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    warshawsky warshawsky Document Transcript

    • PERIODONTAL CASE REPORTS JANUARY 2008 – JUNE 2009A GUIDE TO UNDERSTANDING PERIODONTAL DISEASE AND TOOTH PRESERVATION VOLUME 3 PROVIDED BY PERIODONTICS OF THE DESERT PETER WARSHAWSKY, D.D.S. RODRIGO LAGOS, D.D.S., M.S. STEVEN JACOBSON, D.D.S., M.S.
    • PERIODONTAL CASE REPORTS TITLE PAGEGingival recession: What happens when it is left untreated January, 2008Dental implants: Treatment options for the edentulous mandible February, 2008Combined periodontal-endodontic lesion March, 2008Calculus: Benefits of flap access April, 2008Dental implants: Site development May, 2008Biologic Width: Why is it important June, 2008Cervical erosion: Ideal treatment July, 2008Esthetic crown lengthening: Improving smiles August, 2008Inflammation: Why it leads to bone deterioration, amongst other things September, 2008Dental implants: Timing of placement October, 2008Ridge Preservation: Reconstructing a damaged alveolar bone November, 2008Guided Tissue Regeneration: Preserving teeth December, 2008Gingival recession: What happens when it is left untreated January, 2009Gingival recession: How to correct it and preserve teeth February, 2009Periodontitis: Associated with medication March, 2009Periodontitis: Associated with diabetes April, 2009Periodontitis: Common questions May, 2009Dental implants: Locator abutments and over-dentures June, 2009
    • JANUARY 2008 WHAT CAN HAPPEN WHEN A MUCOGINGIVAL DEFECT IS NOT CORRECTED?The loss of gingival attachment can progress. When deterioration reaches a certain level, correction of the defect may notbe possible. Continued loss of periodontal support can make tooth replacement options much more involved.PRE-TREATMENT PHOTOGRAPH OF TOOTH #27: POST-TREATMENT PHOTOGRAPH OF DENTAL IMPLANT:Tooth presents with 10mm of gingival recession. There is also a Tooth #27 was replaced with a dental implant. The steps necessary4mm periodontal pocket on the buccal so the attachment loss is for this were as follows: 1) extraction of tooth with a „socket‟14mm. The tooth has a class II mobility and is painful to preservation procedure and a lateral sliding flap; 2) onlay bonechewing. THE PROGNOSIS FOR TOOTH graft (donor site from the ramus); 3) dental implant placementPRESERVATION IS POOR. 4) implant uncovery and 5) restorative treatment with general dentist. Photograph of cuspid site following reconstruction of the Radiograph of dental implant shows integration. A short hard and soft tissues. This was the presentation prior to implant length was necessary due to lingual cortical plate dental implant placement. undercut.CONCLUSION: Early intervention in the correction of mucogingival defects, through soft tissue graftingprocedures, can be a more conservative treatment than tooth replacement. This can be seen via this casereport.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • FEBRUARY 2008 TREATMENT SOLUTIONS FOR THE MANDIBULAR EDENTULOUS PATIENT OPTION 1: MINI-IMPLANTS - 4 to 6 mini-implants required - provide improved retention for the denture. - based on mechanical lock of implants to bone opposed to biological integration - uncertain life-span -smallest financial investment for patient OPTION 2: IMPLANT OVERDENTURE -2-4 dental implants; can use locator abutments, ball abutments or a bar. -there still can be some movement of the denture -based on osseo-integration, so has OPTION 3: IMPLANT OVER-DENTURE WITH HADER BAR -4-6 dental implants -very high degree of retention; usually no movement during function -predictable esthetics -very high degree of successOPTION 4: FIXED IMPLANTSUPPORTED BRIDGE-6-10 dental implants-may require bone grafting-can be challenging esthetically-teeth are non-removable-largest financial investment for patientThe options listed above range from least to most involved. Treatment selection depends on clinical andpatient factors. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • MARCH 2008Treatment of a primary periodontal, secondary endodontic lesion related to foodimpaction from an open contact. Radiograph and photograph reveal extensive deterioration associated with tooth #30 distal. The radiograph reveals a vertical bone defect that extended to the apex of the root. The photograph shows the periodontal probe extending down 12mm. Tooth 30 is temporized to close the open contact that had caused the periodontal damage. The tooth was determined to be non-vital by the endodontist. Flap elevation reveals the Photograph shows the bone graft Photograph shows a Bio-Gide membrane infrabony defect between teeth 30 in place. A synthetic growth placed over the bone graft. This membrane is and 31. The temporary crown has factor has been used to stimulate resorbable and provides epithelial cell been removed for better access to periodontal regeneration. exclusion to promote periodontal regeneration. the periodontal defect. Six month follow up radiograph reveals dramatic bone fill of the defect. Also seen is the root canal which helped to eliminate periodontal pathogens that had migrated into the root canal system. The area now probes 3-4mm. Differentiating between periodontal and endodontic etiology can be difficult. Radiographic and clinical evaluation can help determine if the diagnosis is 1) primary periodontal, secondary endodontic or 2) primary endodontic, secondary periodontal or 3) a combined periodontal-endodontic lesion.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • APRIL 2008 BENEFITS OF FLAP ACCESS IN THE TREATMENT OF PERIODONTAL DISEASE Dental calculus is mineralized, mature plaque covered on its surface with non- mineralized plaque, material alba, desquamated epithelial cells and formed blood elements. Root calculus is usually more strongly adherent to tooth surfaces than that found on enamel surfaces. Patient #1 Patient #1 The attachment of subgingival calculus is complicated by microscopic irregularities in cementum. These irregularities include cemental tears, cemental voids once occupied by Sharpey‟s fibers, resorption bays and other surface cemental defects. For this reason, calculus can be very difficult to remove from root surfaces during scaling and root planing. The microbial composition of calculus provides bacterial factors that produce Patient #2 Patient #2 an inflammatory reaction in tissue. The persistent presence of inflammation is what leads to periodontal destruction and tooth loss in the susceptible patient. Numerous university studies indicate that the effectiveness of calculus removal dramatically decreases as pocket depths deepen. Patient #3 Patient #3The photographs to the left show flap elevation of three different patients that had received scaling androot planing within the last six months. The photographs to the right show the benefits of flap elevationin allowing for visualization and access to the calculus. With direct access, more effective calculusremoval can be achieved. This allows for a much improved prognosis for tooth retention.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • MAY 2008 PERIODONTAL SITE DEVELOPMENT IN PREPARATION FOR A DENTAL IMPLANT Pre-treatment photograph Post-treatment photograph The photograph to the left shows the pre-treatment condition of tooth #10. The tooth presented with 4mm.of gingival recession, class III mobility and 7mm probing depth on the distal. The patient desired the best esthetic outcome possible. She was motivated to do whatever was necessary to achieve this result. The photograph to the right shows the completed case with a dental implant, an improved gingival margin position and a reduction in the amalgam tattoo. The black arrows show the difference in gingival margins relative to the central incisor. Without gingival augmentation, the final implant crown would look unusually tall. These radiographs show the pre- and post-treatment views. The radiograph to the left shows an apical radiolucent area and a suspicious position for the post. The radiograph to the right shows a well integrated dental implant.The above two photographs show tissue manipulation following The photograph to the left shows an improved gingival marginextraction of tooth 10. By covering the bone graft, following location. The photograph on the right shows a free gingivalextraction, with a rotated pedicle flap, correction of the pre- graft to correct the amalgam tattoo following removal of theexisting gingival recession could be accomplished. amalgam „flash‟ in the tissue.CONCLUSION: HAVING THE PROPER TISSUE SUPPORT IS IMPORTANT IN ACHIEVING ESTHETICRESULTS.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • JUNE 2008 BIOLOGIC WIDTHThe distance established by the connective tissue (1.07mm), the junctional epithelium (0.97mm) and the gingival sulcus(0.69mm). It has a combined dimension of 3.03mm. Violation of the biologic width can lead to chronic pain, chronicinflammation and unpredictable loss of alveolar bone. Pre-treatment photograph shows severely worn dentition. Gingivectomy is performed. A scalpel is used instead of a laser These short clinical crowns do not provide enough tooth since osseous recontouring is to be performed. This was determined structure for retention of planned restorations. In in the pre-treatment assessment when the alveolar crest of bone was addition, current tooth proportions (width to height ratio) sounded. The frenum has been released as well. are not conducive to an esthetic result. Flap reflection reveals alveolar crest of bone to be at the Osseous recontouring has been provided to allow for 3 mm of space cemento-enamel junction of teeth 8, 9 and 10. Black arrows from the adjusted crest of bone (black arrows) to the proposed final indicate current bone level. On teeth 6, 7 and 11, the crest of crown margin. Without this space, there is not enough room for the bone is where the final crown margins are planned. gingival attachment between the restorative margin and the crest of bone. Restorative margins too close to the alveolar crest can result in unsightly cyanotic tissue margins. Six week healing photograph shows enhanced tooth exposure. This will provide improved retention for the restorations. It will also allow for establishment of improved tooth proportions (80% width to height). The incisal edge will be extended coronally 1-2mm. The final gingival margins were probed and found to be 3mm from the alveolar crest. This will eliminate the possibility of chronic inflammation once the teeth are restored through establishment of the BIOLOGIC WIDTH.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo LagosD.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing currentperiodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presenpatient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • JULY 2008 IDEAL TREATMENT OF CERVICAL EROSION DEFECTS Combined restorative and periodontal treatment to restore lost and damaged tissue. Pre-treatment photograph shows cervical erosion of Post-treatment photograph shows restoration of both the teeth teeth 18-23. Previous restorations have failed on and periodontium. Connective tissue grafting to the cemento- several occasions. In addition, there is only 1-2mm enamel junction has restored the periodontal support and of keratinized attached tissue. This puts the teeth at increased the amount of keratinized attached tissue. Bonding risk for continued periodontal deterioration. was provided by the restorative dentist to replace the enamel. The area has been stable for 3 years.ETIOLOGY: Toothbrush abrasion is often blamed. University studies indicate causes are usually multi-factorial.*Predisposing Factors to Gingival Recession: • Anatomic narrow zone of attached gingiva • Excessive use/pressure with oral hygiene devices • Tooth malposition/thin buccal plate of bone or tissue • Periodontal diseases, including NUG and viral infections*Loss of Tooth Structure Predisposing Factors: • Erosion • • Abfraction Crown preparation • Abrasion • • Anatomic zone of exposed dentin at CEJ Combined effects • AttritionTREATMENT: Sequencing can vary. However, typically gingival grafting is provided first. This involves replacement ofsoft tissue support to where the cemento-enamel junction was. This allows for connective tissue fibers to re-attach to the dentin(instead of soft tissue adhesion). Following this, restorative dentistry is provided to replace the missing tooth structure. Theresults are typically excellent and stable over time. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presen patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • AUGUST 2008 ESTHETIC CROWN LENGTHENINGA periodontal treatment that recontours the tissue to allow for a more esthetic tooth form. A width to height ratio of 75-80% for thecrown is deemed preferable. Crown lengthening combined with restorative dentistry can remarkably improve dental esthetics. Pre-treatment photograph case #1 Post-treatment photograph case #1 Pre-treatment photograph case #2 Post-treatment photograph case #2 Pre-treatment photographs reveal the chief complaints Post-treatment photographs reveal enhanced dental esthetics of these patients: 1) Short, square shaped clinical crowns. and pleased patients. Improvement has been accomplished by: This can give an aged appearance to the patient. 1) Increasing the height to width ratio of the crowns with 2) Excessive gingival display on smiling. crown lengthening that included osseous recontouring. 3) Asymmetry between crowns for case #1. 2) Adjusting the gingival margins to follow the lip line. 4) Mal-content with the shades of the crowns in case #1 3) The restorative dentist providing esthetic crowns. and the teeth in case #2. SOME CRITICAL FEATURES IN SMILE DESIGN ARE AS FOLLOWS: 1. Incisal edge position 3. Gingival margins follow the lip line 2. Tooth form (width to height ratio of 75-80%) 4. Symmetry between the teethThis case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • SEPTEMBER 2008 INFLAMMATION AND BONE LOSS IN PERIODONTAL DISEASENew concepts about the role of chronic inflammation as a destructive mechanism to the human body are being discovered.At a 2008 periodontal conference, information was shared by leading researchers from around the world. Inflammatoryreactions involve interactions among various genes, environmental factors and chemicals from different parts of the body.The above photographs are examples of the destruction to the alveolar bone that is seen in different patientswith periodontal disease when the gingival tissues are reflected. This periodontal destruction is primarily aresult of the inflammatory system. The innate immune system is activated by bacterially derived factors andantigens.Inflammatory mediators, such as prostaglandins and interleukins, and enzymes, such as matrix metalloproteinases, areinvolved in the destruction of periodontal tissues. Eventually a cascade of events leads to osteoclastogenesis and boneloss. This occurs by altering expression levels of a protein called Receptor Activator of Nuclear factor-kappa B ligand(RANKL) on the osteoblast surface. Acquired and inherited environmental risk factors explain the susceptibility ofcertain individuals to periodontal disease. Although our genes do not change, the control of how certain genes areexpressed in specific tissues can change substantially (EPIGENETICS) throughout our lives. Factors such as diet, stress,smoking and bacteria can modify gene expression.THE WHOLE BODY: 1. Inflammatory mediators spread throughout the body via the circulatory system. 2. Although an inflammatory response to injury is necessary, chronic diseases, such as coronary heart disease and diabetes, may develop because of unchecked inflammatory responses that have maladapted over decades. For example, the earliest changes in atherosclerosis occur in the endothelium. This can lead to a cascade of inflammatory responses, such as accumulation of monocytes and T cells, migration of leukocytes into the intima, monocyte differentiation and proliferation, and lesion and fibrous cap development. 3. Inflammation is now known to play a critical role in diseases that are not usually classified as inflammatory diseases, such as cardiovascular disease, diabetes, rheumatoid arthritis, Parkinson‟s and Alzheimer‟s disease. Although this conclusion is the results of many years of research, much of the knowledge has crystallized into coherent concepts only very recently.CONCLUSIONS: As the role of inflammation and its control in periodontal disease management are more fullyunderstood, new prevention and treatment strategies should quickly emerge based on the concepts of blocking orresolving destructive host inflammatory pathways.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • OCTOBER 2008 TIMING FOR THE PLACEMENT OF DENTAL IMPLANTS The decision as to when a dental implant should be placed is critical. The implant can be placed immediately after the tooth is removed (immediate implant placement) or weeks to months later (delayed implant placement). There are advantages and disadvantages to each approach.Pre-operative photograph and radiograph of tooth #8. The patient Post-treatment photograph and radiograph showing the replacementhas had a frustrating 4 year history of chronic problems that have of tooth 8 with a dental implant. Seen in this view is the outstandingnot been resolved. New crowns and endodontic re-treatment have shade and shape of the implant crown. Also seen is the symmetrybeen attempted, to no resolve. The tooth was recently diagnosed and nice adaptation of the gingival tissues. The radiograph shows aas fractured by an endodontist. The patient has high demands well integrated dental implant. The patient is pleased with the resultregarding the esthetic outcome. and is pain free. This photograph shows atraumatic tooth This shows placement of the bone This shows a free gingival graft sutured in place over removal. This will help maintain soft and xenograft into the extraction socket. the bone graft. This will help to augment the soft hard tissue support. tissue ensuring symmetric gingival margins. CONCLUSION: Several treatment approaches can be selected in cases like this one. Given the history of chronic pain, it was decided to remove the tooth and not replace it right away. With this delayed approach to dental implant placement, we could 1) make sure the pain would resolve, 2) ensure a stable and healthy tissue foundation and 3) augment the soft tissue to meet the patients esthetic demands. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presen patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • NOVEMBER 2008 RIDGE PRESERVATION Loss of labial crestal bone following tooth removal remains one of dentistry‟s greatest challenges. The importance of maintaining an adequate bone volume prior to implant placement cannot be overstated. A procedure that can restore and maintain the alveolar ridge following tooth extraction is „ridge preservation‟. Without ridge preservation, the alveolar bone will resorb from 30- 60% within 6 months. At least 1mm of vertical bone height will also be lost without ridge preservation. Photograph 3 months following extraction and ridge preservationTreatment photograph following extraction of tooth #7. The ridge shows impressive regeneration of the alveolar bone. The alveolardefect is due to years of infection. Most interesting is the thinness ridge has been restored to its original anatomy. This is the mostof the buccal plate of bone and apical extent of bone loss (seen at predictable way to ensure successful dental implant integration andarrows). Without a ridge preservation this bone would resorb further restore the boney architecture.due to a lack of vascularity in the cortical layer of bone. Photograph shows Flap elevation shows Photograph shows Placement of a resorbable Suturing to obtain Photograph shows soft tissue swelling severe bone loss on the a bone xenograft in collagen membrane primary closure. vertical root fracture. associated with buccal of tooth #7. place. provides epithelial cell tooth #7. exclusion. CONCLUSION: Variables exist as far as the extent of regeneration which can be achieved with ridge preservation. Variables include 1) the extent of the initial bone defect, 2) the type of bone grafting material used, 3) surgical technique and 4) healing capability of the patient. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • DECEMBER 2008 GUIDED TISSUE REGENERATION TO PRESERVE TEETH Periodontal regeneration is the formation of new bone, new cementum and new periodontal ligament. This creates a new functional attachment apparatus over a pathologically exposed root surface, improving the prognosis for tooth retention.Photograph of tooth #6 with the gingival tissue reflected Photograph six months following the guided tissue regenerationfollowing root surface debridement. Seen is the bone loss that procedure. Seen is the remarkable regeneration of bone; particularlywraps around to the mesial surface. Plans had been to remove the on the buccal and mesial surfaces. This has dramatically improvedtooth, but with flap reflection we thought we could improve the the prognosis for tooth retention. The reason for the re-entryprognosis for tooth retention. procedure is that patient is receiving a dental implant to replace tooth #5, which was a pontic space.SURGICAL SEQUENCE: 1 2 3 4Photograph 1: Pre-clinical view of tooth #6 shows draining fistula tract. This was after a week of antibiotics.Photograph 2: Flap elevation shows heavy calculus build up and loss of alveolar bone.Photograph 3: View following root surface debridement and antibiotic conditioning.Photograph 4: A composite bone graft of Bio-Oss and Demineralized Freeze Dried Bone was placed into the defect. The synthetic growthfactor GEM21-S was used to enhance the regenerative process. A Bio-Gide membrane was placed to allow for regeneration throughepithelial cell exclusion. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • JANUARY 2009 PROGRESSIVE GINGIVAL RECESSIONThe apical migration of the gingival margin can progress if left untreated. The more things decline, the less the chances for completerestoration. A classification system is present to allow predictions to be made about the degree of improvement that can be achieved.The above photographs from different patients show examples of severe gingival recession. The degree of deteriorationpresent reduces the chances for complete root coverage. The above cases all lack attached tissue.CLASSIFICATION:Class I: Full height of papillae, recession within attached gingiva, no loss of interproximal bone; 100% coverage possible.Class II: Full height of papillae, recession at or beyond mucogingival junction, no loss of interdental bone; 100% coverage possible.Class III: Reduced papilla height; recession at/beyond the mucogingival junction, loss of interdental bone apical to the cemento-enamel junction, but coronal to the apical extent of the marginal tissue recession; Coverage only to level related to papilla height.Class IV: Gross flattened loss of papillae, interdental bone loss level to or apical to the gingival recession; Complete coverage notpossible.CONCLUSIONS: 1. Early intervention is the easiest and best time to completely reconstruct a gingival defect. 2. The etiology is usually multi-factorial. Toothbrush abrasion gets blamed a lot and can be a factor. Tooth position, gingival biotype, root prominence, occlusion and plaque are other contributing factors. 3. The presence of keratinized attached tissue is very beneficial in preventing progressive gingival recession.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • FEBRUARY 2009 CORRECTION OF MUCOGINGIVAL DEFECTS THROUGH GINGIVAL GRAFTING Creating gingival tissue reduces the likelihood of further recession. Gingival grafting also helps cover exposed roots, enhances the appearance of teeth and protects roots from decay and sensitivity. Pre-treatment patient #1 Post-treatment patient #1 Pre-treatment patient #2 Post-treatment patient #2 Pre-treatment photographs show the following: Post-treatment photographs show: 1) Gingival recession ranging from 2-5mm 5mm (black 1) Complete root coverage and restoration of gingival arrows). tissues. 2) Very thin zone of attached tissue. 2) Increased zone of attached tissue has been provided This puts the teeth at risk for continued periodontal (red arrows). This strengthens the gingival attachment. deterioration and possible loss. The restoration of gingival tissue has improved the prognosis for tooth retention significantly.CONCLUSIONS: 1. Early intervention is the easiest and best time to completely reconstruct a gingival defect. 2. The etiology is usually multi-factorial. Toothbrush abrasion gets blamed a lot and can be a factor. Tooth position, gingival biotype, root prominence, occlusion and plaque are other contributing factors. 3. The presence of keratinized attached tissue is very beneficial in preventing progressive gingival recession.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • MARCH 2009 PERIODONTITIS ASSOCIATED WITH A MEDICATIONMany medications can cause gingival hyperplasia as a side effect. The hyperplastic tissue can trap plaque. Thisretained plaque can lead to periodontitis or other inflammatory related medical conditions. PRE-TREATME PATIENT #1 POST-TREATMENT PATIENT #1 PRE-TREATMENT PATIENT #2 POST-TREATMENT PATIENT #2Pre-treatment photographs show medication induced Post-treatment photographs show restored gingival health. Treatmentgingival hyperplasia. Bleeding on probing was present. consisted of: 1) Using alternative medications with the consent of theCalculus and plaque were present subgingivally. physicians, 2) Gingivectomy with scaling and root planing and 3) Oral hygiene instruction BLOOD PRESSURE MEDICATIONS ANTI-CONVULSANT IMMUNOSUPPRESSANTSGeneric Name (Trade Name) Generic Name (Trade Name) Generic Name (Trade Name) Generic Name ( Trade Name)Diltiazem (Cardizem) Nimodipine (Nimotop) Phenytoin (Dilantin) Cyclosporine-A (Sandimmune)Felodipine (Plendil) Nisoldipine (Syscor)Isradipine (Prescal) Nitrendipine (Bayotensil)Nifedipine(Procardia, Verapamil (Calan)Adalat, Tenif)This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. andSteven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with thedental community. Questions and comments are welcomed by calling 760-674-4410. * All cases presented are actual patient‟s of Drs.Warshawsky, Lagos, or Jacobson.
    • APRIL 2009 DIABETES AND PERIODONTAL DISEASE Diabetic patients are three to four times more likely to develop chronic periodontal infections.The patient is a 22 year old female with type I diabetes. She presents Due to the severity of deterioration present, periodontal toothwith the chief complaint of “difficulty eating due to looseness of her preservation procedures would have had a poor long termupper front teeth.” She reports that her blood sugar levels have been prognosis. The patient was interested in a definitive treatment.high for several months. Probing depths on the anterior teeth ranged An incredible amount of calculus accumulation is present onfrom 6-12mm with bleeding upon probing and exudate expressed extracted teeth 7-10. The patient understood that eliminatingfrom teeth 8 and 10. The teeth had a class III mobility. infection from her mouth would help to control her diabetes. The patient reports that she has had several “deep cleanings” over the last several years. The radiograph to the left reveals severe bone loss. It is amazing to see this amount of bone loss in a 22 year old. Periodontal infections can impair the ability of the body to process insulin, which can make diabetes more difficult to control. In addition, a periodontal infection may be more severe in a diabetic patient than in someone without diabetes. It is important for diabetic patients to have their periodontal diseases treated to control or eliminate the infection as one more way to achieve optimal control of their blood sugar levels. In the early stages of periodontal diseases, treatment usually involves scaling and root planning to remove plaque and tartar. More advanced cases may require additional treatment combined with antibiotics. Earlier intervention, with more complete treatment, in the above case may have saved the patient‟s teeth. The link between diabetes and periodontal disease is a two- way street. University studies indicate that periodontal treatment can improve blood sugar levels in diabetic patients, and may decrease their need for insulin. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 760-674-4410. * All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • MAY 2009 COMMON QUESTIONS ABOUT PERIODONTAL DISEASE Periodontitis is an infectious disease and is manifested as local inflammation of the periodontium.The above photograph and radiograph show severe periodontal destruction between teeth 18 and 19. The bone loss extendsall the way to the apex of the distal root of tooth 19. The etiologic agent was calculus that wrapped around the root surface.WHAT CAUSES PERIODONTAL DISEASE? Research over the past 30 years has addedThe patient has received regular „cleanings‟ twice a year. to ourWHAT CAUSES PERIODONTAL DISEASE? Research over the past 30 years has added to ourunderstanding of the pathogenesis of periodontal disease. Bacteria produce toxins that pass through the epithelial attachmenttriggering the immune response. White blood cells, particularly neutrophils, come to the area to phagocytize the bacteria,destroying healthy connective tissue in the process. Other immune cells then trigger osteoclasts to destroy the bonesurrounding the tooth.DOES PERIODONTAL DISEASE AFFECT SYSTEMIC HEALTH?The relationship betweenperiodontal disease and systemic health has been well recognized through epidemiologic studies during the last decade.Patients with periodontal disease have a higher incidence of cardiovascular diseases and strokes that are exemplified byincreases in peripheral white blood cell count and C-reactive protein. Many of the diseases associated with periodontal diseaseare also considered to be systemic inflammatory disorders, including cardiovascular disease, diabetes, rheumatoid arthritis,chronic kidney disease and even certain forms of cancer, suggesting that inflammation itself may be the basis for theconnection.WHAT ARE TREATMENT OPTIONS FOR PERIODONTAL DISEASE? The goal ofperiodontal treatment is to eliminate the destructive bacteria (plaque and calculus) from above and below the gum line. Thebest treatment approach is determined by the depth of bacterial penetration. An additional goal of periodontal treatment is toreduce pocket depths so that patients can be effective with their home care.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community.Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • JUNE 2009 Replacement of a worn and deteriorated dentition with an implant supported over-denture Pre-treatment photograph shows severely decayed teeth Post-treatment photograph shows the implant supported over- with periodontal involvement as well as missing posterior denture in place. Health, esthetics and function for the patient have teeth. The prognosis for preserving these teeth is poor. been greatly improved. The patient is very pleased with the results. The long term prognosis for this treatment is excellent.View of locator abutments in place with View of the inside of the over-denture These are the locator inserts. The blue insertthe prosthesis removed. Locators are with locator inserts. One of the inserts has a retentive capacity of 1.5 pounds, theattached to dental implants that are needed to be removed because the pink 3.0 pounds and the clear, 5.0 pounds.firmly integrated in the jaw bone. retention was so strong that the patient For example, the use of 4 dental implants could not remove the prosthesis for with locators and the clear male inserts can cleansing. offer a retention of 20 pounds.CONCLUSION: The standard of care for an edentulous patient is to have a minimum of two dentalimplants in the mandible. With the above patient, the long term prognosis with dental implants wasfelt to be better than preserving worn and deteriorated teeth.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Rodrigo Lagos D.D.S., M.S. and Steven JacobsonD.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions andcomments are welcomed by calling 760-674-4410. * All cases presented are actual patient‟s of Drs. Warshawsky, Lagos, or Jacobson.
    • A GUIDE TO UNDERSTANDING PERIODONTAL DISEASE, TOOTH PRESERVATION AND DENTAL IMPLANTS PROVIDED BY PERIODONTICS OF THE DESERT PETER WARSHAWSKY, D.D.S. ERIC DRIVER, D.D.S. STEVEN JACOBSON, D.D.S., M.S. Volume 4
    • FURCATIONS July 2009ESTHETIC DENTAL IMPLANT THERAPY August 2009GINGIVAL GRAFTING September 2009PERIODONTAL DISEASE October 2009ONLAY BONE GRAFT November 2009PERIODONTAL REGENERATION December 2009SCALING AND ROOT PLANING LIMITATIONS January 2010INFLAMMATION AND SYSTEMIC HEALTH February 2010IMPLANT SUPPORTED OVER-DENTURE March 2010ATLANTIS ABUTMENT April 2010BONE STABILITY AROUND DENTAL IMPLANTS May 2010GINGIVAL GRAFTING STABILITY June 2010ESTHETIC CROWN LENGTHENING July 2010CALCULUS REMOVAL August 2010GUIDED TISSUE REGENERATION Septemebr 2010BISPHOSPHONATE MANAGEMENT October 2010RIDGE PRESERVATION November 2010PERSPECTIVES IN PERIODONTICS December 2010ESTHETIC CROWN LENGTHENING January 2011GINGIVAL GRAFTING WITH A FRENECTOMY February 2011
    • JULY 2009 FURCATIONSMaxillary molars are statistically the first teeth lost due to periodontal disease. Root anatomy and poor accessfor both home care and professional treatment are the main factors for early loss of these teeth.-These photographs depict maxillary molar teeth lost due to deterioration of periodontal support. Thisdeterioration was due to calculus accumulation that could not be accessed and removed. Calculus in thefurcation becomes more difficult to remove as the defect advances.-Bowers (1979) reported that 81% of all furcation entrance diameters measure < 1mm and 58% < .75mm.Since commonly used curettes have blade face widths ranging from .75 to 1.10 mm, it is unlikely that properinstrumentation of furcations can be achieved with curettes alone; due to INACCESSIBILITY of the area. Thisissue can be seen in the photograph on the right.CLASSICIFATION SYSTEM: A variety of classification systems exist. One of the more commonclassifications is the ‘Hamp’ system which divides furcation invasion into 3 grades of severity: Degree I: Horizontal loss of periodontal tissue support < 3mm. Degree II: Horizontal loss of periodontal tissue support > 3mm but not encompassing the total width of the furcation. Degree III: Horizontal through-and-through destruction of the periodontal tissue in the furcation.SIGNIFICANCE OF A CLASSIFICATION SYSTEM: Teeth with more extensive furcation invasion are atgreater risk for continued deterioration and future loss. In addition, the prognosis for treatment solutionsworsen as the furcation deepens. A variety of treatments are available involving flap procedures that improveaccess to the furcation.EARLY TREATMENT, THAT IS SUCCESSFUL, IS THE BEST WAY TO PRESERVE MOLARTEETH.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. andSteven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information withthe dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs.Warshawsky, Driver or Jacobson.
    • AUGUST 2009 A STAGED APPROACH TO SUCCESSFUL AND ESTHETIC DENTAL IMPLANT THERAPYPre-treatment photograph and radiograph of tooth #9 shows Post-treatment photograph and radiograph show thethe following: 1) Marginal gingival inflammation, 2) Short integrated dental implant one year following the stagedroot that shows evidence of apical changes. Clinically the approach. Symmetry of gingival margins, crown shape andtooth has a class II mobility and there is chronic pain. shade provide for an esthetic result that the patient is quite pleased with.SURGICAL SEQUENCE FOR EXTRACTION AND RIDGE PRESERVATION: Photo 1: Atraumatic and flapless extraction of tooth #9. Photo 2: Following the extraction, the socket is explored with a periodontal probe. A bone defect is detected and can be seen at the end of the periodontal probe (arrow). Placement of an immediate implant here would be risky. Photo 3: Shows condenser compressing bone graft into the 1 2 3 extraction socket. Mild compression is provided to allow for vascularization. Photo 4: View following fill of extraction socket with bone graft. The bone graft material is a xenograft. Photo 5: Placement of a resorbable collagen membrane allows regeneration of the extraction socket. Photo 6: View of deteriorated root and calculus below the 4 5 6 crown margin.The dental implant was placed 3 months following tissue maturation and then allowed to integrate for 3 months.CONCLUSION: The timing of the placement of a dental implant is an important treatment planning decision. Ittypically more predictable to have healthy, stable and sufficient soft and hard tissue. A staged approach allows formore control of each step. Higher success rates and more esthetic outcomes often can be achieved with this approach.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. andSteven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information withthe dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs.Warshawsky, Driver or Jacobson.
    • SEPTEMBER 2009 PRESERVING TEETH THROUGH GINGIVAL GRAFTING Pre-treatment photograph of tooth #9 shows gingival Post-treatment photograph of tooth #9 shows complete root recession of 3mm. There is calculus above the class V coverage and an increase in attached tissue. The frenum pull has restoration. There is an aberrant frenum present along with also been reduced and a connective tissue graft was provided. gingival inflammation. These are all risk factors for Treatment has improved the prognosis for tooth retention and the progressive periodontal deterioration. patient is quite pleased with the improved appearance. IF GINGIVAL RECESSION PROGRESSES, IT CAN REACH A POINT WHERE REPARATIVE EFFORTS ARE NOT PREDICTABLE. A FEW EXAMPLES OF GINGIVAL RECESSION DEFECTS THAT HAVE PROGRESSED TOO FAR ARE SEEN BELOW: CONCLUSION: GINGIVAL GRAFTING IS MUCH LESS INVOLVED AND MORE PREDICTABLE WHEN THE DETERIORATION IS LESS SEVERE.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. andSteven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information withthe dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs.Warshawsky, Driver or Jacobson.
    • OCTOBER 2009 PERIODONTAL DISEASE IS TYPICALLY ASYMPTOMATICMany patients lose teeth that could have been saved because periodontal disease typically does not hurt. It can bechallenging to educate patients about their risk of progressive periodontal destruction when they are unaware of anexisting problem. A visual aid, such as the case below, can be helpful as a communication tool, in motivating patientsabout the benefits of periodontal treatment. These photographs are of a 55 year old female that presented to our office with concerns about loosening of tooth #10. The mobility of this tooth bothered her and was tender particularly while eating. Clinical examination revealed probing depths up to 13mm, gingival recession of 2-3mm, bleeding and exudate on probing and a class III mobility. Her dental history indicated that she was consistent with cleanings twice a year at her dentist‟s office. She remembers being told by her dentist, years prior, that she needed to see a periodontist about tooth #10. At the time, the patient reports that she did not perceive a problem because there was no pain and declined the referral. By the time the patient came to our office, it was too late to save the tooth. She was informed that because of the extent of deterioration present, procedures to try to preserve the tooth would have a poor prognosis. The patient realized that if she had seen a periodontist at an appropriate time, she could have preserved her tooth. The photograph in the middle shows the extracted tooth. Please notice the incredible accumulation of calculus present. The calculus serves as a matrix into which plaque is retained. Plaque initiates inflammation that results in bone loss and other systemic health problems.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. andSteven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information withthe dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs.Warshawsky, Driver or Jacobson.
    • NOVEMBER 2009 THE ONLAY BONE GRAFT A predictable treatment to increase the bone volume in preparation for dental implant tooth replacement. Pre-treatment photograph shows missing teeth 5 and 6. Tooth The photograph and radiograph reveal the final dental implants in place. 7 is too weak to serve as an abutment for a bridge. This Restoration of form and function has been achieved. The patient is thrilled with photograph shows how deceptive the clinical view can be the results. regarding the buccal-lingual thickness of bone availability.Surgical sequence: 1 2 3 4Photograph 1: Flap elevation reveals a ridge width of 3mm. This is too narrow to properly contain the dental implants. The arrows point to the extreme thinness of the present ridge of bone.Photograph 2: Shows adaptation of onlay bone graft and stabilization with three Memfix screws. Intimate adaptation is critical. The donor site was the ramus region of the mandible.Photograph 3: Five months following bone grafting, the donor bone has fused to the recipient site. The bone is now of sufficient width to contain the dental implants. Slight resorption of the bone is evident with screw thread exposure. Once the bone is stimulated with the functioning dental implants, this resorptive process will stop.Photograph 4: Shows the dental implants in place surrounded by a solid base of bone. When there is not sufficient bone around the the dental implants, their survival is jeopardized. Note the increased thickness of bone present.CONCLUSION: IT IS IMPORTANT TO BE AWARE OF THE QUALITY AND QUANTITY OF BONE PRESENTPRIOR TO PLACING DENTAL IMPLANTS. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • DECEMBER 2009 WHAT IS PERIODONTAL REGENERATION? The ultimate goal of periodontal therapy is replacement of the lost tooth attachment apparatus and a return to pre-disease architecture. Guided tissue regeneration allows this to happen. The following photographs demonstrate how periodontal regeneration re-grows the lost bone support. Flap elevation shows an infrabony defect associated with The above photograph shows the remarkable regeneration of tooth #18 that extended down 9mm. The defect was the bone support for the tooth. This re-entry procedure was initiated by calculus primarily along the distal root performed 8 months following the initial treatment. The surface. prognosis for tooth retention has been greatly improved. With flap elevation, access to the calculus could be Without the guided tissue regeneration procedure, the defect achieved. The area was thoroughly debrided and treated would have remained. The area would have been susceptible with tetracycline. A bone graft was then placed into the to further plaque accumulation into the defect. The presence defect mixed with a growth factor to enhance the of a periodontal pocket puts the tooth at increased risk of regenerative process. A resorbable membrane was also loss. placed to allow for regeneration through epithelial cell exclusion.-A large case series study using guided tissue regeneration in combination with root conditioning and demineralizedfreeze dried bone allograft showed significant gains in clinical attachment level in a variety of furcation and infrabonydefects. Schallhorn RG, McClain PK, Combined osseous grafting, root conditioning and guided tissue regeneration, Int J Pe34, 1988.-A subsequent study confirmed that the regenerated results were stable over five years. McClain PK, Schallhorn RG, Long-tassessment of combined osseous composite grafting, root conditioning, and guided tissue regeneration, Int J Periodontics Restorative Dent 13:9-27, 1993.MULTIPLE UNIVERSITY STUDIES SHOW THE BENEFITS OF GUIDED TISSUE REGNERATION IN PRESERVING TEETH.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dentalcommunity. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky,Driver or Jacobson.
    • JANUARY 2010 LIMITATIONS OF SCALING AND ROOT PLANINGScaling and root planing is very difficult. Open flap access through periodontal treatment dramaticallyimproves access and visualization (as can be seen in the photographs below) for the removal of calculus.The above photographs show different patients who had received scaling and root planing. At the re-evaluationappointment, incomplete healing was noted. The patient was then referred to our office for phase II periodontal treatment.The continued presence of calculus makes teeth susceptible to further periodontal deterioration and future loss.UNIVERSITY RESEARCH STUDIES INDICATE IT IS DIFFICULT TO REMOVE CALCULUSTeeth were extracted after treatment and evaluated with a microscope. With this microscope, the researchers could seethe amount of calculus remaining on the root surfaces. The results of this study, for various pocket depths, are as follows: POCKET DEPTH SCALED ONLY FLAPPED AND SCALED 1-3mm 86% calculus free 86% calculus free 4-6mm 43% calculus free 76% calculus free deeper than 6mm 32% calculus free 50% calculus free“Scaling and root planning with and without periodontal flap surgery.” J. Clin Perio 3/86CONCLUSION: It is difficult to remove calculus from root surfaces. The residual calculus followscaling and root planing is not a reflection of a lack of skill by the dentist or hygienist. The residual calculusis due to the tenacious adherence of calculus to root surfaces and inability to visualize it with the tissues inplace. OPEN FLAP ACCESS CAN DRAMATICALLY IMPROVE ACCESSIBILITY AND VISIBILITY. The removal ofcalculus increases the prognosis for tooth retention through elimination of an etiologic factor.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. andSteven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information withthe dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs.Warshawsky, Driver or Jacobson.
    • FEBRUARY 2010 INFLAMMATION AND ITS CONSEQUENCES ON SYSTEMIC HEALTH Periodontal infections are common inflammatory disorders caused by the bacteria inhabiting the biofilm of the dental plaque. Studies have suggested that periodontal infections may constitute an independent risk factor for 1) coronary artery disease, 2) pregnancy complications, including pre-term birth, lower birth weight 3) poor metabolic control in diabetes and 4) respiratory disease. Moreover, emerging associations have been described linking periodontitis and kidney disease, rheumatoid arthritis and pancreatic cancer.The above three photographs show different patients with gingival inflammation of varying degrees. Inflammation isthe host‟s response to an irritant. Dental plaque is a bio-film that initiates a series of events that not only leads toperiodontal disease but can affect a patient‟s general well-being. THE SEQUENCE OF EVENTS LEADING TO CORONARY ARTERY DISEASE:BIOFILM BACTEREMIA INFLAMMATORY RESPONSE ELEVATED C-REACTIVE PROTEIN VASCULAR EFFECTSBIOFILM: Is found floating on lakes, in plumbing lines, on the edges of vases, and on top of rivers and ponds. Biofilms grow in stacks withdifferent types of bacteria. There is an order to the stacking of the bacteria as well as communication between the different layers. A slimymatrix forms on top of the bacteria shielding them. The biofilm in the gingival crevice is massive. There are between 10 million and 1billion bacteria in the gingival crevice depending on the depth of the pocket.BACTEREMIA: Direct opening through the inflamed sulcular tissue allows bacteria to enter the general circulation.INFLAMMATORY RESPONSE: Cytokines, PMNs, B-cells and T-cells are produced as a result of the bacteremia. Enzymes are alsoproduced such as: COLLAGENASE (destroys collagen); GELATINASE (hydrolyses gelatin); ELASTASE (breaks down proteins) andPROTEASE (breaks down proteins)C-REACTIVE PROTEIN (CRP): Produced by the liver as part of the normal immune system response to injury, inflammation andinfection. CRP participates in the development of clots and plaques that lead to an increased risk of heart attacks and strokes. Women withelevated CRP have a seven times increased chance of a cardiovascular event. Periodontal disease increases CRP levels. Periodontaltreatment reduces CRP levels.CONCLUSION: MULTIPLE STUDIES SHOW PERIODONTAL DISEASE TO BE A SIGNIFICANT RISKFACTOR FOR CORONARY ARTERY DISESAE. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • MARCH 2010 Improving dental health, function and esthetics through replacement of a diseased and deteriorated dentition with an implant supported over-denture Pre-treatment photograph shows an un-esthetic smile. Post-treatment photograph show improved esthetics. Retracted view shows multiple missing View of locator abutments in place with View of the inside of the over-denture teeth as well as severe damage to the the prosthesis removed. Locators are with female components. Female remaining teeth. The palate was very attached to dental implants that are components come in retentive strengths flat and there was minimal firmly integrated in the jaw bone. The of 1.5 pounds (blue), 3.0 pounds (pink) vestibular depth present. Both of dental implants were placed at the time and 5.0 pounds (clear). The above these anatomic features make of extractions (immediate implant example shows 4 blue components in retention of a traditional prosthesis placement). Treatment time for this place. These can be changed out to meet quite challenging. patient was 3 months. the patient‟s retention requirements. CONCLUSION: The patient is very pleased with the results. Implant supported over- dentures are an excellent way to improve health, function and esthetics.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven JacobsonD.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questionsand comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • APRIL 2010 WHAT IS AN ATLANTIS ABUTMENT? A computer aided design/ computer aided machined (CAD/CAM) patient specific abutment. This custom made abutment is designed with the final tooth shape in mind, for outstanding function and esthetics. It is made from a Virtual Abutment Design software computer program. These abutments can be fabricated for the majority of dental implant systems. Atlantis patient-specific abutments are designed and fabricated to look like natural prepared teeth. Photograph shows a stock abutment on a Photograph shows an Atlantis abutment. This abutment model. This abutment is basically a one size fits has been designed and fabricated to specifically fit the all situations concept. space and tissue profile for this patient.Atlantis abutments can be made from a variety of materials depending on the clinical situation. Seen above are zirconia,titanium and a gold shaded titanium abutments. Advantages and disadvantages exist for each of these materials.CONCLUSIONS: ATLANTIS ABUTMENTS PROVIDE THE FOLLOWING ADVANTAGES: 1. Eliminates the need for ordering products, maintaining inventory and chair-side modification. 2. Patient specific shapes for the ideal emergence. 3. Variety of materials available depending on the clinical situation. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • MAY 2010 CRESTAL BONE STABILITY AROUND DENTAL IMPLANTS IS QUITE BENEFICIAL In the past, it was acceptable for dental implants to lose 1.5mm of bone from the top of the crest, and 0.2mm during each subsequent year. This bone loss could become problematic. Today, dental implants have design features which can minimize crestal bone loss. This results in improved health, esthetic and functional stability. The radiographs to the left are examples of two patients who have lost crestal bone around dental implants that were placed in 1997. The red arrows point to where the bone level was at the time of dental implant insertion. The black arrows point to the current reduced bone level. The photograph and radiograph to the left is an example of a patient who had the dental implant placed in 2008. The radiograph shows crestal bone loss. The patient reports pain and a foul taste associated with the implant. The tissue above the implant is inflamed and exudate can be expressed from the implant sulcus. Successful long term treatment will be challenging. This is an example of a dental implant that has had no crestal bone loss since the dental implant was placed 7 years previously. This provides for stability in terms of health, function and esthetics. CONCLUSION: Maintenance of the crestal bone around dental implants is preferred. This can be accomplished with the use of a dental implant that has specific designThis case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dentalcommunity. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driveror Jacobson.
    • JUNE 2010 STABILITY OF GINGIVAL GRAFTING Practitioners and patients often inquire about the stability of gingival grafting. For gingival recession defects with Class I and Class II type defects the prognosis is good for correction of the defect and a halt to progressive deterioration. PRE-TREATMENT PHOTOGRAPH: 6 MONTH POST-TREATMENT PHOTOGRAPH: The patient and the orthodontist are quite concerned about Photograph shows the initial healing to be adequate. progressive gingival recession on tooth #25. Note The root surface has been covered, the frenum pull the lack of attached tissue and 5mm of gingival eliminated, and a band of keratinized attached tissue is recession. There was also an aberrant frenum pull. present. This will improve the long term prognosis for tooth retention. 12 YEAR FOLLOW UP PHOTOGRAPH: The periodontal tissues are within normal limits. There is a broad band of attached tissue that is firmly attached to the root surface and alveolar bone. Probing depths are 2mm.CONCLUSION: If a patient has less than 1mm of attached gingiva on a tooth and is having activerecession, gingival grafting has a high predictability for success. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • JULY 2010 ESTHETIC CROWN LENGTHENING AND RESTORATIVE DENTISTRYThis treatment plan involves periodontal recontouring followed by restorativedentistry. This two phased approach can dramatically enhance dental esthetics. pre- treatment patient 1 post-treatment patient 1 pre-treatment patient 2 post-treatment patient 2 pre-treatment patient 3 post-treatment patient 3 pre-treatment patient 4 post-treatment patient 4The pre-treatment photographs seen above are patients who wanted to improve their smiles. Complaintsranged from asymmetry (uneven teeth for patient 1) to an aged appearance due to worn teeth (patient 2).Patients 3 and 4 did not like their “gummy smile” amongst other things.-Esthetic crown lengthening was performed by Dr. Warshawsky to: 1) Improve tooth form (width to length ratio of 80%): Creates longer teeth which look more youthful. 2) Establish biologic width (reduces chances of marginal inflammation): Places osseous crest 3mm fromproposed final restorative margin. 3) Create gingival symmetry (enhances esthetics). 4) Allow gingival margin to follow the upper lip.-Restorative treatment was provided to improve the shade and shape of the teeth. This phase of thetreatment was provided by local dentists.CONCLUSION: To achieve an optimal esthetic result, correction of the gummy smile,asymmetric gingival margins and short teeth are important considerations.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. andSteven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information withthe dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs.Warshawsky, Driver or Jacobson.
    • AUGUST 2010 PRESERVING TEETH THROUGH THE REMOVAL OF CALCULUS The gingival appearance can be misleading in regards to the amount of calculus present beneath it. Furthermore, the removal of calculus from root surfaces can be challenging due to the lack of visualization and it’s tenacity . The continued presence of calculus leads to tooth loss in the susceptible patient. Bone loss Bone loss !!Patient 1: Photograph shows the gingival Tissue flap reflection on the buccal and palatal, respectively, showstissues around teeth 13 and14. Minimal gingival Calculus (yellow arrows) along the root surface of tooth 14. The associatedinflammation is present due to good home care bone loss (black arrows) should be noted. Continued loss of bone due to thecurrently and bi-annual dental prophylaxis presence of calculus would lead to tooth loss.appointments. No more calculus !!!Patient 2: Photograph shows the gingival tissues Tissue reflection shows the presence of calculus on thearound teeth 22 through 24. Minimal gingival root of tooth 23. The photograph on the far right showsinflammation is present due to good home care currently. the benefits of flap access in the removal of the primaryNo obvious indications are present of what lays beneath etiological factor in periodontal disease.the tissue. CONCLUSION: Tissue flap elevation can allow for improved visualization of calculus for more effective removal. This helps to preserve teeth. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • SEPTEMBER 2010 GUIDED TISSUE REGENERATION: 18 MONTH FOLLOW UP Periodontal regeneration is the formation of new bone, cementum and periodontal ligament. This creates a new functional attachment apparatus over a previously pathologically exposed root surface. This case report demonstrates long term maintenance of regeneration. Pre-treatment Post-treatment Pre-treatment radiograph of tooth# 7 on the left shows severe bone loss (area between the red arrows) and calculus (yellow arrow). This condition gives the tooth a poor prognosis. The follow up (18 months following treatment) radiograph shows complete bone fill and no calculus. THE PROGNOSIS IS NOW GOOD FOR TOOTH PRESERVATION. SURGICAL SEQUENCE:Pre-treatment photograph of tooth Flap elevation reveals the bone Photograph after Photograph reveals the bone graft#7 shows periodontal probe defect and associated debridement of the root placed into the defect. Theextending down 9mm. following destructive calculus. The surface and bone defect. synthetic growth factor GEM21-Sanesthesia. The tooth has been black arrow points to the Flap reflection allows for was used to enhance thetemporized to allow for: 1) ledge of calculus that was the best access for such regenerative process. FollowingClosure of the open contact that led buried sub-gingivally; the treatment. Also seen is this a barrier membrane was placedto the periodontal destruction (so yellow arrow points to the the crater like bone loss that and the tissue sutured. Thefood does not impact into the bone loss. The patient reports extended 1/3 down the root temporary crown was then re-surgery site) 2) Better access for a history of root planing that surface. cemented.successful periodontal treatment. could not reach the calculus. CONCLUSION: Guided Tissue Regeneration is the ideal treatment for teeth when they have lost support due to periodontal disease. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • OCTOBER 2010 CONSERVATIVE MANAGEMENT OF A PATIENT TAKING A BISPHOSPHONATE, WITH A FRACTURED ROOT Aredia is an intravenous bisphosphonate used in the treatment of osteoporosis, cancer and or multiple myeloma. Aredia has a dangerous side effect, jaw osteonecrosis (ONJ). ONJ is an abnormality in which part of the jaw bone is no longer alive and cannot restore itself due to a lack of blood supply, especially following tooth extractions. The following case report is about an 81 year old male patient who presented with an abscess associated with tooth #3 and multiple myeloma for which he was taking the medication Aredia. Pre-treatment photograph shows tooth #3 with a temporary crown Post-treatment photograph and radiograph show a stable in place. Seen at the arrow is a fistula tract due to a fractured mesial clinical presentation. Gingival health is present, teeth 3 and 4 are root. The pre-treatment radiograph shows the bone loss associated splinted together for stability and the radiograph reveals bone fill with the mesial root. in the mesial root socket. The prognosis is much improved.SURGICAL SEQUENCE FOR FLAPLESS MESIAL BUCCAL ROOT AMPUTATION AND SOCKETPRESERVATION: 1 2 3 4 This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky or Jacobson.Photograph 1 shows the temporary crown removed and the periodontal probe extending down 10mm due to bone loss associated with thefractured root. Photograph 2 shows the coronal view following the root amputation. This coronal approach, without raising a buccal flap, wasused to maximize vascularity to the site to minimize the risk of ONJ. Photograph 3 shows a bone graft placed into the root socket. This willmaintain the clot. Photograph 4 shows the mesial root of tooth #3 that was fractured in three separate pieces. Tissue healing following thesurgery was excellent with no complications.CONCLUSION: A CONSERVATIVE SURGICAL APPROACH CAN BE USED TO MINIMIZECOMPLICATIONS ASSOCIATED WITH BISPHOSPHONATES.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and StevenJacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dentalcommunity. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driveror Jacobson.
    • NOVEMBER 2010 WHY IS RIDGE PRESERVATION BENEFICIAL FOLLOWING TOOTH EXTRACTION? A procedure that can restore and maintain the alveolar ridge following tooth extraction is ‘ridge preservation’. Loss of labial crestal bone following tooth removal remains one of dentistry’s greatest challenges. The importance of maintaining an adequate bone volume prior to implant placement cannot be overstated. Without ridge preservation, the alveolar bone will resorb from 30-60% within 6 months. At least 1mm of vertical bone height will also be lost without ridge preservation.Photograph following extraction of tooth #7. Note the Photograph 3 months following extraction and ridge preservationthinness of the buccal plate of bone and apical extent of shows impressive regeneration of the alveolar bone. The alveolarbone loss (seen at arrows). Without a ridge preservation this ridge has been restored to its original anatomy.bone would resorb leaving a large concavity in the buccal ridge. (The dark object in the back of site 7 is a retractor holding the palatal tissue back). Photograph shows soft Flap elevation shows Photograph shows Placement of a resorbable Suturing to obtain Photograph shows tissue swelling associated severe bone loss on the a bone xenograft in collagen membrane primary closure. vertical root fracture. with tooth #7. buccal of tooth #7. place. provides epithelial cell exclusion. CONCLUSION: University studies support the concept that patients should receive grafting materials at the time of tooth extraction ( Nevins, 2006 IJPDR). This is critical in preserving the natural tissue contours at the edentulous site in preparation for either a conventional or implant supported restoration. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • DECEMBER 2010 PERSPECTIVES IN PERIODONTICS This case report is meant to give you the perspective we have on a daily basis. As a periodontal office, we have a unique opportunity to see underneath the gingival tissues. It is both interesting and alarming to see the destructive nature of periodontal disease. Pre-treatment photograph of tooth #11 shows minimal inflammation. The amount of inflammation does not correspond to the amount of supra-gingival plaque nor the amount of sub- gingival calculus that is present. The presence of inflammation is masked by the patients smoking habit. The pre-treatment radiograph of tooth 11 shows a severe vertical bone defect along the mesial. SURGICAL SEQUENCE: Guided Tissue Regeneration with Platelet Derived Growth Factor to preserve the tooth Proper bone levelFlap elevation reveals the incredible Flap reflection allows for the best A composite bone graft of Bio-Oss andravages of periodontal disease. The access for the removal of the Demineralized Freeze Dried Bone was placed intoyellow arrows point to the bone loss. calculus. Also seen is the bone loss the defect. The synthetic growth factorThe black arrow points to the calculus that extended 3/4 of the way down the GEM21-S was used to enhance the regenerativethat was buried sub-gingivally. The root surface. process. Following this, a resorbable barrierpatient reports a history of root planning membrane was placed and the tissue sutured tothat could not reach the calculus. obtain primary closure. CONCLUSION: The continued presence of calculus can lead to the loss of the teeth. Flap elevation allows access to the calculus for its removal. Guided tissue regeneration allows for replacement of the periodontal attachment structures and thereby tooth preservation. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • JANUARY 2011 Esthetic Crown Lengthening and Restorative Treatment A smile is an important non-verbal method of communication. A pleasing smile conveys a friendly nature and reflects happiness and confidence. A smile is an interaction between not only the teeth, but the lip framework and the gingival scaffold.Pre-treatment photographs are the smile and retracted Post-treatment photographs show the enhanced dentalviews of a 45 year old female. These photographs show esthetics that now allows the patient to smile more freely.the patient‟s concerns that inhibit her from smiling The patient was very pleased with her new smile.fully. 1. Crown lengthening: Involves osseous re-contouring to provi1. Short teeth which she feels gives her an aged appearance. 3mm from the crown the margins to the alveolar bone. This prevents marginal gingival inflammation.2. Poor tooth shape makes her teeth look like „chicklets‟.3. Darker colored teeth makes her embarrassed to smile. 2. Improved tooth form: Crown width to height ratio of 80% leads to a more youthful tooth appearance.4. She does not like to smile big because it exposes so much 3. Restored teeth improves the tooth shade: Provided byof her gum tissue. restorative dentist. 4. Reducing gingival display: Marginal gingiva follows upper lip. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver D.D.S., and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver, or Jacobson.
    • FEBRUARY 2011 Preserving teeth with gingival grafting combined with a frenectomy The apical migration of the gingival margin can progress if left untreated. The success of root coverage procedures is directly related to the severity of the recession. People generally are not born with gingival recession. There is a progression from a healthy gingival attachment to slight gingival recession leading to severe deterioration over a variable time period. PRE-TREATMENT VIEWS OF TOOTH 24 demonstrate gingival POST-TREATMENT PHOTOGRAPH OF TOOTH 24: recession and a minimal band of protective keratinized attached tissue. The Gingival recession is corrected along with an increase in the second photograph shows the etiology of the periodontal defect, the high amount of attached tissue. This was accomplished with a frenum attachment. This view was obtained by pulling the lip out. With frenectomy and addition of a gingival graft. The elimination the lip pulled out, blanching of the tissue is seen. The presence of the of the frenum pull and the presence of attached tissue will frenum and lack of keratinized tissue inhibited the patient from brushing the prevent future recession from occurring and help preserve gingival margin. Plaque (at the yellow arrows) can be seen along the the tooth. The gingival margin levels have also been gingival margin on the photograph to the left. restored to an even level which improves esthetics and facilitates more effective home care. EARLY CORRECTION OF GINGIVAL DEFECTS IS THE BEST TIME FOR A SUCCESSFUL REPAIR. PROGRESSIVE DETERIORATION CAN LEAD TO TOOTH LOSS AS SEEN IN THE CASES BELOW:PATIENT #1: The photograph on the left shows the initial PATIENT #2: The photograph on the left shows the initialpresentation of tooth 24. Calculus can be observed on the root condition for tooth 27 with the associated severe gingivalsurface along with the resulting gingival recession. The heavy recession. The loss of tissue support resulted in class III toothfrenum attachment can also be seen. Infection had spread into the mobility that made eating difficult. An extraction was performedsub-mandibular region necessitating an emergency extraction. (as can be seen) and the tooth was eventually replaced with a dental implant. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • A GUIDE TO UNDERSTANDING PERIODONTAL DISEASE, TOOTHPRESERVATION AND DENTAL IMPLANTS PROVIDED BY PERIODONTICS OF THE DESERT PETER WARSHAWSKY, D.D.S. ERIC DRIVER, D.D.S. STEVEN JACOBSON, D.D.S., M.S. Volume 5 11-2010 through 1-2012
    • TABLE OF CONTENTSNovember 2010: Ridge PreservationDecember 2010: Periodontal Disease TreatmentJanuary 2011: Esthetic Crown Lenghtening and Restorative TreatmentFebruary 2011: Frenectomy + Gingival GraftingMarch 2011: Cone Beam Computed TomographyApril 2011: Periodontal Disease and Coronary Artery DiseaseMay 2011: Onlay Bone GraftJune 2011: Phases of Reconstructive DentistryJuly 2011: Staged Dental Implant PlacementAugust 2011: Dental Implant ComplicationsSeptember 2011: Guided Tissue RegenerationOctober 2011: Natural Looking Tooth Replacement with Dental ImplantsNovember 2011: Deceptive Nature of Periodontal DiseaseDecember 2011: Ideal Dental Implant TreatmentJanuary 2012: Extreme Dental Make-Over
    • NOVEMBER 2010 WHY IS RIDGE PRESERVATION BENEFICIAL FOLLOWING TOOTH EXTRACTION? A procedure that can restore and maintain the alveolar ridge following tooth extraction is ‘ridge preservation’. Loss of labial crestal bone following tooth removal remains one of dentistry’s greatest challenges. The importance of maintaining an adequate bone volume prior to implant placement cannot be overstated. Without ridge preservation, the alveolar bone will resorb from 30-60% within 6 months. At least 1mm of vertical bone height will also be lost without ridge preservation.Photograph following extraction of tooth #7. Note the Photograph 3 months following extraction and ridge preservationthinness of the buccal plate of bone and apical extent of shows impressive regeneration of the alveolar bone. The alveolarbone loss (seen at arrows). Without a ridge preservation this ridge has been restored to its original anatomy.bone would resorb leaving a large concavity in the buccal ridge. (The dark object in the back of site 7 is a retractor holding the palatal tissue back). Photograph shows soft Flap elevation shows Photograph shows Placement of a resorbable Suturing to obtain Photograph shows tissue swelling associated severe bone loss on the a bone xenograft in collagen membrane primary closure. vertical root fracture. with tooth #7. buccal of tooth #7. place. provides epithelial cell exclusion. CONCLUSION: University studies support the concept that patients should receive grafting materials at the time of tooth extraction ( Nevins, 2006 IJPDR). This is critical in preserving the natural tissue contours at the edentulous site in preparation for either a conventional or implant supported restoration. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • DECEMBER 2010 PERSPECTIVES IN PERIODONTICS This case report is meant to give you the perspective we have on a daily basis. As a periodontal office, we have a unique opportunity to see underneath the gingival tissues. It is both interesting and alarming to see the destructive nature of periodontal disease. Pre-treatment photograph of tooth #11 shows minimal inflammation. The amount of inflammation does not correspond to the amount of supra-gingival plaque nor the amount of sub- gingival calculus that is present. The presence of inflammation is masked by the patients smoking habit. The pre-treatment radiograph of tooth 11 shows a severe vertical bone defect along the mesial. SURGICAL SEQUENCE: Guided Tissue Regeneration with Platelet Derived Growth Factor to preserve the tooth Proper bone levelFlap elevation reveals the incredible Flap reflection allows for the best A composite bone graft of Bio-Oss andravages of periodontal disease. The access for the removal of the Demineralized Freeze Dried Bone was placed intoyellow arrows point to the bone loss. calculus. Also seen is the bone loss the defect. The synthetic growth factorThe black arrow points to the calculus that extended 3/4 of the way down the GEM21-S was used to enhance the regenerativethat was buried sub-gingivally. The root surface. process. Following this, a resorbable barrierpatient reports a history of root planning membrane was placed and the tissue sutured tothat could not reach the calculus. obtain primary closure. CONCLUSION: The continued presence of calculus can lead to the loss of the teeth. Flap elevation allows access to the calculus for its removal. Guided tissue regeneration allows for replacement of the periodontal attachment structures and thereby tooth preservation. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • JANUARY 2011 Esthetic Crown Lengthening and Restorative Treatment A smile is an important non-verbal method of communication. A pleasing smile conveys a friendly nature and reflects happiness and confidence. A smile is an interaction between not only the teeth, but the lip framework and the gingival scaffold.Pre-treatment photographs are the smile and retracted Post-treatment photographs show the enhanced dentalviews of a 45 year old female. These photographs show esthetics that now allows the patient to smile more freely.the patient‟s concerns that inhibit her from smiling The patient was very pleased with her new smile.fully. 1. Crown lengthening: Involves osseous re-contouring to provi1. Short teeth which she feels gives her an aged appearance. 3mm from the crown the margins to the alveolar bone. This prevents marginal gingival inflammation.2. Poor tooth shape makes her teeth look like „chicklets‟.3. Darker colored teeth makes her embarrassed to smile. 2. Improved tooth form: Crown width to height ratio of 80% leads to a more youthful tooth appearance.4. She does not like to smile big because it exposes so much 3. Restored teeth improves the tooth shade: Provided byof her gum tissue. restorative dentist. 4. Reducing gingival display: Marginal gingiva follows upper lip. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver D.D.S., and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver, or Jacobson.
    • FEBRUARY 2011 Preserving teeth with gingival grafting combined with a frenectomy The apical migration of the gingival margin can progress if left untreated. The success of root coverage procedures is directly related to the severity of the recession. People generally are not born with gingival recession. There is a progression from a healthy gingival attachment to slight gingival recession leading to severe deterioration over a variable time period. PRE-TREATMENT VIEWS OF TOOTH 24 demonstrate gingival POST-TREATMENT PHOTOGRAPH OF TOOTH 24: recession and a minimal band of protective keratinized attached tissue. The Gingival recession is corrected along with an increase in the second photograph shows the etiology of the periodontal defect, the high amount of attached tissue. This was accomplished with a frenum attachment. This view was obtained by pulling the lip out. With frenectomy and addition of a gingival graft. The elimination the lip pulled out, blanching of the tissue is seen. The presence of the of the frenum pull and the presence of attached tissue will frenum and lack of keratinized tissue inhibited the patient from brushing the prevent future recession from occurring and help preserve gingival margin. Plaque (at the yellow arrows) can be seen along the the tooth. The gingival margin levels have also been gingival margin on the photograph to the left. restored to an even level which improves esthetics and facilitates more effective home care. EARLY CORRECTION OF GINGIVAL DEFECTS IS THE BEST TIME FOR A SUCCESSFUL REPAIR. PROGRESSIVE DETERIORATION CAN LEAD TO TOOTH LOSS AS SEEN IN THE CASES BELOW:PATIENT #1: The photograph on the left shows the initial PATIENT #2: The photograph on the left shows the initialpresentation of tooth 24. Calculus can be observed on the root condition for tooth 27 with the associated severe gingivalsurface along with the resulting gingival recession. The heavy recession. The loss of tissue support resulted in class III toothfrenum attachment can also be seen. Infection had spread into the mobility that made eating difficult. An extraction was performedsub-mandibular region necessitating an emergency extraction. (as can be seen) and the tooth was eventually replaced with a dental implant. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • MARCH 2011 CONE-BEAM COMPUTED TOMOGRAPHY Cone-beam computed tomography (CBCT) has become widely used for implant treatment planning. It provides high resolution and accurate three-dimensional images. In this way more safe and precise dental implant placement can be provided. a CBCT prior to dental implant placement. The following are two There are many advantages to having example cases which show the benefits of this technology: PATIENT 1: The CBCT to the far left shows the pre-treatment cross sectional view of edentulous site #19. The view on the right is after implant restoration. Seen is the precision that can be achieved. The dental implant fixture sits apically at the lingual cortical plate. The pre-treatment CBCT allowed us to know the ideal length of implant fixture that would fit the site. Without this three dimensional information, a taller implant fixture could have been used based on the position of the inferior alveolar nerve (at yellow arrows). If a taller fixture were to be used it could perforate the lingual cortical plate damaging the lingual artery. Damage to the lingual artery can Pre-treatment Post-treatment create a life threatening emergency. PATIENT 2: Presents with a failing anterior bridge. The patient would like dental implants to replace the missing teeth. From the clinical photograph on the far left, the buccal-lingual thickness of the maxilla cannot be accurately determined. The CBCT cross sectional views allows us to know that the bone thickness is 3mm. This information lets us know that bone grafting will be necessary prior to dental implant placement.The main advantages to CBCT is having the cross sectional views in the buccal-lingual dimension. This provides asignificant advantage in evaluating a potential implant site. Research studies indicate a lingual concavity in theposterior mandible in 36 to 39% of the population. Knowing this information prior to implant placement is veryhelpful and decreases the risk of complications.CBCT is also beneficial in providing accurate mapping of the inferior alveolar nerve pathway, the presence ofarteries, fluctuations in maxillary sinus anatomy, as well as variables in the thickness of the alveolar bone.CONCLUSIONS: Previously two-dimensional peri-apical or panoramic radiography was used to assess patientanatomy. Today, three-dimension data gathered from cone beam computed tomography can be extremely revealing.The ability to assimilate this information has the potential to diminish implant complications greatly. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • APRIL 2011 INFLAMMATION, PERIODONTAL DISEASE AND CORONARY ARTERY DISEASE Increased levels of inflammation is recognized as a clinically significant factor in the initiation and progression of coronary artery disease (CAD). In this regard, chronic periodontitis is a common inflammatory disease that is recognized as having an association with and potential casual relationship to CAD. Treatment that reduces inflammation can therefore improve overall well-being. The two cases seen below are patients who presented with chronic periodontal disease. These patients had no pain associated with their condition. Their general dentist had referred them to our office for treatment. Pre-treatment patient #1 Post-treatment patient #1 Pre-treatment patient #2 Pre-treatment patient #2The photographs on the left above are pre-treatment views that show gingival inflammation as a result of bacteria. Probingdepths were 4-5mm with generalized bleeding on probing. The photographs on the right are 3 weeks following scaling and rootplaning and oral hygiene instruction at the re-evaluation appointment. THE RE-EVALUATION IS A CRITICALAPPOINTMENT TO DETERMINE IF TREATMENT WAS SUCCESSFUL.In these two cases, there is a dramatic reduction in inflammation. This not only improves the prognosis for tooth retention butcan positively impact overall well being.CONCLUSION: The presence of bacteria at and below the gingival margins leads to a series of events. The bacteriastimulate the patient‟s immune system to produce a variety of inflammatory mediators to fend off the infection.These mediators then cause the liver to produce c-reactive proteins. These c-reactive proteins participate in thedevelopment of clots and plaques that lead to an increased risk of heart attacks and strokes. Reducing inflammationreduces c-reactive protein levels.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S.,M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and commentsare welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • MAY 2011 Onlay bone graft to correct an atrophied ridge Over a period of time, the jawbone associated with missing teeth atrophies. This often leaves a condition in which there is poor quality and quantity of bone. The onlay bone graft is method to increase the bone volume when the ridge of bone is too thin for dental implant placement.PRE-TREATMENT CORONAL VIEW OF THE LOWER POST-TREATMENT CORONAL VIEW OF THE LOWER LEFTLEFT POSTERIOR RIDGE: due to a failing long span bridge POSTERIOR RIDGE SIX MONTHS FOLLOWING THE ONLAY BONEdental implants are necessary. Flap elevation reveals a narrow GRAFT: This photograph shows the dramatic increased thickness of bone“knife edge” ridge. The ridge is too narrow to contain dental is present following the onlay bone graft; in preparation for dental implant.implants The ridge is no longer knife edge.PHASE1 ONLAY BONE GRAFT: The photograph on the left shows PHASE 2 IMPLANT SITE PREPARATION: Themono-cortical plates of bone that have been secured with Memfix screws. photograph on the left shows the osteotomy site for theThe augmented bone was obtained from the symphysis region of the two dental implants. On the right are the two dentalmandible. The photo on the right shows the addition of particulate bone to implants inserted. Note the adequate bone support forfill in the peripheries. This particulate bone is a combination of the implants on the buccal and lingual. Ideally thereautogenous bone and Bio-Oss (xenograph). should be 1.5mm of thickness of bone buccal and lingual to the dental implants. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • JUNE 2011 PHASES OF RECONSTRUCTIVE DENTISTRYThere are four phases to treatment: Phase I: Infection control, Phase II: Surgical or Corrective, Phase III:Restorative, Phase IV: Maintenance. Staging treatment accordingly is ideal. The following case demonstratesthat approach in a 40 year old female who had neglected her teeth for many years. The photographs to the left show the pre-treatment views. Treatment began with a clinical examination to determine the prognosis for individual teeth. The infection control phase began with the following: 1) Medical consultation 2) Extraction of teeth with a poor and hopeless prognosis 3) Caries control with the restorative dentist 4) Scaling and Root Planing with local anesthetic 5) Endodontic treatment and 5) Oral hygiene instruction. The surgical/corrective phase consisted of: 1) Pocket reduction to preserve the remaining teeth, 2) bone grafting and 3) dental implant placement. During this phase of treatment, the patient was wearing a removable temporary bridge. Please note the reduction in gingival inflammation, particularly on the mandibular anterior teeth. This is a nice indication of the improved patient compliance with home care instructions. The restorative phase, provided by the patient‟s general dentist, consisted of placement of the permanent abutments (seen to the far left). The fixed implant bridge was screw retained to address the minimal inter-arch concerns. Pink porcelain was used to replace missing tissue yielding an esthetic result. The photograph and radiograph to the left are the post-treatment views that show the fixed implant bridge in place. The patient is on a three month alternating recall as part of the maintenance phase. The next phase of treatment will involve implant therapy for the mandible. The patient is extremely happy with the improved esthetics and health achieved.CONCLUSION: PROVIDING DENTAL TREATMENT IN PHASES IS A SAFE AND EFFECTIVE WAY TO ACHIEVESUCCESSFUL OUTCOMES.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven JacobsonD.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questionsand comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • JULY 2011 A STAGED APPROACH, TO ACHIEVING A PREDICTABLE RESULT, IN THE REPLACEMENT OF AN INFECTED TOOTH WITH A DENTAL IMPLANTPre-treatment radiograph of Flap elevation of tooth #3 Due to the poor prognosis for Following degranulation, a bonetooth #3 shows an apical reveals the following clinical repair it was decided to extract graft is placed. The bone graftradiolucency at the mesial root. conditions: 1) A dental the tooth. Following the consisted of Bio-Oss andPeriodontal probing depths were material in the furcation of extraction, the site is Demineralized Freeze Dried9mm along the mesial buccal tooth #3; 2) Extreme bone degranulated. Note the loss of Bone. A Bio-Gide membraneroot, moderate soft tissue loss of the buccal plate of buccal bone. Placement of an was placed over the bone graft toswelling and exudate were bone and 3) Fenestration immediate dental implant at allow for regeneration throughpresent. defect associated with the this time could be done, but epithelial cell exclusion. mesial root. offers a risk for complications.Photograph 6 months following Photograph shows the dental Post treatment photograph and radiographridge augmentation shows implant inserted. Excellent bone show a stable result with the implant crown inremarkable regeneration of the adaptation is present and the place. Probing depths are 2-3mm with nobuccal plate of bone and the implant had good primary stability. bleeding. The patient is quite pleased. He isextraction socket. The regenerated Because of the stability of the bone, also thrilled at how smoothly the wholebone was vascular indicating its the prognosis is excellent for process went.vitality. It is safer to place the successful implant therapy.dental implant at this time when thebone is stable.CONCLUSION: A VARIETY OF SEQUENCES ARE AVAILABLE IN THE REPLACEMENT OF A TOOTHWITH A DENTAL IMPLANT. THE ABOVE CASE DEMONSTRATES AN APPROACH THAT CAN LEAD TOPREDICTBALE RESULTS.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S.,M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and commentswelcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • AUGUST 2011 DENTAL IMPLANT COMPLICATIONS ASSOCIATED WITH EXCESS CEMENT Cement-retained restorations are commonly used on dental implants. Residual excess cement after placement of the crown has been associated with clinical and radiographic signs of peri-implant disease. An increased awareness of this problem can help to reduce complications. PATIENT #1 presented with pain associated with the dental The above photographs are from two different patients implant at the #10 site two years after placement. The who had chronic inflammation associated with their radiograph reveals severe bone loss. Flap elevation shows dental implants. Flap elevation revealed the source of the the etiology of the problem to be cement (at the yellow problems and associated bone loss; which was severe in arrows). the far right case. The photographs to the left show different patients with complications associated with their dental implants. The far left photograph was a patient who had persistent bleeding and tenderness associated with their gingival tissue. Flap elevation (which is what the photograph reveals) allowed access for removal of cement and resolution of the patient‟s symptoms. The photograph to the right shows a failed dental implant in which the cement initiated an inflammatory response. This resulted in severe bone deterioration and loss of the dental implant because of mobility.PROSPECTIVE STUDY: Conducted by Thomas Wilson D.D.S.: Thirty-nine consecutive patients with implantsexhibiting clinical and/or radiographic signs of peri-implant disease were studied. Excess dental cement wasassociated with signs of peri-implant disease in the majority (81%) of the cases. J Periodontol • September 2009;1388-1393. This case report is provided by be challenging to remove excess cement when gingival Driver, are firm, the tissue is D.D.S.,CONCLUSION: It canPERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Erictissues D.D.S. and Stevenor the implants arePeriodontists.674-4410.* All asharingare periodontal cement removal dental orcommunity. M.S.; Board Certified placed deeply.meant as cases of of current problem of informationof Drs. Warshawsky, Driverlead to soluti It is An awareness way presented theactual patient‟s with the can Jacobson. Questions and comments are welcomed by callingretained implant restorations, pre-loading cement retained crowns on the abutment replica to remove excess cement,custom abutments and diligence in cement removal (with anesthesia when necessary) are possible solutions.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S.,M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and commentsare welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • SEPTEMBER 2011 PERSPECTIVES IN PERIODONTICS This case report is meant to give you the perspective we have on a daily basis. As a periodontal office, we have a unique opportunity to see underneath the gingival tissues. It is both interesting and alarming to see the destructive nature of periodontal disease. Pre-treatment photograph of Six month post tooth #11, on the far left, shows treatment radiograph minimal inflammation. The to the left shows a amount of inflammation does remarkable gain in bone not correspond to the amount of fill of the defect. supra-gingival plaque nor the This was accomplished amount of sub-gingival calculus through the sequence that is present. The presence of detailed below. Guided inflammation is masked by the Tissue Regeneration is patients smoking habit. The pre- the best way to improve treatment radiograph of tooth 11 the prognosis of teeth shows a severe vertical bone that are periodontally defect along the mesial. compromised. SURGICAL SEQUENCE: Guided Tissue Regeneration with Platelet Derived Growth Factor to Preserve the Tooth Proper bone levelFlap elevation reveals the incredible ravages Flap reflection allows for the best access A composite bone graft of Bio-Oss and Demineralizedof periodontal disease. The yellow arrows for the removal of the calculus. Also Freeze Dried Bone was placed into the defect. Thepoint to the bone loss. The black arrow seen is the bone loss that extended 3/4 of synthetic growth factor GEM21-S was used topoints to the calculus that was buried sub- the way down the root surface. enhance the regenerative process. Following this, agingivally. The patient reports a history of resorbable barrier membrane was placed and the tissueroot planing that could not reach the calculus. was sutured to obtain primary closure. CONCLUSION: The continued presence of calculus can lead to the loss of the teeth. Flap elevation allows access to the calculus for its removal. Guided tissue regeneration allows for replacement of the periodontal attachment structures and thereby tooth preservation. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • OCTOBER 2011 Achieving natural looking results through a staged approach with dental implantsPhotograph 3 months following the removal of tooth #10 (due to severe Post-treatment photograph of the dental implant at site #10periodontal disease) and site development. Following proper tissue reveals a nice esthetic outcome. What is appealing is, 1) the shapematuration the dental implant can be placed. This staged approach to and shade of the crown provided by the restorative dentist, 2) theimplant placement insures adequate tissue support. This is important level of the gingival margin in comparison to the neighboringfor implant integration as well as esthetics. natural teeth and 3) the presence of the papillas. 1 3 4 5 2 PHOTOGRAPH 1: Pre-operative photograph of tooth #10. The tooth demonstrated a class II mobility and 10mm probing depths on the lingual. The prognosis for tooth preservation was poor due to the extent of deterioration. An immediately placed dental implant would be a risk as far as both esthetics and integration due to contamination of alveolar bone. PHOTOGRAPH 2: Radiograph shows severe bone loss associated with tooth #10. PHOTOGRAPH 3: Photograph following flapless and atraumatic tooth removal. This will help maintain soft and hard tissue support. Seen is the bone graft in the extraction socket. A resorbable membrane was placed over the graft. Without reconstructing the tissue, the resulting implant crown could end up taller than the neighboring teeth. PHOTOGRAPH 4: Shows the extracted tooth #10. Seen is the etiology of the severe periodontal destruction; the palatal gingival groove (at the yellow arrow). This developmental groove acted as a pathway for bacteria to migrate down the root surface and attach to the tooth (seen at the black arrow). PHOTOGRAPH 5: Final radiograph shows an integrated dental implant. The patient is very happy with the results. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comment are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • NOVEMBER 2011 THE DECEPTIVE NATURE OF PERIODONTAL DISEASE Patient #1 Patient #1 Patient #1Pre-treatment photograph of teeth #’s Gingival flap reflection reveals A surgical approach dramatically increases the21 and 22 initially looks innocent. significant calculus accumulation on the chances for calculus removal. The surgicalCloser evaluation shows: 1. gingival root surface. The continued presence of approach is effective due to our ability to directlyrecession for tooth 21, 2. no attached the calculus puts the teeth at risk for visualize the calculus and access it for removal.tissue for tooth 21 and 3. a darkness periodontal deterioration and future loss. Elimination of the etiologic agent for periodontalbeneath the gingival margin. disease improves the chances for tooth preservation. Patient #2 Patient #2 Patient #2 Pre-treatment photograph of teeth #’s 8 Gingival flap reflection reveals A surgical approach dramatically increases the and 9 initially does not appear to be so significant calculus accumulation on chances for calculus removal. The surgical dangerous. Evaluation by the patient‟s new the root surface and severe bone loss. approach is effective due to our ability to general dentist revealed probing depths of The continued presence of the directly visualize the calculus as well as reach it. 10mm and radiographic evidence of bone calculus puts the teeth at risk for We will also be able to regenerate the loss. The patient‟s previous dentist had periodontal deterioration and future periodontal support in this case using guided never informed him of the periodontal loss. tissue regeneration. This will improve the disease present in this area. chances for tooth preservation. CONCLUSION: Since periodontal disease usually does not hurt, thorough evaluation by the dental provider, along with education of the patient is critical. This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver D.D.S., and Steven Jacobson D.D.S., M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver, or Jacobson.
    • DECEMBER 2011 OUR GOAL WITH DENTAL IMPLANT TREATMENT As a periodontal office, we pride ourselves in the replacement of severely damaged teeth with natural looking dental implants. This can be achieved through meticulous attention to the establishment of a stable soft and hard tissue foundation. The following case demonstrates a successful outcome on a patient with very high esthetic expectations: Pre-treatment photograph and radiograph of tooth #8 shows Post-treatment photograph and radiograph show the the following: 1) Marginal gingival inflammation, integrated dental implant. Symmetry of gingival margins, 2) Radiographic evidence of a large resorptive lesion. The crown shape and shade provide for an esthetic result that the patient was in pain and the tooth had a poor prognosis for repair. patient is quite pleased with. SURGICAL SEQUENCE for extraction and ridge preservation (to establish a stable foundation): 2 3 1 4 Photo 1: Flapless and non-traumatic removal of tooth #8 helps Photo 2: View following fill of extraction socket with bone graft. The bone maintain the tissue as much as possible. Following the extraction, graft material is a xenograft. the socket is explored with a periodontal probe. Granulation Photo 3: Placement of a resorbable collagen membrane allows for tissue is detected due to the resorptive defect. In addition, regeneration of the extraction socket. the buccal plate of bone is very thin. Placement of an Photo 4: View of deteriorated root. Minimal root structure remained. immediate implant at this time would be risky. CRITERIA FOR A NATURAL LOOKING DENTAL IMPLANT IN THE ANTERIOR: 1. Gingival margin of the implant crown is level with the adjacent teeth. 2. Symmtery about mid-line. 3. Papilla heights are level and parallel to gingival margins. 4. Natural shape and shade of crown.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S.,M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions and commentsare welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.
    • JANUARY 2012 EXTREME DENTAL MAKE-OVER: THE REPLACEMENT OF A HOPELESS DENTITION WITH IMPLANT SUPPORTED OVER-DENTURES Pre-treatment photographs show an un-esthetic smile Post-treatment photographs show improved with severe periodontal infection for this 45 year old esthetics through the replacement of hopeless patient. All of the teeth have mobility. Purulent exudate teeth with implant supported dentures. The drained from the sulci of most of the teeth. Dental phobia removal of the infected teeth has improved the had prevented the patient from seeking care until his teeth patient‟s overall well being. were so loose he could not chew his food. The photograph shows the extracted teeth. Seen is the heavy Radiograph reveals four calculus build-up that led to the dental implants in the maxilla periodontal disease. The presence and two in the mandible. of periodontal infection has been Photographs show dentures that are This is the minimum number linked to other medical problems retained with locator abutments. The necessary to support the as well, such as heart disease. locator inserts come in different dentures in each arch. retentive holding force levels depending on the needs of the patient.CONCLUSION: The use of dental implants to help retain dentures is a wonderful treatment. Locatorattachments provide for excellent retention of dentures during speaking and eating. This is the mosteconomical implant solution for denture wearers that provides for comfort and stability over time.This case report is provided by PERIODONTICS OF THE DESERT: Peter Warshawsky, D.D.S., Eric Driver, D.D.S. and Steven Jacobson D.D.S.,M.S.; Board Certified Periodontists. It is meant as a way of sharing current periodontal information with the dental community. Questions andcomments are welcomed by calling 674-4410.* All cases presented are actual patient‟s of Drs. Warshawsky, Driver or Jacobson.