My First PET

177 Rating(s).


Posted on By R. Terry Councill In Implants

Mid 50 year old male with fractured central incisor following extubation. My first socket shield using a combination of diamond bur and Piezo tips. The Piezo took a while but was effective. 4.6 X 15.0 mm Bio-Horizons tapered internal plus w Laser-Lok implant inserted to 3 mm below soft tissue level. The socket shield was at the same level. The osteotomies were done with Densah drills using counter clockwise (densification). PRGF with Miner-oss at apex of osteotomy. Screw retained custom provisional along with fibrin clot to provide soft tissue support. The implant was in contact with the shield. Comments please.

CBCT Pre op
Clincial Pre-op

PET Sectioning
PET Implant Placement


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16 Comments

Terry. This is a perfect Indication for PET. However, I have a few questions and concerns.
1)Why did you use a Piezo and remove the interproximal line angles of the shield?
2)Was the shield and implant plat form 3mm from interproximal or buccal height of soft tissue? Also why soft tissue as a guide instead of bone height.
3)Why Mineross?

I look forward to your result. Thank you for sharing. Best regards. Chuck


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Dr. Schwimer, Thank you for your response. The shield was slightly contoured at the line angles to follow the soft tissue contour. From your comment, I probably should have left more of the line angle present. I used Piezo because I wanted to be sure to leave the shield intact and felt this would be better in my inexperienced hands. The shield and the implant were at 3 mm. from the ST height and followed the ST scallop to a degree. Would you recommend something different? I used Miner-Oss b/c I anticipated grafting this socket and this is what I use routinely. In this application, I used it only to graft the apex. But, according to Dennis Tarnow, PRGF and Miner-Oss are used for immediate placement - immediate provisional cases at the socket level to further support the ST. I did not feel I had room for the Miner-Oss and PRGF at the ST level, due to provisional contours so I used fibrin clot alone. I welcome your comments and guidance as I am anxious to do better. Thanks again.


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Hi Terry,

Nice case, but the same way I'm critical with my work, I would like to ask the following :

- is there a buccal plate over the root? Difficult to judge from the cbct image there. If the buccal plate is missing, this technique world not be indicated.
- I would have used a narrower implant. If by any chance the shield has to be removed, the implant will be very close to the buccal.
- and as Chuck says, in my opinion the implant should have been placed deeper. Not guided by the bone, or the soft tissue, but guided by the desired future gingival margin of the restoration. On the final cbct, you can see the margin of the temporary crown, the implant should be at least 3mm apical to this.
Thanks for sharing, we all learn from each case


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Terry, it is,IMO, quite a difficult case but I think you did quite a great job, also considering the benefit of maintening the buccal shield. Provisional line is in a phisyologic area and that is quite interesting just to find out the way system heals. Thanks for sharing your first case and look forward to the follow up. Armando


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Thank you Andoni and Armando for your comments. I was thinking to place the implant relative to the future crown margin; perhaps I didn't allow for enough room though. I measured the shield to be 3 mm from the gingival margin and slightly scalloped to approximate the ST contour. I probably could have allowed for the IHB peaks to be more supported by the shield by including the line angles of the shield. I did not consider the height of the shield relative to the bone margin and should have. I assumed the tissue to be 3 mm thick and then assumed the shield to be at the bone margin. I should have also confirmed the presence of the buccal plate and the height of the buccal plate by probing pre-operatively, l but I did not. The shield was not mobile which indicates the presence of buccal bone, how much is the ?. I again assumed the buccal plate to be present and to be 3 mm from the ST margin. I will give greater consideration to these points and to implant width next time. Good advice! Thank you again.

shield preparation


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Gentleman. OUTSTANDING DISCUSSION. Andoni's observations on implant size and position is most significant. The implant must remain with the "alveolar envelope" so implant survival is not dependent on shield survival. In addition, we need to insure restorative needs do not interfer with shield survival. Chuck


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Great discussion indeed!
I would only "put my 2 cents in " adding a conservative tunnel bone graft on the buccal to thicken the buccal plate


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Hi Terry and all the gang... All this considerations about the presence or not of the buccal plate , the height of the shield in relation to the bone, the height of the implant in relation to the provisional, could have been improved and secured with the Open Flap (mini) variation of the SS.
If there is no buccal plate the treatment is risky. A non mobile root does not always imply that the bone is completely covering the root.
The implant should be positioned the more palatall posible in order to leave room for new bone between implant and shield.
This space must not be obliterated with the abutment or cement.
Let´s see the evolution of the case.
Thanks for sharing your case.
Jorge


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Terry

Great case, I think you did a terrific job.. When only comment, and is is only that is the size of the implant. I think it was too wide against the shield and and the extension of the shield mor toward the palatal aspect.. It was a super job my Brazil companion....


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I've learned a lot from you guys and thank you for your help. Jorge, Would you describe your approach to the modified SS "mini" technique. I will definitely re-post and maybe we can learn more together. James, for your comment, I can only say, Obrigado!!!


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Terry, here I post a pic already posted on Forum as SS open flap.
A mini incision, 4 mm and you can SEE bone presence or not.
And you are right, we´re ALL learning fromo each other.
Regards
Jorge


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Jorge, Thank you so much. I'll review your previous post. A lot of nuances applicable to this technique.


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thanks


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Please be cautious the apex of the implant is above the nasal floor so watch out for a communication as a possible complication/communication.


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This interaction makes me so happy, this is the REASON for the FORUM. TO SHARE our experiences and information TOGETHER and PROFESSIONALLY with RESPECT. Happy New Year to ALL....There will be a RELEASE of a "PET Kit" we created with Brassler USA at the XP Symposium that will make this entire process more straight forward.....regards Maurice


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excellent work with great Forum involvement, and collaborative learning . . .
this is an evolving technique but I believe it is one of the most significant changes in implant dentistry. .
thank you all for your constant input and teaching

David


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