"PET" vs no "PET" in mandibular molar region

PA implant

PA imp coping

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Minor complication....managed with high speed reduction of exposed distal root shield.

Flap dihescence over distal shield

Reduced shield to bone level

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Healing at 4 months...

Healing at 4 months

Healing at 4 months

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Final Ridge Contour.....

Day of Seating

Final Crown after 6 months

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Comparison of PET vs. No PET below...thoughts? Dr. Salama

"PET" at 1 year

No "PET" Socket Graft at 4 months

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Dr Salama,

Nothing beats biology and no GBR technique will provide results similar to PET. IMHO, even with the best augmentation techniques, we hope to regain part of the tissues that were originally there, on the SHORT TERM. Outstanding case and documentation as always. What was the condition of the molar before extraction?
As much as I feel that all forum members here are on the same page with PET, its disappointing that its not the same elsewhere. Long live PET and XP forum :)

Best regards,
Ehab

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Hi Mo, incredible and outstanding documentation of an everyday situation

This is in acordance with Mataraso's paper.
I suscribe Ehab's feelings.

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Hi Maurice, great work. There is no doubt that shield will prevent the buccal bone resorption, but the results with shield hieght is varying from case to case, should we keep the tooth shield 1mm above the bone or at the level of the Bone or 0.5 mm below the bone? All 3 heights has given me both positive and negative results in terms of Post healing shield exposure. I feel It depends on the existence of soft tissue volume Regards . Ashok

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Ashok; You are correct. My rule of thumb for whatever it is worth, is shield at Bone level in posterior and 0.5mm below if we raise a flap. In anterior, I prefer 0.5mm above bone level with flapless but at bone level (level of implant head) if flap is raised. With thick tissue biotype much can be done without issue. regards Dr. Salama

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Mo. Excellent case management and documentation! As Ashok mentioned, we are seeing "random"'shield exposure despite various shield heights relative to the bone either open or closed. Now that more of us are exploring molar PET we can form a better concencus of what do expect. To date I accumulated 1st and 2nd molar data in all quadrants. In addition I have explored 1,2 and 3 root configurations both immediate and delayed approaches. With that said, I would like to propose a working hypothesis that MOLAR SHEILDS HAVE AN INCREASED TENDENCY TO MOVE DURING HEALING AND THIS MAY BE RELATED PRIOR OCCLUSAL FACTORS. For the sake of discussion, I would like to introduce the concept of PDL REBOUND EFFECT. In my limited experience is seems more profound for mandibular molars. The shield s appear to drift and tilt lingual into the open socket with some associated extrusion. Well guys and girls what do think about idea? Best wishes to all. Chuck

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Chuck,
Shield drifting, as proposed by you and Armando at several occasions seems very real. Contraction inside alveola during healing?…
Look at this Dr. Salama`s shield, it`s on the bone level. How interesting your observation that mandibular molars are in a greater risk of shield exposure…
What do you think about mandibular deformation during mouth opening as a possible contributor? At first I wondered about your hypothesis about occlusal forces as possible contribution factor, because most of this shield exposures occur before loading. But then - what about mandibular flexion during teeth clenching? Bruxer as patients in a greater risk of shield exposure?
Looking forward to your answer
Snjezana

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Snjezana. The PDL REBOUND effect I speak of is a response to the removal of previous forces the tooth was subjected to prior to partial extraction. As you suggest other forces may also influence the dynamics of healing. Warmly. Chuck

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Chuck,
I guess we think alike....totally agree with you, shield moves.
Different fashion , different areas.
Why it moves? I guess every one of us has some ideas.
But what about solutions: what happens during healing period? Can we modify healing pattern?
Is 'early load a solutions? Or immediate functional load?
Are we getting on the next level?
Armando

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Dr. Salama,
Pictures speak their own language. Patients don`t ask us for an implant, but for a tooth. Applying PET procedure makes it possible to preserve hard and soft tissue. Consequently the implant supported crowns fit into the tissue naturally - the risk of food impaction, mucositis and other implant-related side effects is minimized.
PET is an important step towards natural looking and functioning implant prosthetic.
Looking at the beautiful pictures 6 and 12 months after PET I can`t help but using all the time expressions like "nature" and "natural".
BTW, have you secured fibrin membrane?
Thank you for sharing this beautiful case!
Best regards
Snjezana

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Thanks Snejzana. Yes, I always secure fibrin with sutures. regards and hope to see you in Vegas.. Dr.S

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Chuck,

This is priceless information as we compile data we notice the trends- As Snjezana mentioned deformation of the jaw but where does muscle pull play a role and what about if the pet molar is the terminal tooth as well if RCT was done,
male vs female, age of patient

Premolars not a factor due to less socket space to drift?
This is really groundbreaking data,

Big Cheers,

Richard

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Richard. My comments are based merely upon UNSCIENTIFIC OBSERVATIONS. I suspect shields move on bicuspids also. In general I have noticed Mandibular shields seem to drift toward the buccal and maxillary shields toward the palatal. Just sayin for what it's worth. Cheers. Chuck

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Chuck; This shield did seem to move to the labial where it dehisced?? If you look at post PET image you would see I reduced to bone level with open flap?? I was surprised by the flap dehiscence at 2-3 months? regards Mo

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Wouldn`t it be an idea, to collect all our shield exposures?
I guess that my students are ready to systematize data regarding upper - lower, time, gender, bruxismus...
Snjezana

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appears the implant is placed subcrestal significantly on lingual or just angle

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Jim; You are looking at implant level to level of Lingual flap as it was NOT raised? Look at PA radiographs to determine depth placement of fixture. See you soon in Brazil....we will have a few cases to do there as well. regards Mo

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Dr. Salama, is your preference to place molar implants into mesial root?


Thank you. XM

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Xavier; If I extract all of the molar roots I am typically selecting mandibular distal roots and molar palatal root sockets to favor placement. regards Dr. Salama

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Chuck,

Sometimes the unscientific can be compared to your quarterback big Ben being able to feel Von Miller coming around his backside without even really seeing him and releasing the ball before he gets smacked

Cheers ,

Richard

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Richard mannnnnnnnnnnnn always with those nice analogies. Mo

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