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Written by Rodrigo Escalante Vazquez, DDS Thursday, 01 March 2007 00:00
In my first article I discussed the advantages of combining the use of radiosurgery and Captek metal, as I have found this combination to be the most reliable and the one that produces the best results in my practice, especially in difficult cases. In this article two more clinical cases are presented in which the combination of radiosurgery and Captek restorations were used.
Research has shown that removing soft tissue with a radio signal (radiosurgery) is less traumatic to the tissue (only 15 to 30 µm of adjacent tissue alteration). This is because of the patented high frequency (3.8 to 4 MHz) at which the unit works, together with the selection of waveforms and the special composition alloy electrodes. The radio wave frequency, waveforms, and alloys are matched to produce the lowest thermal energy in the tissue. The patient experiences a pressureless, sterile incision, with very little bleeding and with a short healing time.
The Dento-Surge 90 radiosurgery unit (Ellman International) has the following advantages: exact, fine, and pressureless cuts; less bleeding; less surgical time; minimal or no pain; less swelling and postoperative infections; fast healing; cost effectiveness. These advantages make complicated cases less difficult and more predictable, as we will see in this article.
The major advantages of using Captek (Precious Chemicals Company) when the gingival tissue is involved are as follows: it repels bacteria and inhibits plaque accumulation, and it offers excellent marginal fit.
Figure 1. Fractured maxillary right central incisor.
Figure 2. Radiosurgery is used to cut the tissue and expose the fracture.
Figure 3. Radiosurgery allowed proper tooth preparation.
Figure 4. Low smile line.
Figure 5. Radiosurgery allowed an accurate impression to be taken.
Figures 6a and b. Captek crown with 360° metal collar margin.
Figure 7. Captek crown immediately after seating. Tissue has not completely healed at this point.
Figure 8. One year after treatment.
Figure 9. Two years after treatment.
An 80-year-old patient presented with a fractured maxillary right central incisor, and even though he didn’t feel pain, he was concerned with his appearance. The fracture went deeply below the tissue, almost in contact with the osseous crest, and the gingival margin was irritated not only because of the trauma but also because of his poor oral hygiene (Figure 1). The fracture didn’t involve the nerve, but the remaining piece of tooth was so weak and brittle that after cleaning his teeth, we had to perform root canal treatment in order to reinforce the tooth with a post and core. Then, with the use of an Ellman radiosurgery unit and a Vari-Tip (Ellman International), we cut down the tissue to expose the fracture and allow trimming of the finishing line with better visibility (Figure 2).
After cutting the tissue to expose the apical part of the fracture and preparing the tooth, it was evident that a significant amount of gingiva needed to be removed to achieve our goal; this left the gingival margin much higher than the adjacent one. I knew since the first appointment that this was going to happen. However, if I hadn’t cut the tissue, then it wouldn’t have been possible to trim the finishing line of the preparation within sound tooth structure apically to the fracture as it should be done, and taking the impression would have been almost impossible regardless of the periodontal pocket we would have created (Figure 3). Fortunately, the patient had enough keratinized tissue to perform the procedure and a low smile line to cover the defect (Figure 4). Following this, it was much easier to take the impression (Figure 5).
Due to all of the traumatic events this tooth had suffered, including the fracture, cutting the tissue, the margin of the preparation close to the osseous crest, and very poor oral hygiene, a good treatment outcome was not certain. Therefore, a well-adapted restoration was essential. That is why my selection was a Captek crown, with a 360° metal collar margin, because I wanted the metal to be in close contact with the sulcus epithelium to take advantage of its bacteria-repelling effect and ability to inhibit plaque accumulation. Metal collar margin? It may sound crazy and obsolete nowadays, but I have found that there is no better restoration in a compromised tissue case like this (Figures 6a and 6b).
Figure 7 shows the crown after cementation; the tissue had not yet healed completely, and because of this patient’s poor oral hygiene we were not sure if it would. In this photo we can realize how big the gingival discrepancy turned out to be at the end of treatment, and due to the traumatic nature of the procedure I was concerned about gingival recession.
This patient has been coming to Acapulco (where I practice) every year during winter time for the last 40 years, and he was going to go back home when I finished his treatment, so I knew that a year would go by before I could see him again. I was a little concerned and anxious to see what was going to happen.
Then the year went by, and I had to beg the patient to come and visit me. Every time I called him, he gave me the same answer: “Why should I go? My tooth is perfect.” Finally he accepted my invitation to come, and he was right. After a year the tooth was perfect beyond all of my expectations. Not only had the tissue not receded, but it had migrated coronally and was thicker at the gingival margin than the other central incisor, as can clearly be seen in Figure 8. Even though his oral hygiene had not improved, the tissue had healed perfectly.
I was very happy with the outcome after a year, but I wasn’t expecting any better for the next year. I was wrong again; after 2 years the tissue is not only better and thicker than a year ago, but it has migrated coronally even more, becoming level with the adjacent gingival margin. The result after 2 years is excellent (Figure 9).
Figure 10. Patient presents with significant subgingival decay at cingulum area of the tooth.
Figure 11a. Radiosurgery is used to remove tissue covering the decayed area.
Figure 11b. Apical extent of decay is revealed after radiosurgery.
Figure 12. Extensive decay resulted in pulp exposure.
Figure 13. Post/core and Captek crown required for restoration of the tooth.
Figure 14. Captek crown seated.
This patient presented with a complaint of pain in his maxillary left lateral incisor due to cold and hot sensation, caused by significant subgingival decay at the cingulum. In order to remove it completely, I would have to cut a fairly large amount of tissue (Figure 10). With an Ellman Vari-Tip I removed all the tissue that was covering the decay, to create full exposure (Figures 11a and 11b).
After cutting the tissue, I started to remove the decay very carefully, trying
to avoid touching the nerve. Everything was in vain, however, because the decay was so deep that after its removal, the nerve was exposed. Figure 12 shows how apically this decay extended, almost to the osseous crest, and the significant amount of tissue I had to remove (compare it to the gingival margin of the teeth next to it).
The patient was sent to the endodontist for root canal treatment. Because of the weakness of the remaining tooth structure, a post and core was needed to provide a stronger abutment for the final restoration. The tissue that had been cut was red, swollen, and still bleeding (Figure 13). Due to the aggressiveness of the procedure, I was concerned about the final outcome and the long-term treatment result.
To restore this second case I selected Captek metal because of the advantages previously noted. A PFM crown with a large Captek metal collar margin would be in contact with the tissue. Due to the traumatic nature of the procedure we had to go through to solve this case, I was expecting chronic inflammation, recession, or at least a redness of the tissue after 2 years, but it was the opposite. The tissue had migrated coronally, was aesthetic, and was as healthy as the adjacent tooth (canine), if not better. But the most important characteristic is that the tissue is thicker at the gingival margin (Figure 14), as in the first case. The Captek metal collar margin is now buried deep into the tissue, and the tissue has responded well.
In these 2 articles I have shown 4 cases in which the use of an Ellman radiosurgery unit and Captek metal has clinically proven to be a very reliable combination to preserve and promote gingival health, to improve aesthetics, and to treat compromised tissue cases. By experience I have learned that what works in my practice may not necessarily work in somebody else’s practice, but in this case, because of the quality of the equipment and materials used, I am sure you can achieve the same results.
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Disclosure: Occasionally, Ellman and Captek will sponsor Dr. Escalante’s lectures.
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