guy? :):):) - Terry

Yeah, right... i just keep forgetting you're pure NBC guy :-))
OK... not selling anything here, but one thing to think about - Ankylos A implant (3.5mm diameter) would
not break even in this type of patients. On the other hand i do understand your situation with
restorative doctors... nevermind.

Terry, you mentioned you're conservative grafter... OK... however, how do you treatment plan and approach
soft tissue grafting? In this case, for instance, would you think of augmenting attached keratinized
tissue on the bucal aspect? Why? When? - Dmitri

You are really razzing me.  I'm not an NBC, CBS, ABC or any other major network guy. :):):)  I wait for
new products to arrive and don't deliver them myself.  Ankylos hasn't come to town yet.  It's hard enough
to get some off my referrals to restore Astra.   Dream on if I'm going to fight to get them to buy into
Ankylos.  If you, Ken, Jim Tinnin, or Jose want to come to Santa Barbara and sell my referrals on Ankylos,
I'll be happy to buy the Ankylos kit as my next system when my referrals are willing to restore them and
want me to place them.  I've seen way to many zealots talk up new products and then have to divorce
themselves from the negative results later.  I'm very happy letting others do the selling and be the
"earliest" adopters.  I'm simply satisfied being an "early" adopter.  Drugs have Phase 1, 2, 3, and
4 trials for a reason.   Dentals products and materials should be accepted in the same way.

Good question,  Why? When?, and What for?

I felt a palatal graft would have been overkill for this case; maybe for a maxillary anterior on a
"smiley patient".   I can do that but for political/specialty boundary reasons usually refer to the
periodontist for those cases.  If I didn't have Dennis Shanelec and Adrianna MacGregor in town I'd probaby
do more of that but I like to respect their turf and play well with others (at least offline) - Terry

Wow!  Another great 4xbi extraction case.  The last thing this guy needed was to have his mouth made
smaller by extractions and retraction mechanics.

I'll bet he's got some serious upper airway obstruction and sleep apnea going on.  BTW, the airway
obstruction cases are the ones that clench and grind the hardest - Arturo

Yep, Very accurate assessment! - Terry

Terry, this is the perfect example of the EIA, where you have to present all the treatment options the
patient has to gi through in order to restore and maintain the tooth. I just recently had a patient that
came for a consultation for a bicuspid, and after telling the patient that he was going to need RCT,
crown lengthening, and post and crown, he decided that he would prefer to have the tooth extracted and
have a dental implant place, he already had two and was very happy with them.

On your case, did you use osteotomes to finish the osteotomy?
why did you go subcrestal in your placement? - Jose

Hi Jose, Yes, I used osteotomes..  It's not really subcrestal at the mid-buccal which is where the only
portion of the platform is even with the osseous crest.  It seems preferable to have no portion of the
platform supraosseous.  Adding graft adds risk.   If the patient was a supermodel instead of a guy with
a beard/moustache that didn't show his bicuspids in the smile line, I might have considered a small block
graft or tacked down membrane with a pouch of Puros.  Unless the patient and referral want it, they don't
get it.  Risk is risk and I do everything I can to protect my success rate. I'm a huge fan of native bone
and believe that the natural blood clot is the gold standard graft material.  "Esthetic plumping" is not
necessary for most patients, especially this one.  I ended up inclining the implant a bit more palatally
than planned after I flapped and saw the buccal bone contour.  3 choices were available:

1. place the implant as planned without grafting (bad idea which could have led to exposed threads
   and a dehiscence)

2. place the implant as planned with grafting (ok option with added risk that this patient didn't require),

3. incline it subtly a bit more lingual but make sure it's deep for a good emergence profile to make
   the referral happy (my choice).

As you can see from the clinical photo, the emergence of the implant driver really doesn't even look like
it's inclined palatally from the clinical view.  I doubt the referral will even think it is angled palatally
because it only looks that way on the CT, not in the mouth. This is the reason I don't really like precision
guides.   I like being able to make some subtle adjustments during treatment if I discover additional
information about osseous contours and bone quality. A rigid precision guide restricts you from making
prudent "on-the-fly" modifications.  I really feel that I placed this one exactly where I wanted it,
There are certainly some differences of opinion, and I'm not going to pretend I always make perfect decisions.

This is simply an interesting example of my developing a definitive plan, communicating it thoroughly,
but then flexibly changing it as I saw fit with no hesitation or lack of confidence. :):):)  Even when
I'm wrong, I'm very confident because at least I spent a lot of time and effort getting other opinions
trying to be right during the planning.  Feel free to rip my rationale, but please don't tell me Ankylos
would have been better, maybe it would have been, but many of my referrals insist on my using NBC because
that's what they are used to restoring.   I've had very good success with NBC and the restorations have
looked great on recall. The key seems to be getting them deep enough so the emergence looks natural.
If the placement is a little off, it's even more important to get them a bit deeper (within reason).

Here is the area of the platform that is flush (right at the mid-buccal - Terry





Terry, great placement and rational. I admire your passion for teaching and to perfection everything you
try to do. I am not going to tell you that Ankylos is better, with the protocol that you followed that
implant is going to work great. In terms of your referrals being use to NBC, remember Schilder's fight
against lateral condensation? that was the only thing people knew at that time, and they refuse to listen
to the new technique. In my practice I went through the same struggle, all they wanted was internal hex,
I just told them to try the Ankylos system and read the studies behind it. I supplied the prosthetic kits
for them so that they would not have to go into another expense, and trust me, once they tried it they
loved it. As a friend and a colleague that respects you, just call the rep from your area and see if you
can borrow a surgical kit to place a couple of implants. The day that you uncover the first one you will
fall in love, it does not smell!!! it is clean!!

We should also get together at some point to coordinate our lecture on marketing for endodotist for the
webinar. Give me a call if you have any questions - Jose

Jose, Actually, Ankylos could be the next system I will buy.  Working as part of a team requires compromise
which for people like us is hard to accept, although necessary. If no one wants to restore them,
then I can't place them. :(  I understand.   - Terry

can you post some pictures with the bicuspid before extraction?:) - Sergiu

Sergiu, I don't have a clinical photo of the bicuspid as it existed before extraction, but I do have this
one with the Collaplug immediately after extraction.  It was a very easy extraction and rotated out.
You can see that the buccal plate was paper thin and collapsed at the osseous crest.  In many similar
instances I would have placed a membrane and graft to insure that it didn't collapse but in this case with
the sinus completely enveloping the socket I wanted no graft to interfere with natural clot formation hoping
to gain maximum native bone regeneration with no foo foo contamination, figuring if it collapsed more than
acceptable i could always place the implant and graft at the same time later (which I've done several times
successfully).  The plan was to get all the native bone I could get first, then augment it later if necessary.

I am a very conservative grafter; there has to be an esthetic concern or a need for adjunctive support for
primary stability during later implant placement.  It didn't' seem to be necessary in this case - Terry



So as usual I want to know whether that is an NBC replace select. - Sanjay Jamdade

Hi Sanjay, It's a Replace Select Straight - Terry

Curious to know why one of the best endodontist we ever knew knocked that one out Terry. Ofcourse pre operative
pictures would probably tell a different story though.Too bad we can't see them. Just loud thinking. May be
the chances of getting a ferrule may have been difficult mesially with out a crown lenghthening. And for some
reason crown lengthening was ruled out as a possibility.

And what might have those reasons been? failed re treatment? poor crown root ratio after CLP? Or the patient
had already had that done before...

How far away am I from your logic? Just curious to know....Sanjay Jamdade

I just went through server upgrade Hell, so I’m a little late with my email responses.  Our  whole office
computer system is in disarray and we’re getting it back together.

I took the tooth out simply because I respect the restorative dentist’s judgment and skills; I wasn’t going
to second guess him. He didn’t feel comfortable having crown lengthening performed.   After definitive caries
removal and a crown prep there was no supragingival dentin left.  With another dentist and another patient
I may have treated that type of case with endo.

These were the determining factors:

1.The patient did not want to accept the risk that the restoration would fail and wanted a definitive treatment
  with fewer risks.   If the patient was tolerant of moderate root fracture risks understanding he may need an
  extraction/implant later, I would have saved the tooth.

2.The referring dentist is one of my best referrals and very talented restoratively.  If he didn’t feel comfortable
  restoring it, I certainly wasn’t going to over-ride him and the patient.  I wasn’t willing to take that risk myself.

3.Crown-lengthening, RCT, Cast Core, and Crown was actually more expensive than extraction and an implant.
  The patient didn’t have insurance so it seemed undesirable for him to save a risky tooth with more expense,
  and if it failed have to pay more than double to replace it in the long run.

I think these are all reasonable considerations for the patient and referral to consider.  Just because I can do
root canal treatment on a tooth doesn’t mean I should.  Treatment planning is not a unilateral decision,
nor should it be - Terry