Our patient presented with an endodontically restored and crowned upper left lateral incisor fractured to the gingiva. All options for treatment were presented and the patient chose what we agreed was the best option: extraction and placement of an implant retained crown.
It was decided that, due to a fistula present adjacent to the apex, facially, it would be prudent to extract the tooth, graft the socket with bone and wait three months for proper healing before placing the implant. The patient was leaving in one week for a cross country flight for a business trip and so it was important to her to have a provisional replacement before she left. Impressions were taken for a provisional partial denture and she was reappointed for the extraction.
Treatment was complicated by several factors. The remaining root was ankylosed, the adjacent teeth had porcelain jacket crowns, and the buccal plate of bone was extremely thin. Consequently it was difficult to extract this tooth conventionally without risking fracturing the buccal plate and compromising a good esthetic result with our implant. In addition, any luxation pressure mesially or distally during the extraction process put the adjacent crowns at risk.
Fortunately, we have developed a technique and protocol for using an Er,Cr:YSGG laser (Waterlase MD) to assist in extractions that all but eliminates the problems associated with such a case. The entire procedure , from injection to dismissal from the treatment room was 4 ½ minutes. (This does not include post operative instructions administered by my treatment coordinator.) The video above was edited down to 2 ½ for purposes of presentation.
Local anesthesia was administered with a intraligamental injection of .3cc of Septocaine. The laser was set to 3.5 watts, 20 Hertz, 60% air and 60% water. A Z -3, 14mm. tip (300microns in diameter) was used as a laser periotome in the ligament space between tooth and bone , advancing nearly to the apex to atraumatically loosen the tooth. A periosteal elevator was placed in the space to attempt to remove the already loose root, but due to the danger of damaging the adjacent crowns or fracture the buccal bone, this was problematic. Consequently an anterior forcep was used to pluck the tooth from the socket with little or no luxation pressure needed.
The socket was then decontaminated and granulation tissue removed using the same laser tip at 1.5 watts, 30 Hertz, 15% air and water.
After checking with a spoon excavator to make certain the socket was clean, bone grafting using Puros Allograft (freezed dried cadaver bone) was accomplished. Atrisorb, a liquid injectable barrier membrane was placed over the socket to keep the bone in place. Then the socket was treated with low level laser therapy for 30 seconds to biostimulate for faster healing. A diode laser set at 3 watts continuous with a bleaching wand in place was used ( EzLase).
Then the provisional partial denture was placed and the patient was given post operative instructions, prescriptions for Amoxycillin, 500 mg and Tylenol # 3. She was also given 400 mg of ibuprophen before she left the office. Three hours later she was in flight from Baltimore to San Francisco for a week long business trip. Upon her return, she reported no pain and no need for any of the pain medication we prescribed. We believe this was due to the lack of trauma during surgery and , most importantly, the fact that since the laser cauterizes the blood vessels, lymphatics and nerve endings, the release of histamine that initiates inflammation, is eliminated and thus the site goes directly from wound to regrowth and regeneration. Her lack of post operative pain and the rapid healing is consistent with that of all our oral surgery patients and periodontal surgery patients.