Introduction
- Loss of blood supply from periodontal ligament has been identified as major etiology for ridge resorption (KOTSAKIS 2014)
- In Implant-Biologic interphase, There is lack of blood supply
- Gradual degradation of Peri-implant tissue, Difficulty to maintain tissue volume and integrity.
- Ridge preservation techniques limit but do not prevent ridge resorption.
- Biologic ratio of Supra-Implant mucosa (NOZAWA 2006)
- Vertical : Horizontal = 1 : 1.5
-No differences in biologic width to height ratio in terms of Implant diameter
- Stable buccal cervical line around Implant supra-structure can be achieved if the ratio is maintained
- Cementum and PDL : The secret of natural teeth's beauty and functional maintenance
- Socket shielding technique started of as an "Extension" of root submerging technique
- Root submergence preserve the periodontal architecture of pontic site
- Blood supply of buccal plate was never disturbed
-Technique such as socket shielding / Root membrane / Partial extraction therapy technique was introduced to reduce long term Peri-Implant tissue volume loss
- Hurzeler 2013 published the first histological, clinical and volumetrics study on the socket shield technique
- Histology shoes healthy periodontal ligament on buccal side of root with new bone between Implant and root shield
- This technique might help preserve labial bone of Implant
Indication
1. All indications of Immediate Implant
2. Horizontal fracture teeth up to bone level
3. Ankylotic teeth
4. Placing Immediate Implant adjacent to an existing Implant (KAN 2013, CHEREL 2014)
Contraindication
1. Periodontally compromised teeth
2. Vertical root fracture
3. Acute inflammation
Patient Information
- 22 years old, Male
- PMH : Medically fit without any known allergies, Non- smokers
- PDH : Root canal treatment done on 21
- Chief Complain : Fracture tooth No. 11 and discolored tooth No. 21
- Diagnosis : 11 Carious induced fracture with lesion extending to cervical of tooth
21 internal stain after root canal treatment
Treatment Plan
1. Immediate Extraction with socket shielding technique to preserve labial tissue dimension
2. Tooth 21 to be treated with internal bleaching and full ceramic crown restoration
Low lip Smile
Close-up View
Pre-operative Intra-oral Photograph
Pre-operative Panorama
Decoronation of tooth and caries removal
Tooth split with high speed handpiece
Palatal root fragment removed.
Extracted root
Re-adjust labial root height
Final position just at crestal bone height
Neobiotech IS-II Implant was placed more palatally giving sufficient jumping distance
Less than 20Ncm torque was achieved.
Implant was not immediately loaded.
A small healing abutment was placed to allow more soft tissue to grow.
Regenoss allograft was used to fill the jumping distance.
Collagen fleece was used to cover on top of the extraction socket.
Post-operative photograph (Frontal View)
Provisional with essix retained with acrylic tooth
Post-operative panorama
3 Months post-operative photograph
Impression for provisional
Provisional Crown
- Larger healing abutment to push out soft tissue
- Provisional crown in place, Internal bleaching on 21
Final Impression
- Gingiva level on 11 was still slightly coronal compare to 21 but patient did not mind
- Since patient is still in his 20s,
It is not a bad idea to leave the soft tissue a bit coronally in case of future recession
- Emergence profile maintained and recorded with customized impression copping
Final Impression
Final Prosthesis
- Cementable UCLA abutment was used.
- Excess cement removed from a duplicated die.
Final prosthesis Photograph
Post-operative Panorama
Final Comparison (Before-After)
Discussion
- Literature review
- 8 Results by September 2016
- Only 3 animal histology study (HÜRZELER 2015, GUIRADO 2016)
- 1 Review paper
- 1 Retrospective study
- 2 Cases reports
- 1 Uncertain Dutch paper
- 0 Randomized clinical trial published
Standardization required for this technique
1. Separate the palatal root fragment or drill through the root?
2. How much thickness of root buccal-lingually?
3. How deep coronal-apical position of remaining root is tolerable?
4. Circumferential of labial root left behind <180 °, 180°, >180 ° ?
5. Need of bone graft for jumping distance
- Root canal treated tooth suitability of the case?
(dentine surface altered by NaOCl, Sealer material and Gutta percha)
- Application in multiple rooted teeth?
Conclusion
- Socket shielding technique could be an alternative technique to prevent buccal bone resorption
- Immediate Implant vs Socket Preservation vs Socket Shielding
- More long term data required