warshawsky

PERIODONTAL CASE REPORTSJANUARY 2008 – JUNE 2009

A GUIDE TO UNDERSTANDING PERIODONTAL DISEASE

AND TOOTH PRESERVATION

VOLUME 3

PROVIDED BY PERIODONTICS OF THE DESERTPETER WARSHAWSKY, D.D.S.RODRIGO LAGOS, D.D.S., M.S.

STEVEN JACOBSON, D.D.S., M.S.

PERIODONTAL CASE REPORTSTITLE PAGE

Gingival recession: What happens when it is left untreated January, 2008

Dental implants: Treatment options for the edentulous mandible February, 2008

Combined periodontal-endodontic lesion March, 2008

Calculus: Benefits of flap access April, 2008

Dental implants: Site development May, 2008

Biologic Width: Why is it important June, 2008

Cervical erosion: Ideal treatment July, 2008

Esthetic crown lengthening: Improving smiles August, 2008

Inflammation: Why it leads to bone deterioration, amongst other things September, 2008

Dental implants: Timing of placement October, 2008

Ridge Preservation: Reconstructing a damaged alveolar bone November, 2008

Guided Tissue Regeneration: Preserving teeth December, 2008

Gingival recession: What happens when it is left untreated January, 2009

Gingival recession: How to correct it and preserve teeth February, 2009

Periodontitis: Associated with medication March, 2009

Periodontitis: Associated with diabetes April, 2009

Periodontitis: Common questions May, 2009

Dental 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 placement

PRESERVATION 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 shorthard and soft tissues. This was the presentation prior to implant length was necessary due to lingual cortical platedental 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 case

report.

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 tobone opposed to biological integration- uncertain life-span-smallest financial investment for patient

OPTION 2: IMPLANTOVERDENTURE-2-4 dental implants; can uselocator abutments, ball abutments

or a bar.-there still can be some movement

of the denture-based on osseo-integration, so has

OPTION 3: IMPLANTOVER-DENTURE WITH

HADER BAR-4-6 dental implants-very high degree of retention;usually no movement during

function-predictable esthetics-very high degree of success

OPTION 4: FIXED IMPLANTSUPPORTED BRIDGE-6-10 dental implants-may require bone grafting-can be challenging esthetically-teeth are non-removable-largest financial investment for patient

The options listed above range from least to most involved. Treatment selection depends on clinical and

patient factors.

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

presented are actual patient’s of Drs. Warshawsky, Lagos, or Jacobson.

MARCH 2008

Treatment of a primary periodontal, secondary endodontic lesion related to food

impaction from an open contact.

Radiograph and photograph revealextensive deterioration associated withtooth #30 distal. The radiograph revealsa vertical bone defect that extended to theapex of the root. The photograph showsthe periodontal probe extending down12mm. Tooth 30 is temporized to close the

open contact that had caused theperiodontal damage. The tooth wasdetermined to be non-vital by the

endodontist.

Photograph shows the bone graftFlap elevation reveals the Photograph shows a Bio-Gide membranein place. A synthetic growthinfrabony defect between teeth 30 placed over the bone graft. This membrane isfactor has been used to stimulateand 31. The temporary crown has resorbable and provides epithelial cellperiodontal regeneration.been removed for better access to exclusion to promote periodontal regeneration.

the periodontal defect.

Six month follow up radiograph reveals dramatic bone fill of the defect. Alsoseen is the root canal which helped to eliminate periodontal pathogens that hadmigrated 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.



APRIL 2008

BENEFITS OF FLAP ACCESS IN THE TREATMENT OF PERIODONTAL DISEASE

Dental calculus is mineralized, matureplaque covered on its surface with non-mineralized plaque, material alba,desquamated epithelial cells andformed blood elements. Root calculusis usually more strongly adherent totooth surfaces than that found onenamel surfaces.

The attachment of subgingival calculusPatient #1 Patient #1is complicated by microscopicirregularities in cementum. Theseirregularities include cemental tears,cemental voids once occupied bySharpey’s fibers, resorption bays andother surface cemental defects. For

this reason, calculus can be verydifficult to remove from root surfacesduring scaling and root planing.

The microbial composition of calculusprovides bacterial factors that produce

Patient #2 Patient #2 an inflammatory reaction in tissue.The persistent presence ofinflammation is what leads toperiodontal destruction and tooth lossin the susceptible patient.

Numerous university studies indicatethat the effectiveness of calculusremoval dramatically decreases aspocket depths deepen.

Patient #3 Patient #3

The 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.



MAY 2008

PERIODONTAL SITE DEVELOPMENT IN PREPARATION FOR A DENTAL IMPLANT

Pre-treatment photographPost-treatment photograph

The photograph to the left shows the pre-treatment condition of tooth #10. The tooth presented with 4mm.ofgingival recession, class III mobility and 7mm probing depth on the distal. The patient desired the best estheticoutcome 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 theamalgam 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-treatmentviews. The radiograph to the left shows an apicalradiolucent area and a suspicious position for thepost. The radiograph to the right shows a wellintegrated dental implant.

The above two photographs show tissue manipulation followingThe photograph to the left shows an improved gingival margin

extraction of tooth 10. By covering the bone graft, followinglocation. The photograph on the right shows a free gingival

extraction, with a rotated pedicle flap, correction of the pre-graft to correct the amalgam tattoo following removal of the

existing gingival recession could be accomplished.amalgam ‘flash’ in the tissue.

CONCLUSION: HAVING THE PROPER TISSUE SUPPORT IS IMPORTANT IN ACHIEVING ESTHETIC

RESULTS.



JUNE 2008

BIOLOGIC WIDTH

The 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 laserThese short clinical crowns do not provide enough tooth since osseous recontouring is to be performed. This was determinedstructure for retention of planned restorations. In in the pre-treatment assessment when the alveolar crest of bone wasaddition, 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 spacecemento-enamel junction of teeth 8, 9 and 10. Black arrows from the adjusted crest of bone (black arrows) to the proposed finalindicate 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 ofbone. Restorative margins too close to the alveolar crest can result in

unsightly cyanotic tissue margins.

Six week healing photograph shows enhanced tooth exposure. This willprovide improved retention for the restorations. It will also allow forestablishment of improved tooth proportions (80% width to height). Theincisal edge will be extended coronally 1-2mm. The final gingival marginswere probed and found to be 3mm from the alveolar crest. This willeliminate 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 current

periodontal information with the dental community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actualpatient’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 teethteeth 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 andof keratinized attached tissue. This puts the teeth at increased the amount of keratinized attached tissue. Bondingrisk 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• Attrition

TREATMENT: Sequencing can vary. However, typically gingival grafting is provided first. This involves replacement of

soft 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.



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 the

crown 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 estheticsof 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

crown lengthening that included osseous recontouring.2) Excessive gingival display on smiling.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 teeth



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 patients

with periodontal disease when the gingival tissues are reflected. This periodontal destruction is primarily a

result of the inflammatory system. The innate immune system is activated by bacterially derived factors and

antigens.

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. Forexample, the earliest changes in atherosclerosis occur in the endothelium. This can lead to a cascade ofinflammatory 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 inflammatorydiseases, 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 intocoherent 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.



OCTOBER 2008

TIMING FOR THE PLACEMENT OF DENTAL IMPLANTSThe decision as to when a dental implant should be placed is critical. The implant can be placed immediately after thetooth 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 result

regarding 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 overremoval. This will help maintain soft and the bone graft. This will help to augment the softxenograft into the extraction socket.hard tissue support. tissue ensuring symmetric gingival margins.

CONCLUSION: Several treatment approaches can be selected in cases like this one. Given the history ofchronic pain, it was decided to remove the tooth and not replace it right away. With this delayed approach todental 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.



NOVEMBER 2008

RIDGE PRESERVATIONLoss 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 thealveolar 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 showssoft tissue swelling severe bone loss on the a bone xenograft in collagen membrane primary closure. vertical root fracture.associated with place. provides epithelial cellbuccal of tooth #7.tooth #7. exclusion.

CONCLUSION: Variables exist as far as the extent of regeneration which can be achieved with ridgepreservation. Variables include 1) the extent of the initial bone defect, 2) the type of bone grafting materialused, 3) surgical technique and 4) healing capability of the patient.



DECEMBER 2008

GUIDED TISSUE REGENERATION TO PRESERVE TEETHPeriodontal regeneration is the formation of new bone, new cementum and new periodontal ligament. This creates a newfunctional 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-entry

procedure is that patient is receiving a dental implant to replace toothprognosis for tooth retention.#5, which was a pontic space.

SURGICAL SEQUENCE:

1 2 3 4

Photograph 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 through

epithelial 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 currentThis 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 not

possible.

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.



FEBRUARY 2009

CORRECTION OF MUCOGINGIVAL DEFECTS THROUGH GINGIVAL GRAFTING

Creating gingival tissue reduces the likelihood of further recession. Gingival grafting also helps cover exposedroots, enhances the appearance of teeth and protects roots from decay and sensitivity.

Post-treatment patient #1Pre-treatment patient #1

Pre-treatment patient #2 Post-treatment patient #2

Post-treatment photographs show:Pre-treatment photographs show the following:1) Complete root coverage and restoration of gingival1) Gingival recession ranging from 2-5mm 5mm (black

arrows). tissues.2) Very thin zone of attached tissue. 2) Increased zone of attached tissue has been providedThis 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 theprognosis 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.



Diltiazem (Cardizem) Nimodipine (Nimotop) Phenytoin (Dilantin) Cyclosporine-A (Sandimmune)

Felodipine (Plendil) Nisoldipine (Syscor)

Isradipine (Prescal)Nifedipine(Procardia,

Nitrendipine (Bayotensil)Verapamil (Calan)

Adalat, Tenif)

MARCH 2009

PERIODONTITIS ASSOCIATED WITH A MEDICATION

Many 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 #2

Pre-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)

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 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.

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 “deepcleanings” over the last several years.

The radiograph to the left revealssevere bone loss. It is amazing tosee 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. Inaddition, a periodontal infection may be more severe in a diabetic patient than in someone without diabetes. It is important for diabeticpatients 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. Moreadvanced 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 canimprove 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. andSteven 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 2009COMMON 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.

The patient has received regular ‘cleanings’ twice a year.WHAT CAUSES PERIODONTAL DISEASE? Research over the past 30 years has added to our

WHAT 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 attachment

triggering 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 bone

surrounding the tooth.DOES PERIODONTAL DISEASE AFFECT SYSTEMIC HEALTH?The relationship between

periodontal 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 by

increases 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 to

reduce pocket depths so that patients can be effective with their home care.



JUNE 2009

Replacement of a worn and deteriorated dentition with an implant supported over-denture

Post-treatment photograph shows the implant supported over-Pre-treatment photograph shows severely decayed teethdenture in place. Health, esthetics and function for the patient havewith periodontal involvement as well as missing posteriorbeen greatly improved. The patient is very pleased with the results.teeth. The prognosis for preserving these teeth is poor.

The long term prognosis for this treatment is excellent.

These are the locator inserts. The blue insertView of locator abutments in place with View of the inside of the over-denturehas a retentive capacity of 1.5 pounds, thethe prosthesis removed. Locators are with locator inserts. One of the insertspink 3.0 pounds and the clear, 5.0 pounds.attached to dental implants that are needed to be removed because theFor example, the use of 4 dental implantsfirmly integrated in the jaw bone. retention was so strong that the patientwith locators and the clear male inserts cancould not remove the prosthesis for

offer a retention of 20 pounds.cleansing.

CONCLUSION: The standard of care for an edentulous patient is to have a minimum of two dental

implants in the mandible. With the above patient, the long term prognosis with dental implants was

felt 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 and

comments are welcomed by calling 760-674-4410. * All cases presented are actual patient’s of Drs. Warshawsky, Lagos, or Jacobson.

A GUIDE TO UNDERSTANDING PERIODONTALDISEASE, TOOTH PRESERVATION

AND DENTAL IMPLANTS

PROVIDED BY PERIODONTICS OF THE

DESERTPETER WARSHAWSKY, D.D.S.

ERIC DRIVER, D.D.S.


Volume 4

FURCATIONS July 2009

ESTHETIC DENTAL IMPLANT THERAPY August 2009

GINGIVAL GRAFTING September 2009

PERIODONTAL DISEASE October 2009

ONLAY BONE GRAFT November 2009

PERIODONTAL REGENERATION December 2009

SCALING AND ROOT PLANING LIMITATIONS January 2010

INFLAMMATION AND SYSTEMIC HEALTH February 2010

IMPLANT SUPPORTED OVER-DENTURE March 2010

ATLANTIS ABUTMENT April 2010

BONE STABILITY AROUND DENTAL IMPLANTS May 2010

GINGIVAL GRAFTING STABILITY June 2010

ESTHETIC CROWN LENGTHENING July 2010

CALCULUS REMOVAL August 2010

GUIDED TISSUE REGENERATION Septemebr 2010

BISPHOSPHONATE MANAGEMENT October 2010

RIDGE PRESERVATION November 2010

PERSPECTIVES IN PERIODONTICS December 2010

ESTHETIC CROWN LENGTHENING January 2011

GINGIVAL GRAFTING WITH A FRENECTOMY February 2011

JULY 2009FURCATIONS

Maxillary 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 common

classifications 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 totalwidth 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 at

greater 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 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.

AUGUST 2009

A STAGED APPROACH TO SUCCESSFUL AND ESTHETIC DENTAL IMPLANT THERAPY

Pre-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 and

shade provide for an esthetic result that the patient is quitetooth has a class II mobility and there is chronic pain.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 aperiodontal probe. A bone defect is detected and can be seen

at the end of the periodontal probe (arrow). Placement of animmediate implant here would be risky.

Photo 3: Shows condenser compressing bone graft into theextraction socket. Mild compression is provided to allow for1 2 3vascularization.

Photo 4: View following fill of extraction socket with bonegraft. The bone graft material is a xenograft.

Photo 5: Placement of a resorbable collagen membrane allowsregeneration of the extraction socket.

Photo 6: View of deteriorated root and calculus below thecrown margin.4 5 6

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. It istypically 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.



SEPTEMBER 2009

PRESERVING TEETH THROUGH GINGIVAL GRAFTING

Pre-treatment photograph of tooth #9 shows gingival Post-treatment photograph of tooth #9 shows complete rootrecession of 3mm. There is calculus above the class V coverage and an increase in attached tissue. The frenum pull hasrestoration. 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.



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 looseningof 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 onprobing and a class III mobility. Her dental history indicated that she was consistent with cleanings twicea year at her dentist’s office. She remembers being told by her dentist, years prior, that she needed to seea periodontist about tooth #10. At the time, the patient reports that she did not perceive a problembecause 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 thatbecause of the extent of deterioration present, procedures to try to preserve the tooth would have a poorprognosis. 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 ofcalculus 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.



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 withphotograph shows how deceptive the clinical view can be the results.regarding the buccal-lingual thickness of bone availability.

Surgical sequence:

2 41 3

Photograph 1: Flap elevation reveals a ridge width of 3mm. This is too narrow to properly contain the dental implants. The arrows pointto 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 donorsite 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 widthto 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 PRESENT

PRIOR TO PLACING DENTAL IMPLANTS.



DECEMBER 2009

WHAT IS PERIODONTAL REGENERATION?

The ultimate goal of periodontal therapy is replacement of the lost tooth attachment apparatus and a return topre-disease architecture. Guided tissue regeneration allows this to happen. The following photographsdemonstrate how periodontal regeneration re-grows the lost bone support.

Flap elevation shows an infrabony defect associated with The above photograph shows the remarkable regeneration oftooth #18 that extended down 9mm. The defect was the bone support for the tooth. This re-entry procedure wasinitiated by calculus primarily along the distal root performed 8 months following the initial treatment. Thesurface. prognosis for tooth retention has been greatly improved.With flap elevation, access to the calculus could be Without the guided tissue regeneration procedure, the defectachieved. The area was thoroughly debrided and treated would have remained. The area would have been susceptiblewith tetracycline. A bone graft was then placed into the to further plaque accumulation into the defect. The presencedefect mixed with a growth factor to enhance the of a periodontal pocket puts the tooth at increased risk ofregenerative process. A resorbable membrane was also loss.placed to allow for regeneration through epithelial cellexclusion.

-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 infrabony

defects. Schallhorn RG, McClain PK, Combined osseous grafting, root conditioning and guided tissue regeneration, Int J Periodontics Restorative Dent 4:9-34, 1988.

-A subsequent study confirmed that the regenerated results were stable over five years. McClain PK, Schallhorn RG, Long-termassessment 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 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 2010

LIMITATIONS OF SCALING AND ROOT PLANING

Scaling 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 CALCULUS

Teeth 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 SCALED1-3mm 86% calculus free 86% calculus free4-6mm 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 3/86

CONCLUSION: It is difficult to remove calculus from root surfaces. The residual calculus followingscaling 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.



FEBRUARY 2010

INFLAMMATION AND ITS CONSEQUENCES ON SYSTEMIC HEALTHPeriodontal infections are common inflammatory disorders caused by the bacteria inhabiting the biofilm of the dentalplaque. Studies have suggested that periodontal infections may constitute an independent risk factor for 1) coronaryartery disease, 2) pregnancy complications, including pre-term birth, lower birth weight 3) poor metabolic control indiabetes and 4) respiratory disease. Moreover, emerging associations have been described linking periodontitis andkidney 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 EFFECTS

BIOFILM: 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 1

billion 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) and

PROTEASE (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. Periodontal

treatment reduces CRP levels.

CONCLUSION: MULTIPLE STUDIES SHOW PERIODONTAL DISEASE TO BE A SIGNIFICANT RISK

FACTOR FOR CORONARY ARTERY DISESAE.



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-dentureteeth as well as severe damage to the the prosthesis removed. Locators are with female components. Femaleremaining 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)dental implants were placed at the time and 5.0 pounds (clear). The abovevestibular depth present. Both of

these anatomic features make of extractions (immediate implant example shows 4 blue components inretention of a traditional prosthesis placement). Treatment time for this place. These can be changed out to meetquite 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. Questions

and 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 madeabutment is designed with the final tooth shape in mind, for outstanding function and esthetics. It is made from aVirtual Abutment Design software computer program. These abutments can be fabricated for the majority of dentalimplant 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 abutmentmodel. This abutment is basically a one size fits has been designed and fabricated to specifically fit theall 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.



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 0.2mmduring 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 functionalstability.

The radiographs to the left areexamples of two patients who havelost crestal bone around dentalimplants that were placed in 1997.The red arrows point to where thebone level was at the time of dentalimplant insertion. The black arrows

point to the current reduced bonelevel.

The photograph and radiograph to the left is an example of apatient who had the dental implant placed in 2008. Theradiograph shows crestal bone loss. The patient reports painand a foul taste associated with the implant. The tissueabove the implant is inflamed and exudate can be expressedfrom the implant sulcus. Successful long term treatmentwill be challenging.

This is an example of a dental implant that has hadno crestal bone loss since the dental implant wasplaced 7 years previously. This provides for stabilityin 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 design


community. 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 defectswith Class I and Class II type defects the prognosis is good for correction of the defect and a halt to progressive

deterioration.

6 MONTH POST-TREATMENT PHOTOGRAPH:PRE-TREATMENT PHOTOGRAPH: The patientand 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 pullthe lack of attached tissue and 5mm of gingival eliminated, and a band of keratinized attached tissue isrecession. There was also an aberrant frenum pull. present. This will improve the long term prognosis for

tooth retention.

12 YEAR FOLLOW UP PHOTOGRAPH: Theperiodontal tissues are within normal limits. There isa broad band of attached tissue that is firmly attachedto the root surface and alveolar bone. Probing depthsare 2mm.

CONCLUSION: If a patient has less than 1mm of attached gingiva on a tooth and is having active

recession, gingival grafting has a high predictability for success.


community. Questions and comments are welcomed by calling 674-4410.* All cases presented are actual patient’s of Drs. Warshawsky,Driver or Jacobson.

JULY 2010ESTHETIC CROWN LENGTHENING AND RESTORATIVE DENTISTRY

This 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 4

The 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 from

proposed 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.



AUGUST 2010PRESERVING 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 visualizationand it’s tenacity . The continued presence of calculus leads to tooth loss in the susceptible patient.

Bone lossBone 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 calculusfor more effective removal. This helps to preserve teeth.



SEPTEMBER 2010GUIDED TISSUE REGENERATION: 18 MONTH FOLLOW UP

Periodontal regeneration is the formation of new bone, cementum and periodontal ligament. This creates anew 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 leftshows severe bone loss (area between the redarrows) and calculus (yellow arrow). This conditiongives the tooth a poor prognosis.

The follow up (18 months following treatment)radiograph shows complete bone fill and nocalculus. THE PROGNOSIS IS NOW GOOD FORTOOTH 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 the crater like bone loss that and the tissue sutured. Theyellow arrow points to 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 lostsupport due to periodontal disease.



OCTOBER 2010CONSERVATIVE 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. Arediahas a dangerous side effect, jaw osteonecrosis (ONJ). ONJ is an abnormality in which part of the jaw bone is no longeralive 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 myelomafor which he was taking the medication Aredia.

Pre-treatment photograph shows tooth #3 with a temporary crown Post-treatment photograph and radiograph show a stablein place. Seen at the arrow is a fistula tract due to a fractured mesial clinical presentation. Gingival health is present, teeth 3 and 4 areroot. 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 23 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 the

surgery was excellent with no complications.

CONCLUSION: A CONSERVATIVE SURGICAL APPROACH CAN BE USED TO MINIMIZECOMPLICATIONS ASSOCIATED WITH BISPHOSPHONATES.


community. 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 ‘ridgepreservation’. Loss of labial crestal bone following tooth removal remains one of dentistry’s greatestchallenges. The importance of maintaining an adequate bone volume prior to implant placement cannot beoverstated. 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 alveolar

bone loss (seen at arrows). Without a ridge preservation this ridge has been restored to its original anatomy.(The dark object in the back of site 7 is a retractor holding the palatal tissue back).bone would resorb leaving a large concavity in the buccal ridge.

Photograph shows soft Flap elevation shows Photograph shows Placement of a resorbable Suturing to obtain Photograph showstissue 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 thetime 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.



DECEMBER 2010

PERSPECTIVES IN PERIODONTICS

This case report is meant to give you the perspective we have on a daily basis. As a periodontaloffice, 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 showsminimal inflammation. The amount ofinflammation does not correspond to the amount ofsupra-gingival plaque nor the amount of sub-gingival calculus that is present. The presence ofinflammation is masked by the patients smokinghabit. The pre-treatment radiograph of tooth 11shows a severe vertical bone defect along the

mesial.

SURGICAL SEQUENCE: Guided Tissue Regeneration with Platelet Derived Growth Factor to preserve the tooth

Properbonelevel

Flap 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 allowsaccess to the calculus for its removal. Guided tissue regeneration allows for replacement of the periodontalattachment structures and thereby tooth preservation.



JANUARY 2011

Esthetic Crown Lengthening and Restorative TreatmentA smile is an important non-verbal method of communication. A pleasing smile conveys a friendly nature andreflects happiness and confidence. A smile is an interaction between not only the teeth, but the lip frameworkand 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 provide

3mm from the crown the margins to the alveolar bone. This prevents1. Short teeth which she feels gives her an aged appearance.marginal gingival inflammation.2. Poor tooth shape makes her teeth look like ‘chicklets’.

2. Improved tooth form: Crown width to height ratio of 80%3. Darker colored teeth makes her embarrassed to smile.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 upperlip.

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.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 frenectomyThe apical migration of the gingival margin can progress if left untreated. The success of root coverageprocedures is directly related to the severity of the recession. People generally are not born with gingivalrecession. 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 afrenum attachment. This view was obtained by pulling the lip out. With frenectomy and addition of a gingival graft. The eliminationthe lip pulled out, blanching of the tissue is seen. The presence of the of the frenum pull and the presence of attached tissue willfrenum and lack of keratinized tissue inhibited the patient from brushing the prevent future recession from occurring and help preservegingival 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 andfacilitates 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 #2: The photograph on the left shows the initialPATIENT #1: The photograph on the left shows the initialcondition for tooth 27 with the associated severe gingivalpresentation of tooth 24. Calculus can be observed on the rootrecession. The loss of tissue support resulted in class III toothsurface along with the resulting gingival recession. The heavymobility that made eating difficult. An extraction was performedfrenum attachment can also be seen. Infection had spread into the(as can be seen) and the tooth was eventually replaced with asub-mandibular region necessitating an emergency extraction.

dental implant.



A GUIDE TO UNDERSTANDINGPERIODONTAL DISEASE, TOOTH

PRESERVATION AND DENTAL IMPLANTS

PROVIDED BY PERIODONTICS OF THE

DESERTPETER WARSHAWSKY, D.D.S.

ERIC DRIVER, D.D.S.


Volume 511-2010 through 1-2012

TABLE OF CONTENTS

November 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 ‘ridgepreservation’. Loss of labial crestal bone following tooth removal remains one of dentistry’s greatestchallenges. The importance of maintaining an adequate bone volume prior to implant placement cannot beoverstated. 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 alveolar

bone loss (seen at arrows). Without a ridge preservation this ridge has been restored to its original anatomy.(The dark object in the back of site 7 is a retractor holding the palatal tissue back).bone would resorb leaving a large concavity in the buccal ridge.

Photograph shows soft Flap elevation shows Photograph shows Placement of a resorbable Suturing to obtain Photograph showstissue 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 thetime 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.



DECEMBER 2010


This case report is meant to give you the perspective we have on a daily basis. As a periodontaloffice, 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 showsminimal inflammation. The amount ofinflammation does not correspond to the amount ofsupra-gingival plaque nor the amount of sub-gingival calculus that is present. The presence ofinflammation is masked by the patients smokinghabit. The pre-treatment radiograph of tooth 11shows a severe vertical bone defect along the

mesial.

SURGICAL SEQUENCE: Guided Tissue Regeneration with Platelet Derived Growth Factor to preserve the tooth

Properbonelevel

Flap elevation reveals the incredible Flap reflection allows for the best A composite bone graft of Bio-Oss andravages of periodontal disease. The Demineralized Freeze Dried Bone was placed intoaccess for the removal of theyellow arrows point to the bone loss. calculus. Also seen is the bone loss the defect. The synthetic growth factor

that extended 3/4 of the way down theThe black arrow points to the calculus 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 allowsaccess to the calculus for its removal. Guided tissue regeneration allows for replacement of the periodontalattachment structures and thereby tooth preservation.



JANUARY 2011

Esthetic Crown Lengthening and Restorative TreatmentA smile is an important non-verbal method of communication. A pleasing smile conveys a friendly nature andreflects happiness and confidence. A smile is an interaction between not only the teeth, but the lip frameworkand 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 provide

3mm from the crown the margins to the alveolar bone. This prevents1. Short teeth which she feels gives her an aged appearance.marginal gingival inflammation.2. Poor tooth shape makes her teeth look like ‘chicklets’.

2. Improved tooth form: Crown width to height ratio of 80%3. Darker colored teeth makes her embarrassed to smile.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 upperlip.

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.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 frenectomyThe apical migration of the gingival margin can progress if left untreated. The success of root coverageprocedures is directly related to the severity of the recession. People generally are not born with gingivalrecession. 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 afrenum attachment. This view was obtained by pulling the lip out. With frenectomy and addition of a gingival graft. The eliminationthe lip pulled out, blanching of the tissue is seen. The presence of the of the frenum pull and the presence of attached tissue willfrenum and lack of keratinized tissue inhibited the patient from brushing the prevent future recession from occurring and help preservegingival 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 andfacilitates 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 #2: The photograph on the left shows the initialPATIENT #1: The photograph on the left shows the initialcondition for tooth 27 with the associated severe gingivalpresentation of tooth 24. Calculus can be observed on the rootrecession. The loss of tissue support resulted in class III toothsurface along with the resulting gingival recession. The heavymobility that made eating difficult. An extraction was performedfrenum attachment can also be seen. Infection had spread into the(as can be seen) and the tooth was eventually replaced with asub-mandibular region necessitating an emergency extraction.

dental implant.



MARCH 2011

CONE-BEAM COMPUTED TOMOGRAPHYCone-beam computed tomography (CBCT) has become widely used for implant treatment planning. Itprovides high resolution and accurate three-dimensional images. In this way more safe and precise dental

implant placement can be provided.There are many advantages to having a CBCT prior to dental implant placement. The following are twoexample cases which show the benefits of this technology:

PATIENT 1: The CBCT to the far left shows the pre-treatment crosssectional view of edentulous site #19. The view on the right is afterimplant restoration. Seen is the precision that can be achieved. The

dental implant fixture sits apically at the lingual cortical plate. Thepre-treatment CBCT allowed us to know the ideal length of implantfixture that would fit the site. Without this three dimensionalinformation, a taller implant fixture could have been used based onthe position of the inferior alveolar nerve (at yellow arrows). If ataller fixture were to be used it could perforate the lingual corticalplate damaging the lingual artery. Damage to the lingual artery cancreate a life threatening emergency.

Pre-treatment Post-treatment

PATIENT 2: Presents with a failing anterior bridge.The patient would like dental implants to replace themissing teeth. From the clinical photograph on the farleft, the buccal-lingual thickness of the maxilla cannotbe accurately determined. The CBCT cross sectionalviews allows us to know that the bone thickness is3mm. This information lets us know that bone graftingwill 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.



APRIL 2011

INFLAMMATION, PERIODONTAL DISEASE AND CORONARY ARTERY DISEASEIncreased levels of inflammation is recognized as a clinically significant factor in the initiation and progression ofcoronary artery disease (CAD). In this regard, chronic periodontitis is a common inflammatory disease that isrecognized 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 painassociated 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 #2

The 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 root

planing 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 comments

are 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 inwhich 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.

The ridge is no longer knife edge.implants

PHASE 2 IMPLANT SITE PREPARATION: ThePHASE1 ONLAY BONE GRAFT: The photograph on the left showsphotograph on the left shows the osteotomy site for themono-cortical plates of bone that have been secured with Memfix screws.

The augmented bone was obtained from the symphysis region of the two dental implants. On the right are the two dentalimplants inserted. Note the adequate bone support formandible. The photo on the right shows the addition of particulate bone to

fill in the peripheries. This particulate bone is a combination of the implants on the buccal and lingual. Ideally thereshould be 1.5mm of thickness of bone buccal and lingualautogenous bone and Bio-Oss (xenograph).

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 JacobsonD.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 DENTISTRY

There 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 demonstrates

that approach in a 40 year old female who had neglected her teeth for many years.

The photographs to the left show the pre-treatmentviews. Treatment began with a clinical examination

to determine the prognosis for individual teeth. Theinfection control phase began with the following: 1)Medical consultation 2) Extraction of teeth with apoor and hopeless prognosis 3) Caries control withthe restorative dentist 4) Scaling and Root Planingwith local anesthetic 5) Endodontic treatment and 5)Oral hygiene instruction.

The surgical/corrective phase consisted of: 1) Pocket reduction to preservethe remaining teeth, 2) bone grafting and 3) dental implant placement.During this phase of treatment, the patient was wearing a removabletemporary bridge. Please note the reduction in gingival inflammation,particularly on the mandibular anterior teeth. This is a nice indication of theimproved patient compliance with home care instructions.

The restorative phase, provided by the patient’sgeneral dentist, consisted of placement of thepermanent abutments (seen to the far left). Thefixed implant bridge was screw retained to addressthe minimal inter-arch concerns. Pink porcelainwas used to replace missing tissue yielding anesthetic result.

The photograph and radiograph to the left are thepost-treatment views that show the fixed implantbridge in place. The patient is on a three monthalternating recall as part of the maintenance

phase. The next phase of treatment will involveimplant therapy for the mandible.The patient is extremely happy with the improvedesthetics and health achieved.

CONCLUSION: PROVIDING DENTAL TREATMENT IN PHASES IS A SAFE AND EFFECTIVE WAY TO ACHIEVE

SUCCESSFUL OUTCOMES.



JULY 2011

A STAGED APPROACH, TO ACHIEVING A PREDICTABLE RESULT, IN THE REPLACEMENT OF AN

INFECTED TOOTH WITH A DENTAL IMPLANT

Pre-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 through

defect associated with the this time could be done, butpresent. epithelial cell exclusion.mesial root. offers a risk for complications.

Photograph 6 months following Photograph shows the dentalPost treatment photograph and radiograph

ridge augmentation shows implant inserted. Excellent boneshow a stable result with the implant crown in

remarkable regeneration of the adaptation is present and theplace. Probing depths are 2-3mm with no

buccal plate of bone and the implant had good primary stability.bleeding. The patient is quite pleased. He is

extraction socket. The regenerated Because of the stability of the bone,also thrilled at how smoothly the whole

bone was vascular indicating its the prognosis is excellent forprocess went.

vitality. It is safer to place the successful implant therapy.dental implant at this time when the

bone 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 TO

PREDICTBALE 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 comments are

welcomed by calling 674-4410.* All cases presented are actual patient’s of Drs. Warshawsky, Driver or Jacobson.

AUGUST 2011DENTAL IMPLANT COMPLICATIONS ASSOCIATED WITH EXCESS CEMENT

Cement-retained restorations are commonly used on dental implants. Residual excess cement after placement ofthe crown has been associated with clinical and radiographic signs of peri-implant disease. An increasedawareness of this problem can help to reduce complications.

PATIENT #1 presented with pain associated with the dental The above photographs are from two different patientsimplant at the #10 site two years after placement. The who had chronic inflammation associated with theirradiograph reveals severe bone loss. Flap elevation shows dental implants. Flap elevation revealed the source of thethe etiology of the problem to be cement (at the yellow problems and associated bone loss; which was severe inarrows). the far right case.

The photographs to the left show different patients with complicationsassociated with their dental implants. The far left photograph was apatient who had persistent bleeding and tenderness associated with theirgingival tissue. Flap elevation (which is what the photograph reveals)allowed access for removal of cement and resolution of the patient’ssymptoms.The photograph to the right shows a failed dental implant in which thecement initiated an inflammatory response. This resulted in severe bonedeterioration 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 Steven Jacobson thick,M.S.; Board Certified It is meantor the implants arePeriodontists.674-4410.* All a way presented theactual patient’s of Drs. Warshawsky, Driverlead to solutions. Screwplaced deeply. An as cases of sharingare problem of cement removal dental or Jacobson. Questions andawareness of current periodontal information with the can community.comments are welcomed by calling

retained 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.



SEPTEMBER 2011


This case report is meant to give you the perspective we have on a daily basis. As a periodontal office, wehave 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 posttooth #11, on the far left, shows treatment radiographminimal inflammation. The to the left shows aamount of inflammation does remarkable gain in bonenot correspond to the amount of fill of the defect.supra-gingival plaque nor the This was accomplishedamount of sub-gingival calculus through the sequencethat is present. The presence of detailed below. Guidedinflammation is masked by the Tissue Regeneration ispatients smoking habit. The pre- the best way to improvetreatment radiograph of tooth 11 the prognosis of teethshows a severe vertical bone that are periodontallydefect along the mesial. compromised.

SURGICAL SEQUENCE: Guided Tissue Regeneration with Platelet Derived Growth Factor to Preserve the Tooth

Properbonelevel

Flap 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. The

point 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, a

gingivally. 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 thecalculus for its removal. Guided tissue regeneration allows for replacement of the periodontal attachment structures andthereby tooth preservation.



OCTOBER 2011

Achieving natural looking results through a staged approach with dental implants

Photograph 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 neighboring

for implant integration as well as esthetics. natural teeth and 3) the presence of the papillas.

1 3 4 52

PHOTOGRAPH 1: Pre-operative photograph of tooth #10. The tooth demonstrated a class II mobility and 10mmprobing 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 alveolarbone.

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 hardtissue 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 palatalgingival groove (at the yellow arrow). This developmental groove acted as a pathway for bacteria to migrate down theroot 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.



NOVEMBER 2011

THE DECEPTIVE NATURE OF PERIODONTAL DISEASE

Patient #1Patient #1Patient #1

Pre-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 #2Patient #2 Patient #2

Pre-treatment photograph of teeth #’s 8 Gingival flap reflection reveals A surgical approach dramatically increases theand 9 initially does not appear to be so significant calculus accumulation on chances for calculus removal. The surgicaldangerous. Evaluation by the patient’s new the root surface and severe bone loss. approach is effective due to our ability togeneral 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 theloss. The patient’s previous dentist had periodontal deterioration and future periodontal support in this case using guidednever informed him of the periodontal loss. tissue regeneration. This will improve thedisease 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 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,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 lookingdental 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 thethe 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 thepatient 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):

3214

Photo 1: Flapless and non-traumatic removal of tooth #8 helps Photo 2: View following fill of extraction socket with bone graft. The bonemaintain 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 fortissue 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.



JANUARY 2012

EXTREME DENTAL MAKE-OVER: THE REPLACEMENT OF A HOPELESSDENTITION WITH IMPLANT SUPPORTED OVER-DENTURES

Pre-treatment photographs show an un-esthetic smile Post-treatment photographs show improvedwith severe periodontal infection for this 45 year old esthetics through the replacement of hopelesspatient. All of the teeth have mobility. Purulent exudate teeth with implant supported dentures. Thedrained from the sulci of most of the teeth. Dental phobia removal of the infected teeth has improved thehad 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 theRadiograph reveals fourextracted teeth. Seen is the heavydental implants in the maxillacalculus build-up that led to theand two in the mandible.periodontal disease. The presenceThis is the minimum numberof periodontal infection has been Photographs show dentures that arenecessary to support thelinked to other medical problems retained with locator abutments. Thedentures in each arch.as well, such as heart disease. locator inserts come in different

retentive holding force levelsdepending 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 and

comments are welcomed by calling 674-4410.* All cases presented are actual patient’s of Drs. Warshawsky, Driver or Jacobson.

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