Dual Zone Socket Management & I-Shell with Ritter Spiral Part 2

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Posted on By Maurice Salama In Implants

Patient presents after Trauma to Central Incisor. Immediate Extraction CLASSIC Technique with Dual Zone Management performed with Ritter Spiral Implant, I-Shell and Immediate Temporary Restoration. Refering dentist DID NOT WISH for PET/SS Approach. Thoughts on 5 months healing? Dr. Salama

Occlusal view at 5 months
Occlusal view with temp

PA at 4 months
Lateral view of Ridge Contour


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26 Comments

See Part 1 in top Right of Screen in related posts.

Day of Sx
with versah drilling


Reply

Mo: Excellent response to Classical approach. I'm afraid at the first year the statistic shows the 1mm retraction, facial retraction and color change.
What's your impression about this?
Regards
Jorge


Reply

Jorge;
A fair question and as you say the evaluation over TIME is what is imperative. I will continue to update this case as well as show 1 year post op CBCT...Let's see what we CAN expect with Dual Zone approach when PET is unavailable??
regards Mo


Reply

Mo,
Excellent result. The management here is much more important, influencing final result.
I have noticed you are using Densah directly in the osteotomy: I believe that the use of the drills around bone facing alveolar in osseodensification modatily can be beneficial for bone recovery follow up.
What do you think about that?
Best regards.
Armando


Reply

Armando;
The OD approach in sockets is somewhat limited to condensing the BG up against the Labial plate internally. It does cut very well when NOT in OD mode and helps stabilize the drill.
Perhaps Salah can provide a presentation on it's use in extraction management cases. regards Mo


Reply

Maurice:

I have already presented a case in this forum regarding socket densification. please find below
http://forum.dentalxp.com/case/details/immediate-implant-placement-osseodensif/5554

We are in the middle of two histological studies addressing socket graft densification. Studies are being finalized and will share clinical and histological data soon, maybe in a presentation format. Paolo Trisi will present histology finding at the OWS in Florida in January.

Clinical parameters:
1- Only pilot in forward to establish trajectory and position.
2- Follow with Densah Burs in CCW OD mode to create densified apex.
3- Socket graft with FDBA allograft preferably (30/70 = cortical/cancellous). Xenograft and biomaterials may not provide the right consistency (slurry) for the next step.
4- Use a densah bur that is one step smaller than the established osteotomy at 300-600 rpm with no irrigation in OD mode to densify the allograft and push it apically and laterally against the socket walls. Repeat this twice to establish a well-densified graft layer (slurry) around a consistent osteotomy.
5- Place implant.
Initial data is revealing that socket graft densification may enhance implant primary stability in a large contained defect (extraction socket). Carlos da Rosa from Brazil is showing great results with this technique even in a non-contained defect, but he is using mainly autogenous graft from the tuberosity.

Salah


Reply

Salah;
Thank you....I particulary like the step you suggest of "Use a densah bur that is one step smaller than the established osteotomy at 300-600 rpm with no irrigation in OD mode to densify the allograft and push it apically and laterally against the socket walls. Repeat this twice to establish a well-densified graft layer (slurry) around a consistent osteotomy." That is what I did here but utilized only 250 RPM in OD mode....thanks Maurice


Reply

Mo. RPM will vary with materials used for OD.


Reply

Chuck what do you use? and what is your experience with OD in Extraction sockets? Mo


Reply

Mo. To date I have been using various mixtures of allografts (DFDBA and/or FDBA).Going forward I intend to try 30/70 cortical/cancellous. My experience with socket OD has been exceptionally good. I consistently "TURN SPINNERS TO WINNERS". The ONLY failure (previously posted on the Forum) was an attempt to place an implant into a socket anchored 100% in OD allograft (DFDBA). Even that remained stable 3 weeks! Chuck


Reply

Great case Mourice, after seeing result like this, now iam thinking, is Socket shield is really required in all the anterior cases,!!! irrespective of pink bio type, thickness of the labial plate,smile line, etc. Thanks for sharing. Ashok


Reply

Ashok; Yes, the question must be asked....WHEN PET, SS, SRT and when Dual Zone Management....
What say the group? Dr. S


Reply

If we only treated SINGLE SITES that ALWAYS REMAIN SINGLE SITES the advantage of SS is less significant.


Reply

PET is a must also for ankylosed teeth.

Snjezana


Reply

Chuck; Why do you feel that way? Please expand. Mo


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Mo. It's not easy for me to explain in words, but the IHB of the adjacent teeth and the distance between adjacent teeth is a most critical factor for non PET cases. If we look at some multiple unit or side by side duel zone implant cases longer term(2 years or greater)the result is self explanatory. Chuck


Reply

That is great Salah. Just want to know if i get it right. After the pilot drill we should go directly to the final drill?


Reply

Mo.
I personally agree with Chuck vision.
One thought to share: main difference between PET and dual zone is NOT the presence of the shield but the maintenance of PDL.
So,IMO,we should investigate about its biomechanical role to maintain vestibular bone vitality in time (forces of occlusion dispersed by ligament fiber so that each osteon system receive a ' biological acceptable' stimoulous in a phisyologic range.)
Armando


Reply

Hi Maurice,

Great work here. Dual zone management with complete extraction works great for thick biotype cases. I think it's a very solid treatment modality and provides great long term results. Immediate provisionalization is key.

I think that in thinner biotype cases a PET approach is a game changer.

Also have to check the emergence of the root in the buccal plate. The more concave the profile, more resorption can be expected, so greater indication of doing PET. The flatter the buccal bone over the root, less resorption will occur so a Dual Zone management should work great.

Regards


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I second your comment Andoni, i think taking a call for Socket shield after assessing Pink biotype, labial bone thickness and smile line, will be more appropriate. But from other angle i always ask myself, whats wrong if we do it correctly for all the cases, lol.


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Ashok. I prefer to perform PET in all cases when conditions permit. That way if an adjacent tooth is lost there is less impact on the existing implant and conditions for future treatment will be more favorable. Best regards. Chuck.


Reply

Hi, I do SS for every case I can. The only acceptable cases non-PET are those of Thick Bone Biotype, that is no more than 13 % of the cases. Don´t get confused by the gingival biotype, a thick gingival biotype does not assure a THICK labial plate.
Regards
Jorge


Reply

I agree with all of the above, all very good points.

One thing I would add is that Dual zone absolutely requires to my understanding a very well designed temporary prosthesis or custom healing abutment and flap-less approach, I do not see this as critical for SS.

Yiannis


Reply

Wow, great discussion, perhaps it's time to make a DECISION TREE for PET and Dual Zone?
Dr. S


Reply

Maurice

I think its really needed. What about doing a multicenter study with large number of patients comparing these to techniques!

Omid


Reply

Great point Jorge

Thick biotype does not mean thick labial plate. I like it


Reply

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