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Table of Contents
CASE REPORT
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 58-62

Socket-shield technique for immediate implant placement with immediate and delayed loading method: Two case reports


1 Dental Centre, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India
2 Division of Periodontology, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission24-Dec-2020
Date of Decision11-Oct-2021
Date of Acceptance11-Oct-2021
Date of Web Publication16-Jun-2022

Correspondence Address:
Dr. Oliver Jacob
Dental Centre, INHS Kalyani, Gandhigram PO, Visakhapatnam - 530 005, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdi.jdi_35_20

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   Abstract 

Immediate implant placement is becoming a routine procedure in esthetic dentistry. The need for placing the implant immediately post extraction helps reduce the alveolar ridge resorption and also maintain good soft-tissue contours post placing the implant and during rehabilitation. However, a cause of concern occurs when the buccal cortical plate is thin, especially in the upper anterior region. This poses a direct implication in the maintenance of primary stability and buccal contour of both hard and soft tissues, thus compromising esthetics. The socket-shield technique (SST) is a recent advancement in placing immediate implant post extraction. The maintenance of the buccal root section helps retain both the compromised buccal cortical plate and soft-tissue contour, thus providing a better esthetic profile. In view of the same, two patients were provided immediate implants with SST; one with immediate loading of implant and other with delayed loading method, and postoperative radiographic analysis was carried out to evaluate bone density around the implant.

Keywords: Delayed loading, immediate implants, immediate loading, root membrane technique, socket-shield technique


How to cite this article:
Jacob O, Kosala M, Sharma D, Nanavati GD. Socket-shield technique for immediate implant placement with immediate and delayed loading method: Two case reports. J Dent Implant 2022;12:58-62

How to cite this URL:
Jacob O, Kosala M, Sharma D, Nanavati GD. Socket-shield technique for immediate implant placement with immediate and delayed loading method: Two case reports. J Dent Implant [serial online] 2022 [cited 2022 Jul 7];12:58-62. Available from: https://www.jdionline.org/text.asp?2022/12/1/58/347670


   Introduction Top


Tooth extraction causes increased resorption and remodeling of the soft and hard tissues. This remodeling poses a challenge for the esthetic and prosthetic rehabilitation due to the compromised vertical and horizontal dimensions of the hard and soft tissues. It requires training and clinical skills to augment the same before implant placement in the anterior region.

This increased demand led to the alternative of immediate implants, wherein implants were placed immediately post extraction of the teeth.[1] However, placing immediate implants does not prevent the resorption of buccal bundle bone. The presence of thin buccal bundle bone and resorption of buccal bone lead to reduced horizontal and vertical bone dimensions, thus compromising the implant stability and esthetics.[2] The socket-shield technique (SST) was described about 10 years back by Bäumer et al., wherein a buccal coronal fragment of the root was deliberately left while extracting the teeth and subsequently placing an immediate implant. This method is popularly known as root membrane technique (RMT).[3] In this technique, the buccal section of the root is retained to prevent resorption and remodeling of the buccal hard tissues and maintain the soft-tissue contours. The tooth planned for extraction with immediate implant placement is sectioned mesiodistally such as to separate the buccal and palatal halves which can be extracted without trauma, leaving the buccal section in situ. The implant is subsequently placed palatally, and the remaining root section is contoured using long shank round burs. This facial section of the root retains its attachment with the buccal bundle bone and provides ridge support for the implant buccally.

The aim of these case reports was to determine and compare the bone density using post placement of immediate implants with RMT with immediate loading and delayed loading methods.


   Case Reports Top


Case 1 (immediate loading technique)

A 24-year-old male reported to the outpatient department (OPD) with the chief complaint of a fractured front tooth. On clinical evaluation, a fractured tooth # 21 was present with a root fragment approximately 4 mm in width, and radiographic evaluation showed minimal buccal bone, approximately 0.4–0.8 mm [Figure 1]. Immediate implant placement with RMT was planned, and the patient was explained about the modality. Consent of the patient was obtained for placing an immediate implant with RMT and immediate loading method.
Figure 1: Case 1 clinical presentation and radiological assessment

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After Phase I therapy involving scaling, oral hygiene instructions, and routine hematological investigations, the surgical phase was planned. For placing the implant immediately after extraction, a full-thickness mucoperiosteal flap was raised to expose the root. Using long shaft diamond cutting burs under profuse irrigation, the root was sectioned mesiodistally into facial and palatal halves, and the palatal half was extracted atraumatically using peristomes [Figure 2]. The implant was placed in the palatal aspect of the facial half of the retained root piece, and a composite bone substitute (hydroxyapatite and β-tricalcium phosphate [TCP]) was placed in the socket space [Figure 3]. The abutment was then fixed and sutures were placed to close the flap [Figure 4]. Impressions were made using silicon putty and light body material.
Figure 2: Case 1 full-thickness mucoperiosteal flap raised and extraction of the palatal root section retaining the buccal root section

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Figure 3: Case 1 placement of implant

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Figure 4: Case 1 placement of the abutment for immediate impression making and loading protocols

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The abutment was removed and replaced with a gingival former. Temporization was done using an acrylic crown [Figure 5]. After 3 days, the final restoration was provided with a ceramic crown [Figure 6]. Postoperatively, the patient was reviewed every 2 months. A radiographic assessment was carried out at the end of 7 months post placement of the implant and immediate rehabilitation showed bone density in the facial aspect of the implant around 1636 ± 458 HU [Figure 7].
Figure 5: Case 1 temporization with acrylic crown

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Figure 6: Case 1 permanent rehabilitation with a ceramic crown

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Figure 7: Case 1 radiographic assessment 7 months postoperative

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Case 2 (delayed loading technique)

A 25-year-old male reported to the OPD with the chief complaint of a fractured front tooth. On clinical evaluation, a fractured tooth #21 was present, with part of the facial root fragment present. Radiographic evaluation showed minimal buccal bone [Figure 8]. An Immediate implant placement with RMT with delayed loading was planned. The patient was explained about the modality, and consent of the patient was obtained for the procedure.
Figure 8: Case 2 clinical presentation and Case 2 radiological assessment

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Post Phase I therapy and routine hematological investigations, the surgical phase was planned. During the surgical phase of the treatment, a full-thickness mucoperiosteal flap was raised to expose the root. The root was sectioned mesiodistally into facial and palatal halves using long shaft diamond cutting burs under profuse irrigation, and the palatal half was extracted atraumatically using peristomes. The implant was placed in the palatal aspect of the facial half of the retained root piece, and a composite bone substitute (hydroxyapatite and β-TCP) was placed around the remainder of the socket space. The surgical phase till the placement of the implant was similar to that described previously. Sutures were placed post placement of the healing screw.

Postoperatively, the patient was reviewed every 2 months. After 7 months of the surgical procedure, prosthetic rehabilitation with a ceramic crown was done, and a radiographic assessment was carried out [Figure 9]. The radiographic assessment showed bone density in the facial aspect of the implant around 2508 ± 267 HU.
Figure 9: Case 2 permanent rehabilitation with ceramic crown and radiographic assessment 7 months postoperative

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   Discussion Top


The residual alveolar bone undergoes resorption following the removal of the tooth.[1] Preserving roots have been an option to maintain and reduce resorption of the residual ridge post extraction of teeth.[3] There are reports that the retention of roots, both vital and endodontically treated, helps preserve the alveolar ridge form.[4] Retaining of roots around implants has shown periodontal and cementum regeneration over the implant surfaces.[5] The innovative technique of placing implants in close contact with retained roots was developed by Bäumer et al. in 2010 who coined the term SST to this method of immediate implant placement.[3] Histological studies by Hürzeler showed cementum formation around the implants, and few studies showed the development of fibrous capsules around the implants.[6]

The RMT or SST provides for the preservation of the buccal bone with a simple technique. The lingual cortex being more thick is less prone to resorption; hence, implants are placed lingual to the retained root fragment on the buccal side to prevent the resorption and remodeling of the buccal bone.[7] The retained buccal root section prevents perforation of the soft tissue during the healing phase and also allows the retention of the facial soft tissue profile, contour, and esthetics around the implants. Preserving the supracrestal fibers permit better esthetics with the maintenance and preservation of the papilla.[8] A recent human histological study confirmed and demonstrated osseointegration between the implant surface and the root dentin surface of the retained root fragment.[9] However, a recent prospective case series study showed mild resorption patterns of 0.7 mm after 6 months of using RMT for immediate implant placement.[10]

Most clinical research has been case reports and series evaluating the resorption of bone and levels of marginal bone around the implants post RMT. The consequence of immediate or delayed loading of the implants has not been assessed or compared while using RMT for immediate implant placement. This case report compared the radiological variation in the buccal bone densities of two cases treated using an immediate implant with RMT or SST. Postoperative evaluation of the bone densities buccal to the implant where the root fragment was retained was analyzed using cone-beam computed tomography systems. Cone-beam CT scan evaluation showed higher HU values on the buccal aspect indicating greater osseo-density around the implant with delayed loading protocol as compared to that of implant with immediate loading protocol. This can be attributed to the formation of the cementum around the implants in the area near the root fragment and increased bone formation with reduced osteoclastic activity, as demonstrated by Bäumer et al. in 2010.[3]


   Conclusion Top


Esthetics and ridge preservation is a major concern for many implantologists while managing anterior teeth extractions and immediate implant placement. SST or RMT was an innovative protocol for retaining both the buccal bundle bone and soft tissue contour and esthetics around immediate implants. Loading protocols for the same have not been well established in such cases with relevant controlled trials. The above case reports can provide an insight into the loading protocols and help further establish the osseointegration of these immediate implants place using this novel technique.

Further controlled trials and radiological analyses are essential to establish this procedure as a standard for immediate implant placement in the anterior region.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Araújo MG, Sukekava F, Wennström JL, Lindhe J. Ridge alterations following implant placement in fresh extraction sockets: An experimental study in the dog. J Clin Periodontol 2005;32:645-52.  Back to cited text no. 1
    
2.
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. 2
    
3.
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. 3
    
4.
Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the root submergence technique for pontic site development in esthetic implant therapy. Int J Periodontics Restorative Dent 2007;27:521-7.  Back to cited text no. 4
    
5.
Buser D, Warrer K, Karring T. Formation of a periodontal ligament around titanium implants. J Periodontol 1990;61:597-601.  Back to cited text no. 5
    
6.
Parlar A, Bosshardt DD, Unsal B, Cetiner D, Haytaç C, Lang NP. New formation of periodontal tissues around titanium implants in a novel dentin chamber model. Clin Oral Implants Res 2005;16:259-67.  Back to cited text no. 6
    
7.
Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: A clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent 2003;23:313-23.  Back to cited text no. 7
    
8.
Filippi A, Pohl Y, von Arx T. Decoronation of an ankylosed tooth for preservation of alveolar bone prior to implant placement. Dent Traumatol 2001;17:93-5.  Back to cited text no. 8
    
9.
Schwimer C, Pette GA, Gluckman H, Salama M, Du Toit J. Human histologic evidence of new bone formation and osseointegration between root dentin (Unplanned Socket-Shield) and dental implant: Case report. Int J Oral Maxillofac Implants 2018;33:e19-23.  Back to cited text no. 9
    
10.
Troiano M, Benincasa M, Sánchez P, Guirado JL. Bundle bone preservation with root-T-belt: Case study. Ann Oral Maxillofac Surg 2014;2:7.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]



 

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