Is this a Socket Shield Failure or Complication?

358 Rating(s).


Posted on By Maurice Salama In Failures

3 months after PET & Implant placement on lower 2nd premolar patient reports for restorative phase. No pain or swelling noted but exposed shield discovered. What now? 1. Is it Stable? No 2. Any probing or fluid discharge? No 3. Is implant stable? YES. Thoughts and options. If shield is mobile it MUST be removed!! Then what? Flap? Implant removal? Bone Graft? Tissue Graft? Call Howie Gluckman? This is what was done TODAY. What say our group? Happy Holidays Dr. Salama

Shield removal
Shield exposure no inflammation

Shield exposure occlusal view
Preop axial 3D section


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24 Comments

Pre and Post PA radiographs

Preop
Post implant at 3 months with Shield


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1st Surgery images of SS...technique issues?

Palatal root removed without complication
Shield before reduction


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Implant placed with mini-flap to ensure reduction to crest.

Implant placed with mini-flap to ensure reduction to crest.
Sutures over fibrin


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I’d call Howie but he’s too far away 😉
Seems that we’ll be facing more of these issues as we continue with this technique.
How much bone is left on labial aspect might determine gbr or just ctg. If no discharge may be able to salvage implant but since not restored i’d probably choose a fresh one. Curious what others have to say.


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Complication in my opinion. But I have seen SS complications that are much much more catastrophic. Mainly related to shield mobility. Probably will need CTG or FGG in this case especially that neighboring teeth are implants.
Thanks for sharing Dr Salama,
Ehab


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My biggest concern here is the buccal position of the implant. Soft tissue augmentation is a must.


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You know, I did not think so... But in hindsight, yes perhaps another 0.5mm or 1mm lingual would have been better. Ahh, Guides would help, free hand let's us be off just enough sometimes.


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Interesting comments... This case for me was very interesting. Extremely thin gingiva at time of shield prep. Root in distal position in relation to implant location. Not sure of cause of shield mobility? In any case, once mobile removed WITHOUT incision. Evaluated space and found BONE..on labial and against implant. Did nothing else. The visit took all of 5 minutes. Will follow up in 4 weeks and evaluate site. Dr. S


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Hi, Ehab, how often do you see complications? Why do you think in your cases the shields get mobile: during shield preparation (I am sure you test the shields immobility before you place implant), or during implant placement or later? I ask because I had (out of 250 socket shields) shield mobility in only one case. It was my fault, the coronal part wasn`t reduced enough and healing abutment pushed and destabilized the shield.
Best regards
Snjezana


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Hello Maurice , If the shield move and the implant is fine , my opinion is take the shield out, clean the tissue fibers between buccal plate and implant , put Prf Membranes or fill the gap with Novabone and close completely the flap.


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I only removed the shield. So nothing in gap. Probed bone on both sides and left to granulate in. Implant ISQ 74. No filler placed.... 1mm shield thickness left very small area for any graft.....now let us see. Will take new CBCT at 5-6 months.


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Hi Mo, interesting case. Even though you have bone on buccal of implant may be a little CTG could help.
I was looking the xr and notice that there was bone resorption on mesial of implant. You didn´t do C shape in this case?
Thanks for posting,
Regards
Jorge


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No c shaped....but I would agree, the tissue here even from initial surgery was extremely THIN, so tissue was always a concern but still I decided not to add to see the progress WITHOUT.....a test if you wish of "healing response' with minimal interaction. regards Mo


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Maurice,
on mandibular, IMO, the relation between shield and buccal bone (Prevalently cortical) may not be adequate to maintain the shield stability. I prefer the shield design that I show in the picture (as part of my technique 'Preserving Nature'): the embrasure on trabecular bone stabilize the shield reducing the risk of mouvement.


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HI Armando, this is the C shape: as I baptisted....
Regards
Jorge


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Jorge,
if you check carefully this design is Beyond your 'C' concept, much more lingual, in order to better stabilize the shield. It also differ for root cut orientation, here oblique and not vertical.


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Armando; Thanks, that is question of course to watch for. I did secure shield with slight extension on mesial as you displayed here. NO mobility at prep, or after implant placed....only reported by restorative colleague at time of impression taking....and it was very slight.....no pain, fluid discharge, bleeding, inflammation or color change noted!!!! So again, Failure or just complication? Or technique requires alteration? Great discussion. regards Maurice


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This is very interesting: bone on the buccal and against the implant, shield not stabile. It would mean, not shield displacement at the time of implant placement, but afterwards. There is no inflammatory response, the question is why this shield moved? Thin cortical bone, no C shape design? Implant is placed distally to the shield-only L shape design would have been possible.
Have we learned from this case that if there is a thin cortical bone the shield should be extended interproximally?
I agree with your conservative complication management, if there is a need for tissue augmentation it can be done in few weeks.
Thank you for sharing, great discussion
Best regards
Snjezana


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Snjezana; My point exactly....WHY? Late? Only utilized Fibrin at closure, no BG or CTG....no mobility at placement....patient was unaware and when checked at 4 weeks was not exposed or mobile?? Shield WAS distal to implant placement location and we knew that from CBCT 3D plan....is it POSSIBLE then that when the SHIELD is NOT directly LABIAL to implant location there is greater risk of SHIELD migration and mobility? regards Maurice


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Test
Test


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Mo,

Food for thought- first question - Define failure of a shield ? vs complication - In my mind its a 2 part answer- if a shield is modified and saved then just a complication? but if the entire shield is removed then failure of shield - but is if the implant is saved - then its a complication of of implant therapy but not a failure of the original goal of providing s restorative solution-

was the case provisionalized with a removable prosthesis ?
What say you about the possibility of adjacent implants and lack PDL and bundle bone on implants - with bone loss - and metal exposure - resultant possible increased bacterial susceptibility invading shield environment ..... food for thought

Cheers,

Richard -
Back on the Block


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Yes, food for thought?


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Thanks for sharing this wonderful post. Ive always been vary of mandibular premolars and incisors for socket shields. I feel there isn't enough bone lingually to place the implant and perhaps that may lead to the implant exerting pressure while being torqued in. At the time of placement it may seem firm but as it heals the mobility may set in. Ive seen Jorge's and your successful cases.
I've been asked often by beginners about attempting socket shields in mandibular premolars. I've always discouraged them from attempting it before doing maxillary premolars and anterior teeth where we have good bone to place the implant palatally and have adequate space between shield and implant.
What are your thoughts and experience with mandibular single rooted teeth?


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Udatta, yes this can be a challenge in small spaces...I had no mobility at placement or 2 months post op. Not sure what is at work here but the complication is minimal IMHO. Regards Maurice


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