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    Socket Shield Technique with and without Implant Placement to Maintain Pink Aesthetics

    Case Report

     

    Haseeb H. Al-Dary

    Private Practice, Amman – Jordan | dary_haseeb@yahoo.com

     

     

    ABSTRACT

    Keeping the tune and the shape of the hard and soft tissues after tooth/teeth extraction happens to be an issue of a great concern in aesthetic and restorative dentistry.

     

    Socket preservation was adopted by many clinicians to try to prevent the volumetric changes of the hard and soft tissues, the thing that would lead to a satisfying aesthetic outcome after restoration.

     

    Many socket preservation techniques were used starting from atraumatic extraction ending with bone augmentation to keep the bone from being subjected to remodeling, but still keeping the tooth in the socket and maintaining the system of periodontium seems to be the golden standard that would never be superimposed.

     

    Root submergence then Socket techniques were suggested to keep the system of periodontium undisrupted the thing that would keep the shape of the gum unchanged giving the optimal aesthetic results.

     

    In this case presentation the socket shield and a technique modified from the root submergence were used trying to get the desired emergence profile.

     

    KEYWORDS

    Partial extraction, Buccal fragment, Socket shield, Modified socket shield.

     

     

    INTRODUCTION

    Many materials and methods have been mentioned in the literature to maintain or preserve the fresh extraction socket especially to support the relatively thin buccal plate of the bone from getting collapsed, these include Immediate implants after extraction protocol,1,2 also bone substitute materials have been used,3-7 and/or barrier membranes,8,9 but those procedures have the ability to maintain the ridge dimension to a certain amount.5,10,11

     

    However, a complete preservation and/or entire regeneration of the extraction socket have not been documented yet.12

     

    The (Root Submergence Technique) RST was described by Salama et al. By maintaining the root in the socket, a much greater amount of surrounding tissue may be preserved than with the other commonly used socket preservation techniques, which almost always leads to crestal bone resorption and thus reduction of the height of the interdental papillae and width of the edentulous ridge. RST instead maintains the natural attachment apparatus of the tooth in the pontic site, which in turn allows for complete preservation of the alveolar bone frame.13

     

    On the other hand instead of leaving the whole root in RST. The Buccal fragment of the remaining root is being left in socket shield technique after a root sectioning is performed from the mesial to distal side of the remaining root as to separate it into 2 fragments, Buccal and Palatal/Lingual. The buccal root fragment is being left while the rest of the tooth is being extracted,12 Leaving a space to place the implant behind it. Or it can be left without placing an implant also, but the ridge would be saved from being subjected to bone remodeling after extraction.

     

    CASE REPORT

    A 60 years old male patient stepped into the office to restore teeth number 24 & 25, tooth number 23 was restored with a loose crown.

     

    Medical history of the patient was taken, non-smoker, in a good general condition, no systemic illness, not on a regular medication.

     

    Dental examination (Figures 1-3) revealed that tooth number 23 was restored with a loose richmond crown on a decayed root, teeth number 24 & 25 were decayed and non-restorable, tooth number 26 was decayed, non-vital and restorable, all teeth were asymptomatic.

     

    Periodontal examination revealed no pockets, no inflammation, no gum recession, no bone resorption around teeth number 23, 24 & 25 teeth were healthy non mobile ones.

     

    Radiographic examination (Figure 4) revealed a root canal treated 23, 24, & 25, with no periapical lesions.

    Many treatment plans was discussed with the patient, and due to financial reasons only one implant was accepted to be received by him.

     

    The patient was educated about Socket Shield Technique and the Modified Socket Shield Technique and he accepted to have the procedures being done using these techniques.

     

    (Fig. 1) Pre-operative lateral view showing number tooth 23 crown unremoved & teeth 24,25 unrestored

     

     

    (Fig. 2) Pre-operative frontal view of same site to give an idea about the soft tissue contour

     

     

     

    (Fig. 3) Pre-operative occlusal view of same site

     

     

    (Fig. 4) Pre-operative Panoramic radiograph

     

     

     

     

    Local anaesthesia was applied, richmond crown over tooth number 23 was removed, then tooth sectioning was performed mesio-distaly, palatal fragment was luxated then removed atraumatically, the buccal fragment was reduced at a bucco-lingual direction and prepared to take a semilunar shape leaving the rest of the socket room for the implant to be inserted (Figure 5), the remaining fragment was reduced from coronal to reach the gingival sulcus, osteotomy was performed, and a Euroteknica implant was inserted 2 millimeters bellow the coronal edge of the fragment and touching it, temporary abutment was then removed and replaced by a cover screw. (Figure 6)

     

    (Fig. 5) Occlusal view of the site showing tooth 23 after performing socket shield technique leaving buccal fragment of tooth 23 intact

     

     

    (Fig. 6) Occlusal view showing the implant being placed in the socket of tooth 23

     

     

     

     

    Same procedure of socket shield was performed on teeth number 24 & 25 but without implant placement in the resulting sockets (Figures 7-10).

     

    (Fig. 7) Occlusal view showing teeth 24,25 after performing socket shield technique

     

     

    (Fig. 8) Post operative frontal view

     

     

    (Fig. 9) The removed richmond crown and palatal teeth fragments after being extracted from teeth 23,24,25

     

     

    (Fig. 10) Post operative panoramic radiograph showing the implant in place

     

     

     

     

    A root canal treatment was done on tooth number 26.

     

    After more than 3 months has elapsed implant abutment was then attached to the implant (Figures 11,12) a 4 unit bridge connecting the implant and tooth number 26 was then fabricated to replace the missing 23,24,25 and to restore tooth number 26 (Figures 13-15)

     

    (Fig. 11) Occlusal view showing implant abutment attached to the implant, and healing of sockets of teeth 24,25 with socket shield coronal tips before being reduced

     

     

     

     

    (Fig. 12) Frontal view showing that the soft tissue contour to compare it with the frontal preoperative one

     

     

     

    (Fig. 13) Occlusal view after the bridge is delivered

     

     

     

    (Fig. 14) Lateral view after the bridge is delivered

     

     

    (Fig. 15) Panoramic radiograph after the delivery of the bridge

     

     

     

     

    DISCUSSION

    Giorgio Pagni et al. concluded that post-extraction alveolar ridge resorption is an inevitable process.14

    In the literature, many techniques have been used to overcome this negative consequence of tooth extraction on the bony socket of teeth, like Immediate implant placement which does not stop the process of socket and ridge remodeling, and on its own, it proves problematic in controlling alveolar bone resorption1,2 also graft materials have been used3-7 and/or barrier membranes,8,9 However, a complete preservation and/ or entire regeneration of the extraction socket have not been documented yet.12

     

    Salama et al. concluded that it’s safe to assume that implants will never surpass the natural tooth’s ability to preserve the surrounding bone and soft tissue height, this came up with the idea of (Root submergence technique) of Salama which is leaving the root of a tooth in the socket to preserve bone and soft tissue dimensions13 provided that the root is not infected or mobile because it might be felt that the roots may act as a mobile foreign body and become a nidus for infection or migration.15-17

     

    Salama et al. also concluded that root submergence technique also eliminates the risk of caries and periodontitis.13

     

    Socket shield technique was first described by Hurzelur et al., in his experiment on one beagle dog, and he concluded that retaining the buccal aspect of the root during implant placement does not appear to interfere with osseointegration and may be beneficial in preserving the buccal bone plate.

     

    Hurzelur applied an enamel matrix derivate between the root and the implant which explain the newly formed cementum on the lingual side of root fragment and the surface of the implant on this side.12

     

    Bauer et al. conducted a study in which they have separated the Buccal Tooth Segment -shield- and they have not used the enamel matrix derivate they concluded that the applied modification seems not to interfere with implant osseointegration and may still preserve the buccal plate. It may offer a feasible treatment option for vertically fractured teeth.18

     

    A draw back of Socket Shield Technique that it’s associated with certain risks, such as the formation of a peri-implant periodontal membrane19 or the development of peri-implant infections, as well as resorption associated with the usual biological long-term complications that may occur. These occur especially in the presence of pre-exiting or developing periodontal or endodontic infections or inflammations of the retained tooth fragments.19

     

    On the other hand, root submergence technique needs a soft tissue grafting over the top of the submerged roots13 the thing that complicates the procedure, and needs a donor site to take the soft tissue graft from, with the possibility of soft tissue graft to fail, which exposes the root to the oral cavity environment with the possibility of the tooth structure to get decayed.

     

    In socket shield technique without Implant placement the shield acts same as root submergence technique but no need for soft tissue graft, the fragment is being covered by healing process of the socket and the exposed small tip of the fragment may be reduced by round bur, reducing the possibility of caries.

     

    Connecting Teeth to Implants was subjected to a great debate by clinicians, due to differences in mobility patterns between a tooth and an implant which could result in the tooth being depressed into the socket, which might cause the prosthesis to be cantilevered off the implant. Theoretically, this could increase stress on the implant and lead to both technical and biologic complications.20-22

     

    Gary Greenstein et al. concluded that despite the fact that the potential mobility between a tooth and an implant are different and the precise etiology of tooth intrusion is unknown, it is reasonable to rigidly connect a tooth to an implant. This is particularly true if the anatomy dictates that placement of an additional implant(s) is contraindicated or if there are economic concerns.23

     

    CONCLUSION

    The remodeling process, which leads to horizontal and vertical bone loss, which take place after tooth extraction, can be prevented and avoided by leaving the periodontal system untouched, this can be achieved by leaving the root in its socket un-extracted, in the so called (root submergence technique).

     

    The buccal plate of the socket can also be preserved from being resorbed by leaving a fragment of the root- the buccal part- intact in its socket whether an implant is placed behind the root fragment (socket shield technique) or the root fragment is left without placing an implant behind the fragment (modified socket shield technique) the thing that would enhance the aesthetic outcome of the future crown bridge work.

     

    REFERENCES

    Botticelli D, Berglundh T & Lindhe J. Hard-tissue alterations following immediate implant placement in extraction sites. Journal of Clinical Periodontology. 2004;31:820-8.

    Araújo M, Sukekava F, Wennstrom J & Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: an experimental study in the dog. Journal of Clinical Periodontology. 2005;32:645-52.

    Carmagnola D, Adriaens P & Berglundh T. Healing of human extraction sockets filled with Bio-Oss. Clinical Oral Implants Research. 2003;14:137-43.

    Nevins M, Camelo M, De Paoli S, Friedland B, Schenk R.K, Parma-Benfenati S, Simion M, Tinti C & Wagenberg B. A study of the fate of the buccal wall of extraction sockets of teeth with prominent roots. International Journal of Periodontics and Restorative Dentistry. 2006;26:19-29.

    Fickl S, Zuhr O, Wachtel H, Bolz W & Huerzeler M. Hard tissue alterations after various socket preservation techniques – an experimental study in the beagle dog. Clinical Oral Implants Research. 2008a;19:1111-8.

    Fickl S, Zuhr O, Wachtel H, Stappert C, Stein J & Hurzeler M.B. Dimensional changes of the alveolar ridge contour after different socket preservation techniques. Journal of Clinical Periodontology. 2008b;35:906-13.

    Araújo M, Linder E & Lindhe J. Effect of a xenograft on early bone formation in extraction sockets: an experimental study in dog. Clinical Oral Implants Research. 2009;20:1-6.

    Lekovic V, Carmargo P, Klokkevold P, Weinlaender M, Kenney E, Dimitrijevic B & Nedic M. Preservation of alveolar bone in extraction sockets using bioabsorbablemebranes. Journal of Periodontology. 1998;69:1044-9.

    Lekovic V, Kenney E, Weinlaender M, Han T, Klokkevold P, Nedic M & Orsini M. A bone regenerative approach to alveolar ridge maintenance following tooth extractions. Report of 10 cases. Journal of Periodontology. 1997;68:563-70.

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    Araújo M, Linder E & Lindhe J. Effect of a xenograft on early bone formation in extraction sockets: an experimental study in dog. Clinical Oral Implants Research. 2009;20:1-6.

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    M. Salama, T. Ishikawa, H. Salama, A. Funato, D. Garber. Advantages of the Root Submergence Technique for Pontic Site Development in Esthetic Implant Therapy. The International Journal of Periodontics & Restorative Dentistry. 2007;27(6):521-7.

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    Johnson DL, Kelly JF, Flinton RJ, et al. Histologic evaluation of vital root retention. J Oral Surg. 1974;32:829.

    Whitaker DD, Shankle RJ. A study of the histologic reaction ofsubmerged root segments. Oral Surg Oral Med Oral Patho. 1974;l37:919.

    Plata RL, Kelln EE, Linda L. Intentional retention of vital submergedroots in dogs. Oral Surg Oral Med Oral Pathol. 1976;42:100.

    Daniel Bäumer, Otto Zuhr, Stephan Rebele, David Schneider, Peter Schupbach, Markus Hürzeler. The Socket-Shield Technique: First Histological, Clinical, and Volumetrical Observations after Separation of the Buccal Tooth Segment –A Pilot Study, Clinical Implant Dentistry and Related Research. 2015;17(1):71-82.

    Parlar H, Bosshardt D.D, Unsai B, Cetiner D, Haytaç C, Lang N.P. New formation of periodontal tissues around titanium implants in novel dentin chamber model. Clin. Oral Implant. Res. 2005;16:259–67.

    Lang N, Pjetursson B, Tan K, et al. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. II. Combined tooth-implant-supported FPDs. Clin Oral Implants Res. 2004;15(6):643-53.

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