What would You do in this Type 1 Socket Case: Dual Zone? Pet? SVG?

139 Rating(s).


Posted on By Andrea Agnini In Anterior/Esthetic

Failing left central incisor in a deep bite patient with an high esthetic risk profile. Gingival asimmetry between the right and left side of the anterior maxilla.
No Bruxism, no periodontal issue, low systemic risk profile and high endo/decay risk profile.
Patient wants to keep the diastema.




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30 Comments

My solution:
Extraction with benexII for to preserve facial bone; immediate implant with palatine guide; biomaterial in the socket residual;
immediate loading screwed...


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Alfonso, where would you place the graft? up to the gingival margin or only at the level of the bone crest?
Maybe using the PET will allow You to avoid damaging the buccal plate during the extraction and avoid the 3dimensional bone remodeling as well?


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IMO PET for sure. Even better if combined with Orthodontic eruption.


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Although in sagittal slice it doesn`t look very PET friendly, I wouldn`t miss opportunity to perform SS. We`ve learned that the reality is often better than CBCT shows. And if socket shield doesn`t have a sufficient dimension, you can switch to post ex with dual zone augmentation.
Immediate provisional could be risky in this case-may be individual healing abutment or provisional but with temporary occlusal stops on laterals.
Thank you for sharing, keep us posted!
Best regards
Snjezana


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Great discussion of everyday case decision making.
If there is a fenestration on labial plate then I would go with SVG.
If no fenestration I would go with PET.
regards Maurice


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Maurice there is not fenestretion
But if we are talking about simplification of therapy,in your experience the dualzone graft technique works really worse than PET in this case?


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This is how the case has been treated:
- Immediate implantation
- Immediate provisionalization
- Connective Tissue graft
- Dual zone bone graft
- screw retained zirconia layered implant crown, created under a full digital workflow.

What do you think about the chosen tretatment plan?
Would you have done something different?


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This is how the case has been treated:
- Immediate implantation
- Immediate provisionalization
- Connective Tissue graft
- Dual zone bone graft
- screw retained zirconia layered implant crown, created under a full digital workflow.

What do you think about the chosen tretatment plan?
Would you have done something different?

surgical veneer grafting (SVG)


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1 year follow up


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final cbct scan


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Spectacular result!
As I already mentioned, I wouldn`t have done immediate provisionalisation, but you taught me (us) more. I believed that immediate temporization without immediate functional loading is not possible in the cases with a deep bite, because of dynamic occlusion. Is there a literature to this topic, I would appreciate it very much?
Thank you for sharing your fabulous work!
Snjezana


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Thank you Snjezana..
The provisional restoration was kept free in dynamic occlusion but not in static. Several articles have shown this..
I think to obtain osseointegration, It is very important primary stability but also the compliance of the patient and of course the correct shape and surface of the provisional restoration to avoid the patient s tongue during the early healing phase.

You think that PET would have worked better?

What is your opinion?


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Hi Alessandro. Nice result. I would have handled it as follows:

1. Regenerate/augment the buccal plate with SMART bone graft.
2. Open the bite with posterior composite stops.
3. Immediate implant placement and provisional.

https://www.smartbonegraft.com/gallery/

First time on the forum. Images did not upload for some reason or another. If you scroll down on the gallery page of smartbonegraft.com site, you will se a case where we augmented the buccal plate prior to immediate implant placement and provisionalization.

Regards


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Dre&Ales,

Spectacular result-Very challenging case on both fronts my thoughts were that you may have done this case before PET therapy was in Full bloom ... but even without a fenestration, this may have been a challenge to do with PET because of the width of the root canal fill at the apex ( childhood injury with CaoH ?) so my thoughts would’ve been start out doing PET and if you noticed that with removing a root canal material it became unstable and then convert to Dual zone/SVG! Win win situation maaan!

Cheers,

Richard


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Dear Richard,

thank You for the comment.

Here, as requested, You can find the 4 years follow up compared with the 1 year. Moreover I am attaching also a profile pics at 4 years.

As You probably notice, there is a continuos maturation of the CTG down the road, which results in an augmented volume bucco palatally.

Would You think that with PET, which was Your treatment solution, would You have been able to obtain the same result over time?
Or would You think that the Surgical Veneer Grafting Protocol might be a reliable alternative approach to utilize in specific anatomical situations?


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Brilliantly executed Alessandro! One can't argue with the final result that you have achieved in this case. Biologically sound.
This is how I approach such cases.
1. Firm tooth no fenestrations: PET
2. Firm tooth with tiny fenestrations: PET with Esthetic buccal flap and apisectomy.
3. Very thin labial bone which may not support a shield: Extraction of the tooth and dual zone grafting.
4. Thin labial bone and fenestration: Esthetic buccal flap and Dual zone grafting.
5. Dehiscence after extraction. : Early placement with contour augmentation.
6. Large periapical lesions: Delayed placement.


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Dear Udhatta,

thank You for the comment.

Here, as requested, You can find the 4 years follow up compared with the 1 year. Moreover I am attaching also a profile pics at 4 years.

As You probably notice, there is a continuos maturation of the CTG down the road, which results in an augmented volume bucco palatally.

Would You think that with PET, which was Your treatment solution, would You have been able to obtain the same result over time?
Or would You think that the Surgical Veneer Grafting Protocol might be a reliable alternative approach to utilize in specific anatomical situations?


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I agree Andrea. The result you'll have achieved is as good as it gets. I have been hugely in favour of SVG until I started to see how predictably the PET has been working. Not just in my hands but in many hands all over the world. With PET one may not achieve an increase in volume but can ensure maintenance of what existed pre-treatment.
Attaching a 3.5 year post op of a PET done on #11. Notice an improvement in tissue contours and quality compared to the adjacent crowns on teeth.
I just find PET a more minimally invasive option to achieve comparable results in the right case type.

PET


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Thanks Ernesto,Richard and Udatta..

What I have seen in the follow up of Type 1 cases treated with the correct SVG protocol, there is often an improvement of the quality and quantity of perimplant soft tissue.
As you can see in the occlusal picture after only one year.


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Great surgical work and result Agnini. My only concern is occlusion , did you mount the case in CR before and OR after the treatment to check for any interference. So many of cervical defects and the lingual surface looks to be erroded up to some extent, natural cingulum is almost lost, how is the anterior guidance? Bit risky in long term IF there is any issue in occlusion . I have burnt my finger in few cases. Compliment to your great surgical skills. Regards. Ashok


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The case has been restored in maximum intercuspidation position with static contacts and with the two central incisors guiding the protrusion.
The wear is not given by any parafunction
Actually the case has 4 years follow up without any biomechanical complication


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Andrea congratulations for the nice result. I would go for a PET solution for sure...
Can you post a 4 year post op pic? I would like to see contour evolution and keratinized quality width also.
Thank you very much!
Regards
Jorge


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Dear Jorge,

thank You for the comment.

Here, as requested, You can find the 4 years follow up compared with the 1 year. Moreover I am attaching also a profile pics at 4 years.

As You probably notice, there is a continuos maturation of the CTG down the road, which results in an augmented volume bucco palatally.

Would You think that with PET, which was Your treatment solution, would You have been able to obtain the same result over time?
Or would You think that the Surgical Veneer Grafting Protocol might be a reliable alternative approach to utilize in specific anatomical situations?


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Great Debate....we need an Algorithm for decision making between DZ, PET and SVG treatment concepts. Coming soon!! Dr. Salama


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Having an algorithm for decision making would be great Maurice. There is a lot of confusion while picking the right treatment approach. This is what we follow in practice. Are we on the right track? Or would you suggest a change?

Strategies after tooth extraction
Strategies after tooth extraction


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Thanks shearing like this information. Is really helpful for my studes


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Love the discussion that came out. Lets move on with this case: failing left upper canine with an internal resorbtion. Type 1 Socket with Thin Biotype.
We think is critical to assess the biotype prior deciding which approach to take. What would You guys do here? DZ, PET or SVG?

Initial Vestibular situation
Occlusal initial Situation


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I would still opt for PET.


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Brasseler
Hu-Friedy