Root Submergence complication

137 Rating(s).


Posted on By Howard Gluckman In Failures

This is a case of full mouth combination PET. We did multiple socket shields as well as pontic shields and some root submergence cases. The RST was closed only with PRF which subsequently did not close. hence 2 months after implant placement you can see incredible ridge maintenance as well as the exposed Submerged root. We then did a soft tissue closure with harvesting tissue from the tuberosity. The root was further prepared to remove any contaminated root and then a pouch was prepared both buccal and lingual. The tissue was sutured into place and then the flap closed


At suture removal showing the opening of the RST
1 month post op


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28 Comments

CTG sutured into place making sure there is no mobility of the tissue


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Final closure


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Perfectly managed. Well done and a rather minimal issue. Regards Mo


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agreed


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Dr. Gluckman, When and how do you discriminate between using RST vs pontic shield? Both accomplish tissue maintenance and yet pontic shield is more difficult to prepare. Thanks for your post!


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The pontic shield is far more difficult but is only used when one cannot do a RST. So if there is apical pathology or when you section the tooth and you fond that there is no bleeding of a vital pulp then I would do PS. That way it ensures that there is no possibility of later infection.


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That makes total sense. Thanks


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Luckily we mostly deal with a small PET complications.
Great csse, no possibility to PET is missed.
Cheers
Snjezana


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that is so True Sjnez this is as big as it gets. so easy to fix yet the value and the benefit are so amazing.


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Thank you for sharing with us, very nice case management. In case of staged approach (for example upper premolars with two roots), is it possible to fill the space between the socket shield and rest of the alveolus with collagene sponge, leave it to heal for 3 months and afterwards put the implant? Or do you prefer using xenograft?


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That is a perfect approach. I find it better to place the implant at the same time but. staged approach is possible


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Hi Howie, in this case I found that the root was cut FLUSH with bone. This explains the partial coverage. I found that have better coverage when the root is cut 2 mm bellow bone, leaving more space to coagulum (clot) and bone walls. Is difficult but the idea is to reduce root length leaving the same socket depth.
Well done!
Regards
Jorge


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Jorge I agree totally with you and how you manage. This is exactly how I do it and how this case was done. I always try and sink the middle of the root by 2-3mm. But in this case it didn't work. I generally find I have to actively close the RST


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Interesting...typicallyi just scllop with rise and fall of CEJ...you suggest "cupping it out"?? Jorge. regards Mo


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I definitely cup the central portion of the root to make as much room for the clot as possible. it also allows more space for the ovate pontic so the minor pressure exerted there does not cause necrosis and exposure of the root.


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``````final soft tissue healing after 2 weeks and the final integration check in this case.


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Upper Jaw complet and integration check. Full arch Combination PET at its best


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Amazing maintenance of ridge anatomy. PET rocks!

Ioannis


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Totally nothing else compares and nothing is as consistent as this. or as predictable.


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Howie. Outstanding case management as always. I have a few of these RST exposures as well. I really don't have a good explanation as to why. However, most recently they all have been Mandibular bicuspids. In addition, I have noticed an increased frequency of Socket Shield external exposures of Mandibular bicuspids compared to other sites. Just sayin. Maybe occlusion, flex of mandible, dehiscence??


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Chuck I don't get many exposures at all. I always make sure that I get either primary closure or I use a graft to close it up. Secondly make sure the margins are smooth and that they are at bone level and the mid root portion needs to have a 2-3mm depth from the edge of the bone for the clot to settle and then to turn into soft tissue. This case I did not close as I tried Sjnezanas technique of PRF which did not work for me.


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Absolutely agree! In addition, I believe release of the buccal tissue to insure reduction to bone level and to permit tension free closure is important.


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Hello Howard,
Great case and management .. Am a fan of your precision of work and systematic approach..
I think one Italian doctor here on XP had a research on that issue of ST thickness to vover the root surface ..and got the magic number is 2.5mm the minimume of ST thickness..
I don't know if it's relevant in here ..although you said that you went 3mm ..!!
but I noticed that the lip ligament is high a bit.. and close to the RST site ..might pulling the gingiva while healing ..and that is why it didn't heal while using the PRF as it's not resilient as STG?!!

Just a thought.. and is the quantity of of PRF play a roll of success ?
What do you think..
Regards and sorry for the length of the Q..cheers
Claude,


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Hello Howard,
Great case and management .. Am a fan of your precision of work and systematic approach..
I think one Italian doctor here on XP had a research on that issue of ST thickness to vover the root surface ..and got the magic number is 2.5mm the minimume of ST thickness..
I don't know if it's relevant in here ..although you said that you went 3mm ..!!
but I noticed that the lip ligament is high a bit.. and close to the RST site ..might pulling the gingiva while healing ..and that is why it didn't heal while using the PRF as it's not resilient as STG?!!

Just a thought.. and is the quantity of of PRF play a roll of success ?
What do you think..
Regards and sorry for the length of the Q..cheers
Claude,


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Claude you make an interesting point. I'm not sure about the 2,5mm i don't believe there is any research that will quantify this. I do it more to make space for the pontic to place pressure on the soft tissue so that it doesn't expose as a result. the lip ligament pulling could be an issue I'm not sure perhaps others could elaborate on that. The PRF for me is simply to help the epithelium grow across. The others in the group do more of this and may have a better answer


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Howard, if a PET should fail down the road after an implant was already placed, how would you manage that complication? Thanks, very nice case here!


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Great question Mathew. The roots in SRT you need to keep an eye on a regular basis. I follow these cases up 1, 3, 6 months and then yearly. if there is an issue which has been very rare in my cases and as I get better so it becomes even rarer. Socket shield usually fails or creates problems before integration check while SRT can fail in the long term. if I have an infection of the shield we either remove and graft or reduce the shield and cover with soft tissue. If a SRT has an apical infection you have a few options depending on the amount of apical infection. 1. extract through a buccal flap and graft to prevent too much collapse. 2. remove the bridge and do an endo on the tooth , 3. remove the bridge and convert the SRT to a pontic shield.
The best way to prevent this is to make sure of vitality if you are doing a vital SRT and if not then either an endo but I generally do a pontic shield if I don't get a nice healthy bleeding nerve when I section the crown off. If I get no bleeding or hyperemia then I pontic shield and that way you have less problems. I hope this helps.


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Great, thanks Howard


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Brasseler
KLS Martin