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Table of Contents
CASE REPORT
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 91-94

Socket shield technique, a novel approach for the esthetic rehabilitation of edentulous maxillary anterior alveolar ridges: A special case file


1 Consultant Periodontist and Implantologist, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India
2 Department of Periodontology and Implantology, Narsinhbhai Patel Dental College and Hospital, Visnagar, Gujarat, India
3 Department of Oral and Maxillofacial Surgery, Bharati Vidyapeeth (Deemed to be University) Dental College and Hospital, Sangli, Maharashtra, India
4 Departments of Conservative Dentistry and Endodontics, Saraswati Dhanwantari Dental College and Hospital and Post-graduate Research Institute, Parbhani, Maharashtra, India
5 Department of Prosthodontics and Crown and Bridge, NIMS Dental College and Hospital, Jaipur, Rajasthan, India
6 Oral Medicine and Radiology, Saraswati Dhanwantari Dental College and Hospital and Post-graduate Research Institute, Parbhani, Maharashtra, India

Date of Web Publication13-Jan-2020

Correspondence Address:
Dr. Sandeep Patel
Consultant Periodontist and Implantologist, 29-D, Rameshwar Apartments, Murar Road, Mulund (W), Mumbai - 400 080
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_23_19

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   Abstract 

Implant placement in the maxillary anterior region has always been challenging for the implantologists. Different levels of gingival display, along with the uncertainty of soft- and hard-tissue changes postextraction make things highly predictable in this part of the alveolar ridges. This difficulty is augmented by the patient's desire to have teeth in this esthetic zone immediately. Researchers have devised certain techniques to address this issue and one such method of an immediate, highly esthetic rehabilitation is called the socket shield technique (SST). The use of cortical engagement in this region along with SST gives the operator an opportunity to immediately load the prosthesis with optimal esthetic outcomes. Another challenging issue secondary to implant therapy is peri-implant infections, including the more common peri-implantitis. The presence of rough implant surfaces, when exposed to the oral environment, leads to the formation of a kind of nidus, which, further, feeds soft- and hard-tissue loss. The presence of a periapical pathology from previous dentition may also infect the implant surface. An attempt was made in this case to utilize the SST along with the provision of smooth-surfaced dental implants, stabilized with cortical engagement, for the replacement of missing maxillary anterior teeth.

Keywords: Edentulous, esthetic rehabilitation, immediate loading, implant prosthesis, maxillary anterior alveolar ridges, novel approach, peri-implant infections, peri-implantitis, smooth surface dental implants, socket shield technique


How to cite this article:
Patel S, Parikh H, Kumar B B, Das M, Pandita A, Nayyar AS. Socket shield technique, a novel approach for the esthetic rehabilitation of edentulous maxillary anterior alveolar ridges: A special case file. J Dent Implant 2019;9:91-4

How to cite this URL:
Patel S, Parikh H, Kumar B B, Das M, Pandita A, Nayyar AS. Socket shield technique, a novel approach for the esthetic rehabilitation of edentulous maxillary anterior alveolar ridges: A special case file. J Dent Implant [serial online] 2019 [cited 2020 Jul 13];9:91-4. Available from: http://www.jdionline.org/text.asp?2019/9/2/91/275698


   Introduction Top


Edentulous maxillary anterior region poses a challenge to the operator as different levels of lip line along with different tissue biotypes make postextraction tissue changes highly unpredictable.[1] The existing literature is devoid of studies supporting complete tissue preservation and immediate implant placement. Postextraction tissue changes are always expected and unpredictable, and this uncertainty is best understood by the classification given by Kan et al.[2] which describes the relationship between the housing of roots in the alveolar bone and the eventual resorption patterns expected or seen. Historically, attempts have been made to control these changes using the pontic shield technique and the root submergence technique. Socket shield technique (SST) is one such procedure toward this effort of complete tissue preservation and immediate implant placement.[3] This procedure, which forms a protective shield, helps achieve periodontal ligament-mediated ridge preservation. The SST was first described by Hürzeler et al.,[4] which consists of leaving a root fragment when extracting the tooth, specifically, the vestibular portion of the coronal third of the root. Socket shield principle states that root fragments intentionally retained in proximity to or in contact with the dental implants help to preserve or promote the buccal and/or proximal crestal alveolar bone.


   Case Report Top


The present case involves a male patient who reported to the Department with a chief complaint of grossly destructed teeth in upper front tooth region [Figure 1]. The medical history was not conclusive. The patient was advised cone-beam computed tomography for diagnosis which revealed periapical lesion in relation to the endodontically treated tooth in the maxillary anterior region [Figure 2]. The presence of peri-apical lesion was explained to the patient. After discussing the peri-apical lesion, esthetic consideration and need for immediate restoration of the lost teeth, the treatment mode decided was the placement of cortically engaged, smooth-surfaced implants using the so-recognized SST. Following the required steps, the palatal aspect of the tooth was carefully removed using a periotome [Figure 3]a and [Figure 3]b. Slight elevation of the buccal and palatal flaps was performed to allow proper access for carrying-out curettage of the periapical lesions. Curettage was performed using curettes and rotary degranulation burs followed by copious irrigation with betadine and saline. Osteotomy was performed and a 2 mm drill was used to perforate the nasal floor. Nasal floor engagement provided rigid stabilization to the implant. The implant system used was BCES EX®. This implant system is designed to engage the fresh extraction sockets. It has a tapered design with smooth surface and active threads [Figure 4]. Three implants were placed ensuring that they engage the nasal floor. Care was taken not to pressurize socket-shield during the placement of implants. Immediately after implant placement, impressions were made for the final prosthesis. According to the principles of immediate loading of the implants using smooth-surfaced implants with cortical engagement, a rigid splinting among the implants is advisable, which was achieved in the present case by providing immediate final prosthesis using the metal framework as a rigid splint [Figure 5]. Rigid splinting of implants prevents micromovement of the implants during the healing phases in implant therapy. The soft tissues showed some degree of inflammation [Figure 6] on the day of cementation as they were manipulated during degranulation the peri-apical pathology. The patient was recalled after 1 week and then, after 1 and 6 months to evaluate the soft tissues as well as the occlusion. At the end of 6 months, the patient reported no discomfort and was satisfied with the esthetic outcome [Figure 7] of the entire procedure.
Figure 1: Grossly destructed teeth in maxillary anterior region

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Figure 2: Cone beam computed tomography revealing peri-apical lesion in relation to the endodontically treated tooth in maxillary anterior region

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Figure 3: (a) Palatal aspect of tooth being removed using a periotome; (b) Extracted tooth

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Figure 4: BCES EX® implant system with a smooth surface implant revealing active threads for cortical engagement

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Figure 5: Immediate final prosthesis provided in the present case using metal framework as a rigid splint

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Figure 6: Immediate post-cementation view

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Figure 7: Successful clinical and esthetic outcome in the treated case as revealed on the follow-up visit of the patient after 6 months

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   Discussion Top


SST has successfully demonstrated its potential to preserve the buccal tissues with predictable esthetic outcomes.[4],[5],[6] This approach helps eliminate the ridge contour changes associated with extraction and facilitates immediate implant placement. The literature, though, is devoid in this aspect with sufficient cases and studies done in this regard emphasizing long-term results, though, the ones published have shown promising results with high success rates.[7],[8],[9],[10] The procedure involves a learning curve but can be mastered if the protocol is technically followed.[11] Other methods involving ridge preservation and maintenance involve the use of various biomaterials to obtain results, though, that, again, is highly unpredictable. Such techniques and procedures may also demand added surgical intervention, which leads to inadvertent tissue manipulation and added postsurgical morbidities. The noted advantages of the so-called SST lies in the fact that the use of biomaterials can be avoided which drastically reduces the cost and treatment times. This may also improve the chances of patient acceptance, which was particularly observed in the present case.[12] The use of biomaterials also is not requisite and recommended in all cases as there is plethora of literature supporting evidence of successful clinical outcomes without the use of such materials.[13] The present case report, also, describes the successful use of SST with smooth-surfaced implants using nasal cortical engagement. The technique of cortical bone engagement has been well-documented in the literature. The implants used in this case were machined, smooth-surfaced implants with no surface roughness. The presence of such surface gives the operator the confidence that the implant will stay unaffected even if they are exposed to oral environment and/or residual peri-apical infections. Unfortunately, with the use of conventional, surface-treated implants, year by year, the prevalence of peri-implantitis reported in the literature has increased alarmingly. The existing prevalence reported for such cases in case of surface-treated implants has been calculated between 11.3% and 47.1%.[14] Clinicians have successfully placed implants in the presence of periapical lesions, though, such conditions have been documented as the cause of retrograde infection on the implant surface.[15] The use of smooth-surfaced implants may prevent such a scenario as well as promote uneventful healing of the lesion postimplant placement.[16] Rigid splinting with the help of prosthesis along with cortical engagement permits the operator to immediately place and load these implants, though, the existing literature is almost lacking with very few attempts made using SST along with immediate implant placements with the above-mentioned design.[17],[18] More cases along with long-term studies are, thus, mandated to collect evidence to support this type of treatment approach.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Araújo MG, Lindhe J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. J Clin Periodontol 2005;32:212-8.  Back to cited text no. 1
    
2.
Kan JY, Roe P, Rungcharassaeng K, Patel RD, Waki T, Lozada JL, et al. Classification of sagittal root position in relation to the anterior maxillary osseous housing for immediate implant placement: A cone beam computed tomography study. Int J Oral Maxillofac Implants 2011;26:873-6.  Back to cited text no. 2
    
3.
Gluckman H, Du Toit J, Salama M. The pontic-shield: Partial extraction therapy for ridge preservation and pontic site development. Int J Periodontics Restorative Dent 2016;36:417-23.  Back to cited text no. 3
    
4.
Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis N, Fickl S. The socket-shield technique: A proof-of-principle report. J Clin Periodontol 2010;37:855-62.  Back to cited text no. 4
    
5.
Bäumer D, Zuhr O, Rebele S, Schneider D, Schupbach P, Hürzeler M. The socket-shield technique:First histological, clinical, and volumetrical observations after separation of the buccal tooth segment – A pilot study. Clin Implant Dent Relat Res 2015;17:71-82.  Back to cited text no. 5
    
6.
Glocker M, Attin T, Schmidlin PR. Ridge preservation with modified “socket-shield” technique: A methodological case series. Dent J 2014;2:11-21.  Back to cited text no. 6
    
7.
Mitsias ME, Siormpas KD, Kotsakis GA, Ganz SD, Mangano C, Iezzi G. The root membrane technique: Human histologic evidence after five years of function. Biomed Res Int 2017;7269467:1-8.  Back to cited text no. 7
    
8.
Gluckman H, Salama M, Du Toit J. A retrospective evaluation of 128 socket-shield cases in the esthetic zone and posterior sites: Partial extraction therapy with up to 4 years follow-up. Clin Implant Dent Relat Res 2018;20:122-9.  Back to cited text no. 8
    
9.
Bramanti E, Norcia A, Cicciù M, Matacena G, Cervino G, Troiano G, et al. Postextraction dental implant in the aesthetic zone, socket shield technique versus conventional protocol. J Craniofac Surg 2018;29:1037-41.  Back to cited text no. 9
    
10.
Abadzhiev M, Nenkov P, Velcheva P. Conventional immediate implant placement and immediate placement with socket-shield technique: Which is better. Int J Clin Med 2014;1:176-80.  Back to cited text no. 10
    
11.
Petsch M, Spies B, Kohal RJ. Socket shield technique for implant placement in the esthetic zone: A case report. Int J Periodontics Restorative Dent 2017;37:853-60.  Back to cited text no. 11
    
12.
Saeidi Pour R, Zuhr O, Hürzeler M, Prandtner O, Rafael CF, Edelhoff D, et al. Clinical benefits of the immediate implant socket shield technique. J Esthet Restor Dent 2017;29:93-101.  Back to cited text no. 12
    
13.
Siormpas KD, Mitsias ME, Kontsiotou-Siormpa E, Garber D, Kotsakis GA. Immediate implant placement in the esthetic zone utilizing the “root-membrane” technique: Clinical results up to 5 years post-loading. Int J Oral Maxillofac Implants 2014;29:1397-405.  Back to cited text no. 13
    
14.
Koldsland OC, Scheie AA, Aass AM. Prevalence of peri-implantitis related to severity of the disease with different degrees of bone loss. J Periodontol 2010;81:231-8.  Back to cited text no. 14
    
15.
Ayangco L, Sheridan PJ. Development and treatment of retrograde peri-implantitis involving a site with a history of failed endodontic and apicoectomy procedures: A series of reports. Int J Oral Maxillofac Implants 2001;16:412-7.  Back to cited text no. 15
    
16.
Baron M, Haas R, Dörtbudak O, Watzek G. Experimentally induced peri-implantitis: A review of different treatment methods described in the literature. Int J Oral Maxillofac Implants 2000;15:533-44.  Back to cited text no. 16
    
17.
Lazarov A. Immediate functional loading: Results for the concept of the strategic implant®. Ann Maxillofac Surg 2019;9:78-88.  Back to cited text no. 17
[PUBMED]  [Full text]  
18.
Ihde S, Ihde AA. Diagnostics and Treatment Plan for the Work with the Strategic Implant®. Munich: International Implant Foundation Publishing; 2017.  Back to cited text no. 18
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]



 

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