PET upper first molar: possibility of maintaining the palatal root.

38 Rating(s).


Posted on By armando ponzi In Implants

This is a case presentation where several thoughts were combined and technique we shared on Dentalxp.
First upper molar roots were split and initial Versah drill was used to define initial drilling path and depth.
PET was performed on the three roots, including palatal, and Versah drill provided fast and reliable ‘osseodensification’ and a crestal sinus augmentation of 3mm.
As first experience on Versah I decided to use a speed of 800 and all steps with minimum diameter in a diagonal fashion(from VT1525 to VS42248). Last drill was the one of implant kit to check the fit.
Pet can be challenging and time consuming on molar approach and I found Versah drill to be very useful on this peculiar clinical situation reducing time and making sinus lift sufficiently easy for the operator and comfortable for the patient.
A 5x11.5 implant was positioned and a granular bone substitute was used to fill spaces and PRF membrane on top.
I will sent some follow up of the case.
Any thoughts about it?




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22 Comments

Armando, what can I tell? For me this is the true GOLD standard of the treatment. Congratulations, excellent documentation and decision making.
I also found the same experience by using Densah burs.
I do agree with you that PET is time consuming, but the benefits are worthy. I think that one day, perhaps, we could charge an extra fee for SS and Oseodensification...What do you think?
Regards, happy Xtmast to All,
Jorge


Reply

Jorge,
let me thank you first of all for all you shared on dental XP.
Most of the thought derive from your mentoring.
I also believe that PET and Densah are a new and unique treatment very beneficial for the patient and therefore should be valued adequately. But changing paradigm is not a simple task and may require time to have more dentist aware of this new clinical possibility. Happy holidays, I will mail you sometime these days
Armando


Reply

Armando

I agree with Jorge. Excellent surgical ability and perfect positioning. Guide or free hand?
What was the final torque value at the site?
The question, charge more ? Absolutely

Buon Natale a te e famiglia

Rocco


Reply

Rocco,
I actually did the virtual planning as usual and produce a Stent but I then decide to clinically define the initial drilling: this procedure could be more difficult on digital planning in terms of accuracy.
So the entire procedure was conventional but Versah drill as you mentioned on your mail are quite a friendly and reliable tools.
Ciao my friend.
Armando


Reply

Excellent! Yes time consuming and requires a strategy and visualization. Why SS on palatal root? The bone is quite dense here? I agree with Densah drills, they seem to allow for more control of osteotomy preparation. Keep us posted. Regards Mo


Reply

Mou,
the idea of using the 3 roots for PET is, IMO, not really a waste of time as I found on the few I made a discrepancy gengival level if compared to vestibular. We don't clearly see that area so we don't pay too much attention (and neither the patient), but, as Jorge mentioned this is probably the gold standard on molar superior area.
I will show all that on a short presentation I will share with all of you very soon.
Best wishes.
Armando


Reply

Armando:

Welcome to Osseodensification my friend. This is a great case.
I would suggest to:
1- Try higher speed. It will allow you even better control. I use the D burs at 1200 RPM both in cutting and Osseodensification mode.
2- Bone preservation will allow the bone to spring-back to the implant body regardless of its shape, so there is no need to use your implant system final drill to match the implant shape.

I believe that both PET and Osseodensification are site optimization procedures. IMO, system/site optimization will become more notable in the future of implantology, and we, here on DentalXP, are in the heart of it.

Thank you for sharing

Salah


Reply

Salah,
thanks for kind word on the case.
I couldn't agree more with your explanation and experience. I didn't know anything about handfeel of drill so I decided to have lowest speed suggested, but I immediately appreciate the way they worked and I thought, it is so true your expression' the speed is a friend, that I could improve the speed with simpler and better result.
I also agree with your vision of multiple high value therapy standard of care. I believe on single treatment (one visit) can be now possible with a new concept of 'one time healing.'
I will get in touch with you soon for some information and thanks for the insight on the use of densah burs.
Armando


Reply

Very nice case but I am not sure what the palatal SS adds except more time to the overall procedure. I love using the Densah drills, the majority of cases I run them in reverse at 1000 to 1300 rpm except in very soft bone, reduce to 800 to 950 rpm for soft bone. Using the Verban drill stops made for the Densah drills becomes an excellent vertical sinus lift technique with great control.


Reply

Jerome, I used 800 considering a maxillary area, but I will improve speed the way you suggest and possibly using the Verban stop that can be of invaluable help in many circumstances. I did not have them available now but I will in the next future. Thanks for your comments. Best wishes. Armando


Reply

Spectacular case Armando!
What brand is the implant?


Reply

Anton,
thanks for your words. Your ideas about digital are very meaningful to me and could be merged with others like PET and Densah drill that work beautifully on these circumstances.
Implant is DIO s chorean company involved on integrated digital processing.
Ciao.
Armando


Reply

Armando. Of course you must know how much I LOVE THIS! Outstanding diagnostics, planing and execution. Absolutely the "Gold standard" for implant dentistry. Yes it is worth the effort to preserve all roots. You are right the Palatal bone resorption is not noticed as much because in general it is approximately half that of buccal resorption. However, complete removal of a palatal root can be quite destructive in some instances. This is especially true if a palatal dehiscence and /or sinus communication occurs as result of extraction. Maintaining all roots can MINIMIZE DAMAGE and OPTIMIZE REPAIR. I will post an example shortly. Armando I appreciate you more everyday! Happy Holidays my friend. All the best!Chuck


Reply

Chuck,
Thanks for the kind word. It is of interest that You also confirmed the need of maintaining the palatal root: I guess it is important to have same observation results in an area basically unesplored as PET on molar. I tried to think about a strategy and I found that including the Densah bur can be of outmost relevance expecially when long time is spent for PET. The ability of predictable and easy sinus lifting together with osseodentification can improve concept of 'one time healing'.
Dental implantology is probably the only surgical area in medicine where multiple session are required to achieve a final result: don't' You think it is time for a change? How many healing process a specific area has to go through? Is 'one time healing' a possible goal now with New paradigm, new technique, New instruments together with a digital planning approach?
Happy New Year.
Armando


Reply

Armando
I was thinking
3 root molar, 2 root pre molar, leave all the roots, instrument all the roots ( clean and disinfect the canals or not )
Use the densification protocol to compact the bone and cementum into a coagulum. Immediate implant possibly a smaller diameter???

Rocco


Reply

Rocco. I thought of this approach as well and I believe it may be a possibility. This needs to looked upon. Perhaps Densification of allograft into a PET site can facilitate implant stability and promote healing.Hypothetically perhaps we could place a 4.5 mm implant into a 5mm PET site after densification of the gap with DFDBA. I believe this may be possible so long as there is adequate apical bone and blood supply. IMO this concept would be ideally suited for digital planing. Much to explore. Best regards. Chuck


Reply

Armando. Yes indeed. HAPPY NEW YEAR and NEW ERA. Chuck


Reply

Armando
Why not leave the entire root if healthy?
To me the space was there...
I agree the palatal root of these teeth may be problematic
w sinus entry ( In Dogs )

Rocco

Both MB / MP Left


Reply

Rocco,
I believe this could be a simple and clever opportunity: if you see my case you can observe that root is sufficiently distant and with different angle to the implant.
I will take your suggestion into consideration when approaching new cases.
Thanks for the insight.
Armando


Reply

Please excuse my ignorance but what does PET stand for? I've been using the Densah burs with excellent results but have never heard the acronym PET other than positron emission tomography which I'm sure is not the meaning here.
Thanks
Loyd


Reply

Loyd:

Here is a link to Step by Step approach to SS or PET

http://forum.dentalxp.com/case/details/step-by-step-ss-open-flap/5365

Salah


Reply

Loyd,
PET is an acronym adopted here on Dentalxp, proposed by Dr. Salama and stand for ' Partial Extraction Therapy ', a concept firstly introduced by dr. Hurzeler as ' SS ' : 'Socket Shield'.
Armando


Reply

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