Extracted teeth used for alveolar ridge augmentation

384 Rating(s).


Posted on By snjezana pohl In Bone Grafting

Extracted teeth used for alveolar ridge augmentation

PET: RST, SS, PS; dentin grinder - is there an another possibility to utilize tooth roots?

JOCP April 2016: Schwarz and other authors published an animal study:
“Extracted tooth roots used for lateral alveolar ridge augmentation: a proof-of- concept study “.
JOCP SEPTEMBER 2016: Periodontally diseased tooth roots used for lateral alveolar ridge augmentation. A proof-of-concept study. Animal study.
JOCP 2016 accepted in July: Initial case report of an extracted tooth used for lateral alveolar ridge augmentation. Human case.
Histology looks great.
Could it be a possibility for some (a lot of) cases to avoid a donor side morbidity and go autogenous?
Today I have performed Khoury technique with root plates.
And added a root for lateral ridge augmentation (and taking histology in 4-5 months).
Patient was actually referred for an immediate implant placement:)). I`ve done some mistakes, like too apically fixed root. And I fought with huge screws, since there is a delivery problem with Stoma screws in Croatia.The time was very short. But I have done a first Khoury block with root plates! I am happy to share it with you!
Snjezana, looking forward to a great discussion




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75 Comments

Very creative...The only issue would be what happens to the tooth root adjacent to flap? Please keep us posted. Dr. Salama


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Thank you Dr. Salama for your quick response.
I hope to see the similar result as Schwarz`s group.
Best regards
Snjezana


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Snjezana

You have got to be kidding me. I would have never considered all this stuff a few years ago, SS, RST, Root grinding, now this
Amazing...
Couple questions:
How to clean and prepare the root? Looks like you used the
root plate and a complete root? Any problem with the pilot hole in the root fragment (cracking) Allograft?
St cortical or Ti screws ?

Sorry for all the questions, I find this so interesting A dog canine root would yield a fantastic plate or plates...


Thanks

Rocco


Reply

Rocco, as you know, there is nothing better than a lively discussion and lot of questions showing interest!
I`ll be more than happy if this novel approach would be what it promises for your (and our) patients.
The root:
I just cleaned the rooth with a round burr. The layer of cementum was carefully removed using a diamond burr under copious saline irrigation until the underlying dentin was entirely exposed on the site facing the recipient site. It should help to achieve ankylosis and replacement resorption.
The animal study has shown slight better results if pulpa was vital. Compared were cortical bone block, vital roots and roots filled with CaOH2. Vital roots have shown less exposure.
Root plates:
It was easier to slice the root then the bone block. It is practical that you can hold the crown (I used Luer-bone forceps, pressed the tooth on sterile wooden mouth pattel-or tongue depressor-google translator:) and cut it with a sterile disc, like dental technicians use them.
Although I fought with a huge Meisinger bone screws and drills, the root plates were easy to handle and fracture resistant.
If you give me your mail address I'll be glad to share everything I know about this topic.
Warmly
Snjezana


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Snjezana

Thank you for the offer. Yes I would like any material that may be helpful.

Thanks again

eastpointpet@gmail.com

Rocco


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Easy.


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Wow, mind blowing. Incredible skills !!
I knew about this technique and waited for the oportunity to do it.
Please, keep us posted as we all are( i am sure) very interested in how this with turn out.
Thank you !


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Cristian, be sure that in 5 months I am going to show what happened.
And regarding skills - although I do a pretty amount of bone blocks, I never feel confident like when doing plastic surgery or surgical crown lengthening...I guess that I hate aggressive but necessary retractors while harvesting blocks from linea obliqua. Plates taken from sinus window make it easier and now-these teeth today were easy to handle.
Thank you for your comment
Best regards
Snjezana


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I got goose bumps!!!!! SNJEZANA, Incredible mind!


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Mia:))
I only read a literature, a lot of literature.
Looking forward to Saturday
Big hug
Snjezana


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Wow, great surgery! I have struggled with this area several times as it always seems the teeth (that I usually get referred) are periodontally involved and mobile with no alveolar envelope to work with and often extremely cortical bone present that is resistant to expansion etc. This would be a huge help to employ in this area. Please keep the case updated. You do beautiful surgeries! -Jonathan

Three different cases in the past two months


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Snjezana. I LOVE THIS! Maybe in some instances preservation of the remaining PDL could be of value. GREAT WORK! Warm wishes. Chuck


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Chuck, if you look carefully the image #2 you see a root with PDL. I am absolutely going to include roots with PDL, but I had not a time to screw this one peace.
How long would you wait before implant placement?
Warm regards
Snjezana


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Based upon Karring, Nyman. Lindhe work, I believe at least 24 weeks. Howwver, we don't have much literature to guide us with a gap this large.


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Jonathan,

Thank you so much for your comment.
I know those cases: dentists see a great vertical dimension on panoramic radiograph and send for implant placement. And we sit frustrated in the front of CT and seem incapable to do our job.
It would be so great for so many cases if it works. And biology says that it must work.
Best regards
Snjezana


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Snjezana,
The case you show here is opening new Doors, meeting the patient and dentist necessity to be minimalist in their procedure.So autogenous rigid barrier (do we have some time barrier in the mind?:))well recognized by soft tissue and with collagen similar(but not the same) to bone Is gold standard.
No doubts about biological fuction but the question is about biomechanical: how will it work in time?
Thanks for sharing this innovative case.
Armando


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Armando, you recognized each point, it is so good to have you on forum.
I guess that the root plates should be a bit thicker. The study has shown that the replacement resorption took less time with root plates than with cortical bone plate. Turn over was comparable with a cancellous bone.
Thank you for your input
Snjezana


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Dear Snjezana,

Creativity level = EXTREME !!
Beautiful work as usual. What did you use as particulate? the tooth?
I imagine this should work out, your surgery has all the required biological principles for successful bone augmentation. I too have had the problem with large screws, however they are available from Deve-med and Helmut-Zepf. Using those large screws makes breaking the block so easy. Did you feel stabilizing the tooth fragment is easier than the bone plate?

Congratulations on having an extremely creative mind and very skillful hands. I look forward to seeing the follow-up of this case and hopefully incorporating this technique in my armamentarium.

Warm regards,
Ehab


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Snjezana; great case! you really put this technique under very difficult testing conditions (mandible, muscle tension, big screws, etc). Looking forward to the follow up!

Why did you completely remove the cementum? Maybe keep it and treat it with TTC?

Yiannis


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Yiannis, thank you, great question and no precise answer.
I leaned on Schwarz study and has done the same thing for my first case. Schwarz has found out that exposure of the dentin layer facilitates ankylosis.
I`ve already changed it today. I just cleaned the tooth and left cementum. I expect the same amount of ankylosis if there is a cement layer at the defect site. And I expect a limited peripheral root resorption by preserving the cementum layer and the periodontal ligament on the opposite site.
Best regards
Snjezana


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Ehab, thank you so much.
Autogenous bone taken with Bone Scraper is in-between.
It was peanuts to screw the whole root.
I`ve bought STOMA screw set, since I`ve learned Khoury technique from Khoury and he uses it. It`s not cheap and I am angry about the firm selling you an expansive set and stopping provide you with screws!
Best regards and thank you for tips:)
Snjezana


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Snjezana very ingenious and innovational! really looking forward for the evolution of this. How lung would you wait for the implants to be placed?
If possible also send me an email with your information about this topic to manolo@drsdelarosa.com
Thank you and my deepest congratulations on your cases and your always willing to share knowledge.
Best regards,
Manuel


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Manuel, thank you so much! You are always so kind, thanks to you I still don`t need psychotherapy:)
I am going to wait 5 months. In the animal study they waited 12 weeks. Khoury technique we wait normally 3-4 months. Since I want to see what happens to screwed root I am going to give some more time and wait (a long!!!) 5 months. Chuckipedia recommended 24 months, so I think 5 months is OK.
Thank you for your mail, I`ll contact you in no time.
Best regards
Snjezana


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24 WEEKS only because that is what we have as a histological reference. Your GEUSS is a good as mine:-)


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Excuse me,weeks,of course.BTW if I am going to publish anything I'll give as reference just "Chuckipedia,DentalXP forum".
Warmly,Snjezana


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Snjezana, I love this concept. I was about to do it few months ago. In reality, there is no need to have bone plates, root plates if we fill the space with bone chips. The plate has a passive roll on bone formation.
My point is: If we could have titanium plates, diferent sizes, with holes to screw trhu...wouldn´t be interesting?
We can still do the Khoury´s tech without taking out the plates, as you are doing with your roots.
Well done my friend! I´m sure it will work!
Regards,
Jorge


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THIS Dentalxp FORUM is more creative and interactive than I ever imagined. There is more significant changes being discussed in treatment here than any other place in dentistry.....well done to ALL! Great Case for discussion. Dr. Salama


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Jorge, thank you for your input - giving always some new points for discussion.
I am pretty sure that root plates are going to work as good as bone plates. And because I strongly believe in it, I have utilized root plates for my patients, convinced that I am not doing an experimental surgery but reducing a donor site pain.
What interests me even more and what I don`t want to do for my patients before there is an evidence, is to simply screw the whole roots for lateral ridge augmentation. Imagine:cleaning, two holes, two screws, ready to go! No bone scrapers, no thin plates, no foreign materials. To my knowledge there is only an animal study with histology and the other one case presentation on human, without histology.
And now: I don`t want to try it on my patients for the sites where the bone augmentation is really important. For this sites I`ll perform Khoury block with root plates. But a few millimeter further where tissue augmentation is desired but not essential and taking a probe for histology doesn`t do any harm, I`ll screw the whole roots. With and without PDL, with and without cementum.
Lucky me, already today I had an opportunity to do my second case.
Best regards, my cowboy friend
Snjezana


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After 4 weeks...
Snjezana


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Congratulations for your 2nd case!
Another great example of "tissue" (in this case dentin) management!
Regards
Jorge


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Snjezana:

Just perfect. This may shift the paradigm further. Nature preservation at its best.
The question would be in exploring the possibilities of a gentle roots shield process on the spot that may preserve the tissue structure (maintain roots elasticity and prevent micro-fractures) to reduce the risk of resorption and to optimize healing. Great approach.

Salah


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Salah,

Missed you in NY- can you kindly look at one of my responses to Jorge when I asked him about what he thinks happened to the shield when Thevdensah bur,comes in contact with it? And are you also developing some guided densah burs?

Cheers,

Richard


Reply

Salah, thank you for your interest and sharing with me (and us) excitement about a possible alternative.
I already see your great mind designing and Versah manufacturing the best tools for root cleaning and preparation!
BTW, I am fallen in love with Densah burs like all other before me. The learning curve is bearable and...it really makes a difference.
Best regards
Snjezana


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Snjezana!

Creativity runs deep on your team- Incredible mind- next you will show implant placement at the same time or a buccal -lingual concept like Howie-

Few questions and ideas- What is your provisional - Next case combine bone on one site and root on the other to compare healing -conebeam-

As far as bone screws- I have found many differerent brands to work well - Salvin- / KLS Martin-
maybe we can find a distributor for you and Ehab

Cheers,

Richard


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Richard, as I understood both of my young colleagues would be more than happy to have you all time around.
We prepared a mosaic to show you what we have done yesterday. Almost all knowledge from Dental XP. Mia is going to show her work separate:)
Provisional: two Essix and one flipper, but well teeth supported.
Your idea caused an another (fourth) sleepless night. It is great, love it, going to do it for sure.
Bone screws-it is almost impossible getting something from USA in official way. Densah: Versah send it to my friends in USA and they bring them to me. Now I run again out of Densah:(
Cheers
Snjezana & Co


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Snjezana,


Yes, that would be an incredible experience! The mosaic is amazing- all in one day? Wow- As far as screws - do you have access to hospital with maxilla facial coverage? Most will have fracture or orthognathic bone kits that pretty much have similar screws that can be used-

I am including my first attempt and documentation of "Digital Healing" hopefully you will be able to sleep after this.. I know Jorge is poetry but Chuck is Chuckapedia - I like to look at it as food for thought....

Case in progress- redeveloping tissue after finalizing

1 week post tuberosity grafts and new provisionals 7&10
Trios scan 14 days- I will also get cleaner image- and next visit take HD photo on trios


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Pre op -


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Richard Man......


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Amazing! It is a fantastic way to follow, register, compare changes.
And your case fits very well into Friday`s poetry, congratulations!
Attached is a surprise, done today. Thank you for giving me this idea and pushing me. The roots a very small, but nevertheless... One of the roots has a PDL on the surface opposite to jaw.
Thank you so much for taking care for my screws, it`s going to be fixed in a few days.
Cheers
Snjezana


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Mo,

As Ray Charles said. " make it do what it do baby"


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Snjezana,

Thank you- Amazing tell you yesterday, apply today!

I am going to hold off on the the ideas so you can sleep this weekend!

I do have another idea up my sleeve- I will show you next week - just keep "digital healing" in mind

Cheers,

Richard


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Richard,
For communication with you I really miss emoticons on forum. You know, a light bulb for you all the time, me with wide open eyes:)
Today evening we`ll (my students-young doctors and me)
have brainstorming about "digital healing".
Best regards
Snjezana


Reply

Snjezana


Maybe we can ask Tyler to apply them to the menu on the forum..

Maybe no Brainstorming tonight- with all the brilliant minds in the room the light bulbs may explode!


Cheers,

Richard


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Wow wow wow. Now im interested. Maurice told me about this I had not seen it yet but now it makes more sense. I love the innovation and the idea behind it. Some questions. I am not a great one for doing advanced grafting at the time of extraction as flap management is so difficult. So the questions then come. Can I take the roots out and keep them and then sterilise like I would the TOP Graft and then use at a later stage and perhaps with the top graft at that stage. Or would you only use the autogenous chips in these cases.

Well done great idea. and again great to haver Dentalxp sharing ideas well before they become close to mainstream.

regards
Howie


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Dear Howie,
Wow,wow,wow, now I am excited about YOUR interest and even more about the fact that Dr. Salama mentioned it.
Probably because I extracted a small incisiors and soft tissue management was easy, I haven`t thought about saving the teeth for a later usage. But your question makes a lot of sense. I am not an expert in this field, but I hope that our discussion will motivate colleagues doing basic research to share their knowledge. And, of course, Chuckopedia.
Let me think aloud about cryopreservation and gamma sterilization.
In my previous life (before dentistry, after human medicine university) I have done one year training in orthopedic surgery. Doing hip prosthesis we used to freeze patient`s caput femoris and storage it frozen for the case that another surgical intervention for this patient should be necessary.
Bone freezing is not destructive process. There is no difference to be seen in light microscope and only light micro-fractures with EM.
It is shown that cryopreservation doesn`t influence negatively human tooth germ stem cells, rat pulpa, germs in toto...
To my knowledge TOP vacua Sonyc System utlises gamma sterilization. Gamma radiation has a negative influence on bone grafts, but to avoid disease transmission by allografts it is accepted. Practical problem: in which medium would you keep the roots (nonsterilized) for the time till sterilization and utilization? And if we would prefer cryopreservation: who has -70° freezer in the office? BTW, -70° is official recommended in Germany, but research has shown that -20° is fine until 2 years.
I am going to do a decent number of cases (10-12), get clinical view, histology. If it works well, for sure the further investigations will follow.
And for the end: I got so much knowledge and motivation from DentalXP, that I try to give something in return. And -where else could I gather so much bright minds and brainstorming (in no time?)
Thank you for your thoughts and questions
Best regards
Snjezana





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Morning Snjezana

Question: Any membrane or biologic to cover the dentin plates or particulate

Rocco


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Good afternoon, Rocco,

no membrane yet. Periodontal ligament for periodontal healthy teeth on the upper surface (opposite to the recipient site).
May be for one case to see is there is a difference.
Thx
Snjezana


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Snjezana,

I had to read that twice to digest- very good knowledge to move forward- You are titled "Professor Pohl" - Info like this is what makes the site evolve !!

Cheers,

Richard


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Richard,you are too kind. BTW, I've seen yesterday everything from you on XP and it is impressive. And I am going to post a case that fits well into your presentation about congenitaly missing teeth. But the numbers that bring fortuna (money)-zero.
Cheers
Snjezana


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Very innovative!! Thank you!


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One of this cases that I admire and also spend enough time to read everybody's comments!! So much to learn. Great forum!! Thank you for your post!!


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Dear dr. Ntounis,

thank you for your compliments! It motivates me even more. Forum is really a great place.

Best regards
Snjezana Pohl


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Howie,

You should feel proud of the followers on the site that cherish your posts - Your desire to teach share and inspire is priceless!

Cheers,

Richard


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Thanks my friend. Appreciate your kind words


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The XP Way.....Snjezana, it is time to do your own presentation for Dentalxp, perhaps along with your colleagues?? Let us know if you are interested? Regards Dr. Salama


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Dr. Salama,

I'm honored and my team is very excited, messages are coming in no time.
I have already posted two presentations (ups!)

http://www.dentalxp.com/video/surgical-protocols-socket-type-in-1152932.aspx?locale=

http://www.dentalxp.com/video/single-incision-technique-harvest-free-1153003.aspx?locale=

But as time goes by the topics and the way how I approach them have changed a lot. Let us finish our PET studies and having some more screwed root plates and roots with histology, sinus window plates etc.
Thank you for your invitation!
Best regards
Snjezana


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Finally another case (after vacation) for root plates. After extraction of second left premolar with apical cyst, only a narrow vestibular bone bridge was left. Since the first right molar was also extracted I have had a good root plates source. A narrow ridge # 12 is also augmented in Khoury technique with root plate. Autogenous bone chips are harvested with bone scraper distal to extracted molar.
Forceps designed by Dr. Gluckman was helpful.
And micro screws are eventually arrived (Richard, you can relax, thank you).
Cheers
Snjezana


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Snjezana. SPECTACULAR! This could be a "GAME CHANGING CONCEPT"! I LOVE IT! CONGRATULATIONS! BF Chuck.


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Green medicine, no waste.
And long 5 months to wait the result:(
Best regards
Snjezana


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Four weeks after surgery uneventful healing.
Another 4 months to wait...
Snjezana


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Snjezana,

Looking very promising!! I think micro screws help in decreasing microfracture of tooth plate - by chance do you do any imaging?

Cheers,

Richard


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Hi, Richard,
it was hard to resist, but I haven`t done CBCT 4 weeks after surgery. I have only postop X-ray.
I agree that micro screws reduce fracture risk. Once I experienced root plate fracture. Before suturing I decided to tighten one screw, it was definitively too much.


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Snjezana. Healing looks good as expected. IMO the challenge ahead will be site preparation without root damage or dislodgment. I would suggest using Howies plate instrument to stabilize the roots during screw removal and during site preparation. In addition, I would prepare the site with DENSAH G2 in both forward and reverse directions. I can't wait to see the next phase! Very promising indeed! Warmest regards. Chuck


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Chuck, you have good news and bad news for me. Good news: you believe in root blocks. Bed news: you expect them to dislodge during implant site preparation. If I waited a few more months, this risk would be less...
Densah anyway. But I`m not sure about reverse direction. I remember vividly one bone block that jumped, flew and landed on the floor after my colleague tried to prepare implant site with osteotomes 4 months after bone block surgery. OK, Densah CCW is not like osteotome, but my fear is that hydraulic force may contribute to root dislodgment.
And, anyway, I expect more bone, less roots:)
Warmly
Snjezana



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Snjezana. Densah G2 run IN FORWARD cuts precisely and chatter free. Therefore that is how I use them when drilling cortical bone or roots. ( sometimes at 1500 rpm). However, you may further enhance the less dense portions of the site without the "osteome effect" by running PASSIVELY IN REVERSE prior to removal. That way the small amount of slurry remaining in the flutes wil deposit into the more porous bone with minimal pressure upon cortical bone or dentin. In other words, the slurry will passively flow to the path of least resistance. If you are not comfortable with this concept just use in forward and observe the bone/ dentin removal with the bur. Time to hit the trail:-). Warm wishes. Chuck


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Snjezana & Chuck:

The G-2 Burs will give a controlled optimized operation in both directions. CCW gives the most optimum results. Coelho & Neiva et.al has validated its advantage over the regular drill.
https://www.ncbi.nlm.nih.gov/pubmed/27341291

In Snjezana's case example, I would still recommend the use of the DB in CCW with more gentle pumping operation. The gentle pumping will allow osteotomy expansion even with the dentin plates.

I agree with Chuck. The CW operation may enhance the feed rate to depth. If used, one still needs to run the DB in reverse before leaving the osteotomy to preserve the cut bone/dentin and compact it back into the osteotomy walls.

Salah


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Thank you, Salah. I`ll follow your instructions.
Kind regards
Snjezana


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To summarize. So long as you are not in direct contact with the dentin OD is desirable. Otherwise CW is safer and more efficient when directly cutting dentin having less elasticity than bone. However, thinner dentin allowed to remodel over an extended period of time may behave similar to bone, but that story hasn't been written YET :-)


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Chuck, Snjezana is writing it!
Let's help her. ASAP I'll do a case like this just to share.
Jorge


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Ha, Jorge, welcome in club!!!
The patient Nr. 4 (09.15.2016) has a nice healing two weeks post op, although a heavy smoker.
Best regards
Snjezana


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The same patient: #7 with a large cyst, #9 with a periapical cyst, hopeless #8 with a buccal bone defect.
#9 socket shield.
This time I used also a PRF.
Best regards
Snjezana


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Snjezana it's Fantastic. I like the concept and I'm sure that in a couple of years this concept will be accepted worldwide.
I think that we will obtain an ankylosis on the inner side of the teeth, and nice bone in contact.
The out side, with PDL will integrate better.
In one word: an improve on block ramus.
Thanks for updating.
Jorge


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Jorge, thank you for your support.
If the teeth are periodontal healthy, I keep PDL on the outer surface.
5 months to go...
Best regards
Snjezana


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