The 1st PET CONSENSUS #JTI2017

The 1st PET CONSENSUS #JTI2017

On november 17th at Madrid was held the 1st PET CONSENSUS prior to the JTI meeting. The vast majority of the implantologists on this consensus were at Madrid . All of them gave their opinions by mail prior to the meeting.

The Socket Shield technique is actually practiced by thousands of implantologist trough out of the world. We selected the most experienced clinicians that has published SS cases from the last 5 or more years in order to establish some guidelines on the practice of the Socket Shield technique.

The purpose of the SS technique is to maintain hard and soft tissues at the maximum while allowing immediate implant placement. A thorough questionare was sent to each participant regarding many aspects that we haven´t agree yet in order to know what are we doing, what are we saying to our patients, referral doctors, etc .

Here is the list of members of this 1st PET CONSENSUS.

Maurice Salama (USA)  Michael Pikos (USA)  Paul Kozy (USA)  Chuck Schwimer (USA)  Salah Huwais (USA)Richard Martin (USA)  Snjezana Pohl (HR)  Haakon Kuit (NL)  Luis Bessa (PT)  Marcelo Ferrer(CHN)   Udatta Kher (IND) Ali Tunkiwala (IND) Miltiadis Mitisias (GRC) Francisco Barbosa (PT) Armando Ponzi (ITA) . Howard Gluckman (ZAF) Jonathan du Toit (ZAF)  Alberto Fernández Ruiz (ES)  Jorge Campos Aliaga (ES)

The general agreement  regarding the Shield position respect to the bone is a Flush preparation, although 1mm above bone is also accepted specially on thick biotypes.

The Following issues were addressed by the author and with collaboration of some participants to get to final consensus that has to be revised after 2  years to study the results.

1. Why does SS work clinically? Is it the vascular maintenance thru PDL that preserves nutrition to Bundle Bone on the buccal plate?

89% of the participants were in accordance with this hypothesis: the PDL nurtures the buccal wall in a very significant quantity. On the past we thought that the periosteum played a role but we realized that the resorption takes place on the buccal wall even with flapless extractions. Some participants also add some ideas:

a.- SS prevents inner exposure of bone to oral media

b.- A biomechanical factor: prevents bone pressure of gingiva.

2. Do you consider internal exposure of the shield a failure or just a complication?

A 94% of the group consider it just a complication while the rest 6% only said no.

Internal exposure is due to  a lack of soft tissue over the shield that usually happens because there is a prosthetical invasion of the area that should be left for soft tissue covering. Provisional crowns or abutments can interfere with normal gingival covering of the coronal portion of the shield.

3. Do you consider external exposure of the shield a failure or just a complication?

Here we have a 100% agreement that an external exposure is just a complication that can be treated easily on the mucogingival phase. Normally shields above bone can be exposed due to provisional removable prosthesis pression on mucosa while healing on submerged implants. The best way to treat an external exposure is to raise a mini flap and grind with a diamond bur the shield portion above bone.

4. RST versus Pontic Shield: difference in clinical application and future perspective

Root submergence technique  (RST) is similar to Pontic Shield (PS), so we wanted to define in wich cases can be used.

Definition:

A: VITAL ROOTS

B: TREATED ROOTS WITH NO SIGNS OF INFECTION CLINICALLY AND RADIOGRAPHICALLY

C: TREATED ROOTS WITH SIGNS OF INFECTION CLINICALLY AND/OR RADIOGRAPHICALLY

1 RST CAN BE DONE ON ROOTS A & B only.

2 PS CAN BE DONE ON ROOTS A, B & C( combined with apicoectomy)

1  AGREE WITH TERMS 1 AND 2

2 DO NOT AGREE. PLEASE EXPLAIN________________

All experts agreed on the subject. Pontic Shield can be used on cases A,B &C. Root Submergence needs a clean periapical status.

5.  Has bone level shield preparation any advantage?

1 YES

2 NO

When we talk about shield height related to bone there are two main levels: flush with bone crest or 1 mm above bone. The first one claims that bone level makes more difficult to have an external  exposure. While the latter claims dentogingival fibers maintenance.

6. Preparing the shield before palatal slive extraction represents an advantage?

(Do you usually prepare the Shield before extracting the palatal/lingual part of the root?

1 YES,  ALLWAYS

2 NO, NEVER

3 SOMETIMES

7. DO YOU BELIEVE THAT the C shape IS NECESSARY FOR  papilla maintenance?

A mix of proximal SS (J.Kan 2013) and SS is what we call “J”SS  with only one proximal shield and “C”SS with two proximal SS providing pdl maintenance to interproximal bone that, finally, sustains the papilla.

The concept is important when you have a neighbor implant or you suspect you will have on the near future.

1 YES

2 NO

8. WOULD YOU CONSIDER THE 360º SS THE FUTURE EVOLUTION?

Some of us consider this the future evolution of SS, some a risky attempt not justified clinically. We wanted to know what were the opinion of the group.

1 YES

2 NO

3 NEED TO BE EXPLORED

 9. IN YOUR OPINION, Is it necessary to fill (GRAFT) the GAP between implant and shield?

Gap grafting has been our common procedure on immediate implants in order to prevent buccal  collapse. But , with SS we no longer experiment such collapse: so do we “need” to fill the gap?

1 YES

2 NO

10. IN CASE YOU ANSWER YES, WHAT KIND OF GRAFT DO YOU USE?

1 ALLOGRAFT

2 XENOGRAFT

3 SINTHETIC

4 ANY

11.  ON PF1 (MISCH CLASIFICATION) YOU SET THE IMPLANT PROSTHETICALLY DRIVEN, IDEALLY. WHAT DO YOU THINK ABOUT Shield separation vs Shield contact: DOES IT MATER?

 A very close implant to shield does not prevent osseointegration. A gap between Shield and implant also is filled with bone. A total proximity can dislodge the shield during preparation or implant placement.

1 YES

2 NO

12. ON PF2 OR 3 YOU CAN CHOOSE  GAP OR CONTACT BETWEEN IMPLANT AND SHIELD: YOU PREFER ESPECIALLY

We can do SS even on cases of resorbed ridges with the sole condition that roots must be firm with buccal bone. In that cases we can choose the position of the implant on the ridge. What do we choose?

1 CONTACT

2 GAP

3 ANY OF TWO

13.  How much vertical  ROOT length do we need to achieve the bone preservation Shield effect? IN YOUR EXPERIENCE, WICH IS THE HIGHEST AMOUNT OF ROOT % YOU HAVE TAKEN OFF WITH AND APICOECTOMY CONCOMITANT WITH A SUCCESSFUL SS?

1 10-20%

2 20-40%

3 40-60%

4 60-80%

14. WHEN YOU DO A Glocker TYPE OF TREATMENT, DO YOU FILL THE SOCKET?

1.Glöcker et al 2014 described a SS that was performed without the immediate implant insertion. He filled the socket and covered with a membrane. A delayed implant insertion was performed.

1 YES

2 NO

15. IF YOU FILL THE SOCKET ON GLOCKER TYPES WICH IS YOUR FAVOURITE FILLING MATERIAL?

(IN CASE YOU DON´T HAVE AUTOLOGOUS)

1 ALLOGRAFT

2 XENOGRAFT

3 SINTHETIC

4 ANY

16. DO YOU EXPLAIN TO YOUR PATIENTS THAT YOU ARE GOING TO DO A SS TREATMENT?

Latelly, the PET treatments are more popular between clinicians. But there still a barrier to overcome, that is the information to patient and referral Doctors.

1 YES

2 NO

3 ONLY RECENTLY

17. DO YOU EXPLAIN TO YOUR REFERRAL DOCTORS THAT YOU ARE GOING TO DO A SS TREATMENT?

1 YES

2 NO

3 ONLY RECENTLY

The great majority of Clinicians mentioned to patient and referral doctors. There is the need to include on the inform consent prior to surgery.

18. SUPOSE YOU CHARGE 100 U$D FOR AN EXTRACTION  ON A SINGLE ROOT TOOTH WHEN YOU ARE GOING TO DO A SIMULTANEOUS IMPLANT (IMMEDIATE) HOW MUCH DO YOU THINK WE SHOULD CHARGE FOR A SOCKET SHIELD ?

1 SAME: 100 U$D

2 DOUBLE : 200 U$D

3 TRIPLE: 300 U$D

4 MORE: ESPECIFY__________________

19.  SUPOSE YOU CHARGE 100 U$D FOR AN EXTRACTION  ON A MULTI ROOT TOOTH WHEN YOU ARE GOING TO DO A SIMULTANEOUS IMPLANT (IMMEDIATE) HOW MUCH DO YOU THINK WE SHOULD CHARGE FOR A SOCKET SHIELD ?

1 SAME: 100 U$D

2 DOUBLE : 200 U$D

3 TRIPLE: 300 U$D

4 MORE: ESPECIFY__________________

20. HOW MUCH SHOULD WE CHARGE FOR A RST TREATMENT IN RELATION TO TOOTH EXTRACTION? SUPOSING EXTRACTION IS 100 U$D.

1 SAME: 100 U$D

2 DOUBLE : 200 U$D

3 TRIPLE: 300 U$D

4 MORE: ESPECIFY__________________

21. IN CASE YOU DO A SS WITH IMMEDIATE IMPLANT AND YOU DON´T PROVISIONALIZE. DO YOU FIND NECESSARY TO COVER THE SOCKET?

1 YES WITH CONECTIVE TISSUE

2 YES WITH PRF ALONE

3 YES WITH A CUSTOMIZED HEALING ABUTMENT

4 NOT NECESSARY

22. Does an immediate provisionals improve outcomes? Or only increases risks?

Choose 1,2 or 3 ( can choose more than one)

1.- Provisionals only add more risks to SS treatment

2.- Provisional helps maintain the natural emergency profile and avoids 2nd surgery

3.-Custom healing abutments can do the same at gingival level without any risk

 

 

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Adrian F Robador

Comments

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