The authors have declared that no competing interests exist.
Dental implant restoration is challenging procedure when it involve the esthetics zone, and since implant dentistry is prosthodontically driven procedure, care were practice in restoration of missing teeth in esthetics area which will fulfill the objective.
Extraction of teeth leave buccal plate bone unsupported and decrease the blood supply and since this plate is very thin resorption will be expected. Different attempt was done in order to prevent this sequence and create natural emergence profile around dental implant prosthesis. Socket preservation procedures were introduced, however in case of ridge deficiencies, hard and soft tissue augmentation procedures are indicated.
Socket shield technique meets the demands of minimal invasion, tissue preservation, and no need of bone substitute materials. And can be applied not only for maintaining buccal contour of an edentulous ridge but also for keeping the inter-implant soft and hard tissue
In this review paper we present different articles and case report using socket shield technique as treatment protocols and try to explore different protocol are practice in order to achieve high treatment out come with optimal success.
Tooth loss due to extraction or trauma result in absence of periodontal ligament which is associated with variable but inevitable time dependent bone resorption. reported data has shown dramatically resorption of buccal cortical plate compared by lingual one
Preservation of thin buccal cortical plate in freshly extraction socket has got many debate in literature and different methods were introduce including immediate implants after extraction protocol
Araújo and Lindhe demonstrate the physiology processes following tooth extraction, presence of osteoclasts inside socket will result in resorption of bundle bone. Anatomically buccal bone plate are thin and has more bundle bone than lingual wall resorption of hard tissue will be pronounced buccal wall than lingual
Different hypothesis on root retention have been tested clinically in order to avoid tissue alternation and minimize the influence of teeth removal in resorption process;
Salama et al
However certain risks are associated with these approaches, such as formation of pre-implant periodontal membrane
Narrative review on published articles written in English language only reporting data related to socket shield technique. Comprehensive electronic search was performed using PubMed, Google scholar, furthermore a manual search was conducted in related journals. The search terms including extraction socket preservation, socket shield, tooth retention, and tooth fragment.
The search include original articles , case report, and animal studies are including in this review, the articles have been selected after critical assessment of research. A total of 15 articles were reviewed carefully and thoroughly in order to extract the information regarding different technique of preservation of bone with an attempt to offer suggestion that clinicians could be use as guideline in the clinical practice in attempt to preserve the post extraction tissue especially in esthetically challenging cases.
Loss tooth initiate the remodeling process which it's a natural reaction of healing process, involving various degrees of alveolar bone resorption both vertical and horizontal, and more pronounced on the buccal than on the lingual aspect of the extraction socket . the bundle bone is primarily vascularized by the periodontal membrane of the tooth. Insufficient nutrition to alveolar bone leading to total or partial resorption
Retaining a root for alveolar ridge preservation and prevent tissue alterations after tooth extraction has been tested in several clinical studies. Hypothesis tested by Filippi et al
Malmgren et al, Malmgren et al, Andersson et al.
A study that confirmed regeneration of alveolar bone around endondonticllay treated teeth done by Bjorn
Root Submergence Technique (RST) reported by Salama et al
Five- case report study done by Davarpanah & Szmukler-Moncler
No study yet has evaluated partial root retention around dental implants. the aim of the article review is the evaluate the effect of partial root retention around dental implant, and present different treatment modalities have been reported.
In 2010, Hürzeler et al
The study concluded that retaining the buccal aspect of the root in conjunction with immediate implant placement is a viable technique to achieve osseointegration without any inflammatory or resorptive response.
A case report presented by Al-Dary
In his study he concluded after 5 month waiting time retaining the buccal aspect of the root in conjunction with immediate implant placement is a viable technique to achieve three dimensional positioning of the implant which requires optimal support and stability of surrounding hard and soft tissues.
Another case report conducted by same author he used a bone trephine was used to take out the remaining root, leaving an organized rounded section of the palatal/lingual extraction site with a semi lunar internal shape of the buccal aspect of the root that will receive an implant. He concluded that preparing the shield with a trephine may be of a great advantage than using fissure bur
A new case report
A case report conducted by Chen & Pan
A comparison study was performed by Abadzhiev M, Nenkov P, Velcheva P
Radiological examination immediately after implantation and on every 6 months during the next 2 years shows considerable bone loss in conventional implantation. Up to 12% in the first two years, which is equal up to 5mm. Contrary in socket-shield technique during 2 years follow up bone loss is 2% which is equal to 0.8mm.
Soft tissue volume is assessed by the quantity of attached gingiva. Almost same results are observed in this criteria as in the bone loss. 18% compared with 2% in favor of the socket-shield technique. High bone resorption leads to lack of soft tissue support and is a precondition for mucogingival surgery for increasing the volume of attached soft tissue. The result from the clinical assessment of aesthetics showed the predominant natural appearance of socket-shield treated teeth.
A Pilot Study
1. healing of all experimental sites proceeded without adverse events and without signs of inflammation.
2. Presence of a tooth fragment apically in contact with the threads of the implant. which was still attached to the buccal bone plate by periodontal ligament.
3. On the buccal alveolar crest, no osteoclastic remodeling was found.
4. Junctional epithelium ending at the cemento-enamel junction detected using a higher magnification.
In a clinical case, the same technique was applied and impressions taken for volumetric evaluation by digital superimposition. selected surface measured about 28.68 mm2. 5 month later, a mean loss of 0.66 mm in labial direction was detected. sine bone loss was not homogenous a maximum value of 1.16 mm and a minimum of 0.01 mm could be identified. more loss in the middle of the area, decreasing toward the mesial and distal.
Finally the author conclude that applied modification of this protocol have no interfere with implant osseointegration and also apply the benefit of preserving the buccal plate. It may offer a feasible treatment option for vertically fractured teeth.
Kan and Rungcharassaeng
Proximal socket shield technique (PSS) is sensitive procedure, success depends on proper case selection, the tooth an periodontal apparatus of the failing tooth must be healthy with no evidence of pathology (eg, internal/external root resorption, perforation, infection, or fracture) to avoid future complication.
They conclude that well-preserved inter-implant papilla and satisfactory esthetic results after 1-year follow up were shown in their case report. However, more studies are needed to prove the feasibility.
One study in which twenty-two fixtures were placed. and all implants were immediately loaded with a cement-retained acrylic interim restoration using "Root membrane technique". The protocol of this technique involve reduction of crown tooth structure to the level of one millimeter above the osseous crest. then the implant site were prepared by drilling through the long axis of roots. This technique implements with gradual endoroot extraction (dentinotomy- osteotomy) of the palatal aspect of the root following the drilling sequence suggested by the implant manufacturer. The ‘Root membrane technique’ (immediate implants placement and loading in the aesthetic zone of the maxilla), has been proven to be a successful alternative method for the aesthetic preservation of the tissues in this demanding area.
Long term success of implant in aesthetics zone requires prudent participation of clinicians to contribute to the knowledge base before the procedure can be routinely prescribed.
Socket shield technique is cost-effective but still technique-sensitive, success require a precise case selection to achieve successful results. Moreover, appropriate surgical treatment, restorative procedures, and clinical experience are essential when performing immediate installment of implants
This treatment modalities have advantage of, ultimate esthetic outcome imitating the natural emergence profile, preserving the soft and hard tissue volume, lack of bone loss, additional material cost, No co-morbidity, Single surgery, Applicable in sites with endodontic apical pathology. The disadvantage include not yet reliable or predictable, no long-term data available,
Long term clinical studies and observation are needed in order to achieve high esthetics result and long lasting implants outcomes using the protocol described by socket shield technique. Science and technologies guides us to desired results by using the most valuable prove in medicine.
The authors reported no conflicts of interest related to this study.