This morning I saw patient “RH” for her 3 month visit and a 5yr periodical was taken. Clinically the tooth has had no mobility since 2008 but it seems that the not only has the area filled in but held up as well. Coincidentally, she does not want to know how well the tooth is doing lest I put an ” Ayin Hara ” ( evil eye ) on it…. So goes some peoples lives….and far be it from me to bring on the “curse”

The 2 periodicals are almost exactly 5 yrs apart. The first is from 1/07 and the second from this morning…

pre-op 1/07 n.b. defect on mesial #12

5 yr p.o. complete fill and tooth has no mobility or pathologic probing depths / nor is there bleeding on probing..

PHOTOESSAY

The first photo is shows us the mirror view of 30, which is depressible and purulent as well as having a through and through furcation involvement. Standard protocol was utilized. pre-op 2/2011

ibid. macro view showing extent of edema and distention of tissue. Radiographs at the end of case....

2 week post-op. n.b- some occlusal adjustment performed, but apparently not enough. Note the developing recession on DB of 30, as would be expected.

4 month healing

6 month healing.. tissue resolving nicely but remnant of original lesion still present. The uneven tissue margins reveal uneven topography but perhaps speak to an issue of occlusal trauma as well. I expected better adaptation of the tissue at this point. After re-adjusting the occlusion ( reducing all cusp tip etc. ) I advised the patient to to return in 3 months.

9 months. altered occlusal pathway allows for excellent resolution of gingival tissues, which is as important as the healing of the underlying bon attachment.

ibid. Here we see normal gingival architecture which indicates underlying healing. n.b- distinct MucoGingival junction. Using the MB cusp tip as a guide, we see the healing taking place only after the landing point is re-oriented.

pre-op.

6 month .. beginning of fill. Apices not involved.

9 months. Increased fill into furca and greater trabeculation.

Neal Lehrman, DDS

Today’s discussion revolves around a mandibular cyst that was referred for biopsy/ removal. This 64 y.o. fellow, medical history non-contributory, had developed this lesion over the course of the last year. It was painless and had the Dentist not told him about it he wouldnt have known. In terms of why this happened, your guess is as good as mine.

Enclosed we will see the clinical course of this progression. Radiographs will come later but are not what makes this case interesting. To wit, there has been excellent healing of the site internally, but to see the films before complete fill has been achieved will not shed much light on the situation.

What interested me about this situation was twofold… Firstly, the idea that I would be able to separate out the epithelial lining without disturbing the underlying connective tissue as well as the possibility from an operator’s point, to be able to perform the procedure sans suturing. This is no small thing as a flap of this nature would require significant closure over the site to prevent collapsing of the soft tissue into the defect. Moreover, no grafting of the site was performed, which would normally necessitate some sort of “scaffolding” to support the healing.

The procedure was performed with a standard full thickness trapezoidal-flap, and then laser enucleation was completed. Upon achieving clotting in the site, the flap was replaced but only laser energy was used to ” tack ” it back to its original position. This allowed for a virtually painless recovery period, one which would have been decidedly uncomfortable had there been suturing involved.

Finally, we see 2 month healing and what is particularly interesting to note is that there was no in-folding of the tissue into the site despite the lack of a sub-structure , be it a graft or a membrane. This was a pleasant surprise to the patient. For the record, the patient was apprised that a secondary procedure might be necessary, and he was ok with it from the outset.

Review of the pathology reveals that it was a cyst and that there is no further treatment necessary at this time.

As more films become available I will distribute them periodically. For now however, we now know that we can add these types of procedures to our arsenal in our ever evolving attempts to improve patient care. Comments, thoughts and pithy-isms are always welcome and as always, keep on healing.

pre-op view of anterior mandible. n.b. “bluish”
appearance of cyst

ibid. this view helps us appreciate the actual size of the lesion
relative to the jaw.

with flap elevated

after laser ablation

after laser hemostasis

with flap replaced and ” Sewing machine- like tacking”
back into place. No suturing involved. Excellent hemostasis

one week post-op. slight creeping of fibrin around the margins.
Pt reports no post-op discomfort although still some slight
inflammation.

2 month healing with excellent tissue remodeling.
n.b. the normal architecture of the mandible.
preventing the collapse of the tissue is paramount to
uneventful healing. In cases like this where no
scaffold is utilized, this take on even more significance.

Neal

To conceptualize this , there was  no lingual plate present and unlike in an endo-perio lesion, the probing was not limited to a narrow focal point. Rather, a wide swath was accessible from buccal to lingual. The tooth was treated in 2008 and the most recent film was taken approx 1 month ago.

While it is clear that there is significant fill and from a clinical standpoint there is minimal probing on the lingual aspect of the tooth, more importantly
the tooth is solid ( no Mobility ) , probing no greater than 5mm without bleeding on the distal and has been so for a few years. Although I would have liked to see complete fill of the defect, the important part here is that he is comfortable and stable. Even assuming we only got a few more years out of a diseased tooth, how significant is that? In actuality, the recent re-eval leads me to believe that this tooth is here to stay, but that is almost beside the point.

As a periodontist who was trained on fixture placement as the ideal form of therapy- perhaps we need to re-shift our focus. We now have technology that will allow us to extend the “Dental-Lives ” of our patients, with minimal risk in terms of loss of attachment that would impede future therapies. Perhaps, if anything, the collateral benefit of these procedures is the strengthening of the attachment so that if necessary, we have more options down the road.

Happy Thanksgiving…

N

Left: Pre-op 2008. Probing to apex, painful to percussion , suppurative and class II mobility.

Right: October 2010. 5 mm on lingual, no bleeding. zero mobility and excellent radiographic fill. Pt is comfortable and does not even think about this tooth.
( which is a dentists best result!)

After a brief hiatus in sunny Cerritos, Ca. we return to our regularly scheduled programming. This week we are confronted with a tricky situation. Tricky not because the fix is difficult… but until LANAP, there was no fix (but to wait it out) . And, as you will know if either you or a patient has had this condition, it can be brutal during its self-limiting course.

In July of 2007 a 36 year old caucasion male presented upon recommendation of his General practitioner due to severe pain, swelling bleeding and sloughing of the tissues. Not to mention that this gentleman had been febrile and unable to swallow for approximately 4 days. Getting lucky as I sometimes do, he immediately told me that his daughter had been sick with Coxsackie A Virus and it presented exactly the same way..That pretty much confirmed one of the possibilities of the decision tree but left me wondering how to alleviate some of his pain. Note well the suture placed by the previous dentist in a valiant attempt to stop some bleeding due to curettage. Moreover, the first few photos show the depths of the tissue destruction that had taken place in a very rapid time frame.

Traditional therapy for this problem is to scale as much as possible  and place the patient on some sort of “Magic Mouthwash”, in the hopes of palliatively helping until the disease runs its course. Usually in about 14 days time.  In this case, LANAP was performed with the idea that although this was not garden variety periodontitis- at least we could speed up the process. What happened was instead a very pleasant surprise. For everyone.

The final 2 photos are 2 yr post-op and this fellow is not a great hygiene patient. And off we go.

As always, thought’s are appreciated and as I still haven’t received a critical mass who are interested in a lecture , I will keep the idea open until mid -December to see if we get enough attendees.

When I met this patient almost 3 yrs ago the first thought that went through my mind was ” Why would anyone try and save this tooth ( #18 )” ? Not only was the existing restoration “poor” to say the least, the tooth required endodontic therapy ( if even possible ), had 2+ mobility and was suppurative to percussion. Forget the furcation involvement. Most importantly, the fellow belonging to this mandibular left 2nd molar was at the time -87 years old.

As I was debating ( in my ” inside voice” ) how to tell him delicately that I didn’t think it prudent for him to follow through with any treatment other than extraction- he gently chided me and said ” Don’t look at me as an old man- I don’t look at myself that way.” That was the AHA! moment that I’m certain every one on this list has had at one time or another…the moment when we realize that what we want is not necessarily what the patient wants- or needs. ( within reason of course). To which he concluded ” They are all mine, and I would hate to lose my first tooth at this age.”

To that end, I offered  to treat the area including the adjacent tooth with LPT ( LANAP ) and hoped for the best. Another sign from above that should have told me that this was going to work was that the gentleman left immediately after the procedure to Vermont for the annual ” college roommate w/wife/s reunion weekend ” which had been a tradition for 63 yrs.!..

The rest is straightforward with a few interesting points to ponder. Firstly, the distal root seemed to be calcified and  the widened pdl space tells us clearly that there is an occlusal component to this particular case. Indeed, the tooth was hitting significantly on the wrong cusp and the distal marginal ridge..This was adjusted at the time of surgery. And again, and again and again. But, no endodontic therapy was performed and the symptoms have abated at least until this point. Very Surprising.

Standard LPT protocol was followed and follow-up w/ occlusal adjustment were performed for 1 yr. The final film was taken in May of 2010 just shy of 36 months post-op. Patient, Tooth and College Room-mates are all doing very well. The tooth in question has 0 mobility and probings are wnl…

As always, I look forward to your comments and if there are cases that you would like to share with the group, send them to the above email and we will take it from there. As always, if shown you will get full credit for your work.

Finally- and I am sending this out as a test balloon to both Lanaper’s and Non Lanaper’s alike- Would there be interest in a lecture/ dinner/ ce course with a more formal presentation on LANAP? If there is enough of a critical mass, I will gladly arrange it. There are some excellent speakers out there willing to share.  It would probably be mid-winter here in NYC. For those that already do the procedure- there could be a case conference where people present their own cases and dialogue with the group. For those not yet familiar or more interested in just getting their patients’ to the right place, not necessarily doing the procedure themselves- a much more in depth talk focused on the possibilities and capabilities of LANAP  as a modality of periodontal care will be arranged.

Let me know….and Keep on Healing,

Neal

Left: pre-op june 2007. Tooth was mobile, suppurative and as well note the
areas apical to #19. This tooth was not symptomatic but nonetheless was treated at the same time.

Right: May of 2010- almost 3 yrs post-op. Pt is now 89 yrs old and his teeth are going strong.
Note the bone fill on the distal root of #18 and the return to
“normal ” of the pdl space around said root.

Pt is comfortable and reports no symptoms. Mobility has all but disappeared
and there is no significant pathologic pocketing.
#19 seems to have re-trabeculated as well.

This week’s case is interesting for a few reasons. Firstly- the response was much better than expected, and moreover, it is an excellent example of how these patients can fare over an extended period of time.

We are greeted by a 38 year old caucasion female- Literally ( I think she is from the Caucasus region ) who presented to me in early ‘06 with only one issue. ” MY I-tooth is loose “. The photo clearly shows the area around 26-27 to be inflamed and clinical evaluation of it revealed sig mobility.

1. Pre-Op February 2006
” MY I-tooth is loose ”

In fairness to the practitioner on the other side of the pond, I am not sure what materials were available at the time of all of this treatment but needless to say the issues far exceeded her chief complaint. n.b.- the crown on #10 was replaced, other than that- she refused any other treatment.

LANAP was performed ( Full Mouth ) and she had #10 replaced.

Immediate Post-Op LANAP

Immediate Post-Op LANAP

The Photos are annotated but of particular interest are the 3-5 pics. Here is an excellent example of the immediate post-op clotting which is the key to LANAP success. As the clotting pathway is different from the traditional mechanism, there is little if any “oozing” associated with traditional surgery.As well, pt’s who are on anti-coagulant therapies ( aspirin, coumadin, plavix etc.) can be safely treated without any cessation of their medications.

2 week post-op.   So far so good.

This is an excellent example of how the “Clot” forms after a LANAP procedure.
It has been described as ” gelatinous” and indeed it just kinds of sits there.
This is crucial in the healing of the case and to allow the underlying connective tissues to
re-organize.

Ultimately, what pleased me the most about this case was the ultimate healing and continuation of “health” even without the greatest compliance. The mandibular right cuspid has no mobility and probing depths are wnl. ( from an initial 12 mm on the mesial prior to surgery).

August 2010

In truth , the tissue has looked  this good  for at least 2 yrs now,
but this is an excellent example of how these cases hold up over extended periods.
This patient presents only 1x a year for maintenance but somehow has kept up.

As always, feel free to comment, ( constructively ) criticize and share.

Actually, this case is interesting as it helps us to understand the potential for treating otherwise difficult periodontal defects and enable patients to retain their own teeth rather than extract and place fixtures. That said, fixtures are terrific, but in the esthetic zone there are significant hurdles to overcome, so why not work with what we have, when we can.

pre-op..Jan 2006-note the discrepancy of the
incisal edges 8-9

14 mm probing depth

13 mm horizontal defect

This fellow, at the time was 35 and a smoker. He presented with a defect on the mesial of #8. At first blush, it didnt seem that anything was wrong- but probing and radiographs proved otherwise. To treat a defect of this nature, one with both a vertical and horizontal component in this area, is always a challenge. By elevating the tissue alone to place a graft/membrane you will be left with recession and the dreaded  “black triangle”.

Immediate Post-op- pre incisal adjustment

incisal adjustment

The case was treated with LPT ( LANAP ) and the results were excellent , if not curious…. The radiograph at the end shows the pre-op lesion and on the left- 4 yr post-op….  note the incisive canal as a landmark for the re-growth of the interproximal bone.

1 yr post-op

4 year post-op ( slight triangle )

4 yr post-op p.a.        pre-op showing extent of defect.
n.b. – the foramen as  a landmark for bone-regrowth

Please share your thoughts, they are always appreciated. To have your own cases displayed on this list, please send me an email with the case and history and we will take it from there. As always, you will receive all credit due for your work.

*As always, to be added to this list just send an e,ail to the above address with a request in the subject line. To opt-out, do the same with “please remove”  as the subject.

January 2010 Pre-op

The question remains- is if the the tooth is indeed non-vital, how does one explain the healing from inside the root canal system? ( n.b.- now that the tooth has healed and has none of the aforementioned issues- it is slated for endo, but that is to prevent recurrence moving forward..). What about the laser energy changed the periodontal environment?

September 2010 Post-op

If there are any endodontists or endo enthusiasts out there- points for creativity… and always… dont forget to show your work:
N

Pre-Op Photo showing Diastema 9-10 with Ill fitting
crowns and significant Inflammatory component.
( N.B.-#’s 9&10 have significant mobility with #10 being
depressible.)

The case went well and here we will focus on one curious area- 9-10. #10 was depressible, suppurative and the duration of the diastema was approx 9 mos. The restorative Dr. wanted it out and a fixture placed- as did I. As we weren’t the deciding factors- the tooth stayed to live another day, and the assumption was that it would exfoliate on its own and we would proceed with the implant at that time. Occlusal adjustment was performed throughout the entire mouth at the time of surgery and at every post-op.

1 month post-op with resolving lesion apical #10.
(This is notable too… LANAP cases tend to heal in a fashion that clearly
defines the Mucogingival Junction) Tissue contours have returned
as close as possible to physiologic dimensions.

Much to my surprise ( then-not now) the tooth slowly began to heal as evidenced by the series of photos seen below. At first the tissue apical to interproximal 9-10 began to heal from papilla up, with the lesion  decreasing in size until at about 23 months- it was gone completely.Very Strange. There is currently no mobility, BOP or pathologic pocketing in that or any other area.  Most interestingly- the papilla for the most part- has not disappeared.

6 month p.o. from full mouth LANAP. Diastema closing

My question is: Has anyone else seen healing of a lesion in this fashion- in such a discreet focal manner? If so- do you have any idea why this might be so?  All answers are appreciated.

2 year post-op. Probing depths WNL. Minimal spacing
and excellent overall tissue-tone.Neither 9 or 10 exhibit
any pathologic mobilities.

Secondly, this case is a great example of why procedures such as LANAP- specifically, and technology-in general- require us to think ” differently than we were taught.” Had I ( or any one of you ) elevated a flap in this area and degranulated- the result would be an esthetic disaster. Moreover, true regeneration can take up to 2 yrs post surgery.. and in this case that was the ticket. The human body has the capacity to heal- if we let it.

As always- if you want to forward this to someone who might want to join in the discussion feel free and if you want out just send me a note to the above address with your request in the subject line…

For anyone who has interesting cases that you would like to publish to this group- send to me under separate cover and if used, you will be given full credit for your contribution. The more that we share the more that we get back.

Thanx For Playing:

Neal