Mandibular incisors socket shield, Implant failure & recovery part 3

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Posted on By narayan tv In Implants

Dear friends, I'd posted 2 parts of this case earlier, One part showing the Socket shield & immediate implant placement, following which there was loss of the right lateral implant.At this time, I curetted the defect but left the socket shield intact. In the second part, re-entry surgery showed bone regeneration lingual to the socket shield, enough to install a 3.5 mm dia implant and contour augmentation GBR with an allograft. This is the concluding part of the case, showing completion. Interesting to note is the difference in buccal bulk between the two sides. The successful Socket shield is clearly the winner.

After 2nd stg, at impression appointment
Impression recorded. Protemp used to splint impression posts, and record the crest intervening between the iplants

Prior to impressioning
Final screw retained restoration


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10 Comments

Looking back at your procedure, when you removed the failed SS, there was no mechanism employed with the GBR to neutralize the soft tissue envelopes compressive forces on the bone graft. These forces will cause the resorption instead of maintanence of the bone graft.Using a reinforced membrane ,titanium mesh,bone plate or sonic weld technique would have resulted in a better labial profile.


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Dear Dr. Jerome,
Thank you for your comment and observation, however with all due respect, I beg to differ.If you look at the picture immediately post insertion, you will notice that the implant is completely encased in bone with about 2 mm bone labial to it, with a small sub coronal defect where the shield was removed. Now the grafting was for contour augmentation using classical GBR and we know to expect 30-40% resorption with this procedure, hence the overgrafting.At all stages,the provisional was a Maryland Rochette bonded bridge . In the final stages with the healing abutment & without, if you look at the right side implant in isolation, it is an adequate result, (As was the bone volume facial to the implant on 2nd stg surgery. The pics were botched up by a new assistant and I'm not able to use them) and would have been what we all aimed to achieve in the days of yore, before the socket shield. Its only in the context of the other implant where the socket shield succeeded, that the tissue bulk looks less. In toto however, the aesthetic outcome is more than acceptable. Do you really believe in this scenario its worth putting the patient through the additional expense/trauma/risk of complications using the techniques you have mentioned, in an aesthetically not so critical site?.Perhaps some views from Drs. Salama & Gluckman on this?


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Great job Narayan, compliments. You have done a neat conservative implant work for a 50 yrs old female pt. Its a lower anterior quadrant with an existing good keratinized tissue, and the soft tissue is not in a visible zone. Complex G.B.R procedures are unnecessary. Thanks for sharing, Ashok.


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Thanks Ashok, was just typing out a reply to the earlier comment, :-)


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Narayan; Well managed case all the way through and well documented. Thanks for sharing with our group. regards Maurice


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Thank you Maurice, for your encouraging comment. Much appreciated.


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Narayan. Great case and follow up. Your work here truly tells the story of partial and total extraction therapy. Important "take home" messages demonstrated:
1) Successful uneventful SS facilitates an optimal outcome.
2) A well prepared / healthy SS is resilient and can facilitate socket preservation under adverse conditions.
3) Loss of the SS (intentional or non intentional) will predictably result in loss of tissue.
Your work here is most significant! Thank you for sharing. Best regards.
Chuck


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Thank you Dr. Schwimmer for your analysis and summary. I couldn't have said it better.


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Since you elected to put the patient thru a repair with a bone graft and membrane anyway using a titanium reinforced membrane should not be considered any additional trauma,as you point out there was adequate labial bone over the implant.


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A Ti reinforced membrane is considerably more expensive as are bone plates and sonic weld, besides the fact that these are not freely available in the part of the world I practice in,than a simple collagen, and using a reinforced membrane or a Ti mesh would run a higher risk of complications as in exposure etc.,and have necessitated a far more elaborate second stage surgery for removal, than what was done here, i. a small slit to visualise the implant and the facial bone. In my clinical judgement at the time, I felt this was the best for my patient, and given a choice to do this again, I would do the same. I don't believe there is a critical need for greater bone or contour bulk here, though admittedly,your options would provide that. I would reserve those techniques for more demanding situations than this. Thanks for responding to the case.


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