Key points
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Clinical indications for socket shield therapy ( SST ) are selective , requiring a healthy retained root portion and periodontal ligament.
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SST promotes superior esthetic outcomes by preserving the bundle bone and soft tissue contours.
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Papilla fill between adjacent implants is a challenge in esthetic implantology; SST improves predictability in achieving embrasure fill.
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SST can eliminate the need for augmentation procedures by proactively preserving hard and soft tissues, thus simplifying treatment and reducing surgical morbidity.
Abbreviations
| IIP | immediate implant placement |
| SS | socket shield |
| SST | socket shield therapy |
Video content accompanies this article at http://www.oralmaxsurgeryatlas.theclinics.com
Introduction
Applying advanced protocols for immediate implant placement (IIP) and hard and soft tissue augmentation in delayed or late implant placement can yield excellent esthetic outcomes, particularly in patients with a thick phenotype. However, ensuring long-term tissue stability, especially in patients with a thin phenotype, and achieving predictable papilla fill between adjacent implants remain significant concerns.
Integrating innovative techniques such as socket shield therapy (SST) has transformed implant surgery by shifting the focus from tissue reconstruction to proactive preservation. SST protects the bundle bone by retaining strategic portions of the tooth root with healthy periodontal ligament, which would otherwise be lost during conventional extraction. This biologically driven approach minimizes alveolar ridge resorption and maintains natural soft tissue contours.
The indications for SST are limited. Root or root fragments may only be retained when the periodontal ligament is healthy or when the root is ankylosed. Contraindications for SST include tooth mobility, inflammatory buccal bone defects requiring guided bone regeneration (GBR), internal or external root resorption, and periodontal pocketing.
SST has consistently demonstrated better esthetic and functional outcomes than conventional IIP. , All published clinical trials have reported less marginal bone loss, improved periodontal parameters, and higher Pink Esthetic Scores when SST was utilized. , SST enhances papilla fill, an essential factor in esthetic implantology. Insufficient distal papilla fill on a single central incisor implant remains a well-known challenge in esthetic area implantology.
One of the most complex aspects of esthetic implant dentistry is achieving adequate papilla fill between 2 adjacent implants. Recent studies have shown that when SST is applied, the embrasure fill between adjacent implants closely resembles that of natural teeth. ,
This article will explore the effectiveness of SST in preserving ridge dimensions through 3 representative cases ( [CR] ).
Representative clinical cases
In all cases, socket shields (SSs) were prepared according to the published protocol.
In the first case, a fractured central incisor was partially extracted, and an implant was placed immediately.
In the second case, orthodontic tooth extrusion was applied to augment the hard and soft tissue, followed by IIP with SS.
In the third case, SST was performed for the left central incisor, which ensured papilla fill between the adjacent central and lateral incisor implants.
Case 1
A 58 year old healthy man was referred for evaluation of a fractured maxillary right central incisor (tooth #8) with a history of previous root canal treatment. Clinical examination revealed severe attrition, and radiographic examination showed a small periapical lesion associated with tooth #8 ( Figs. 1 and 2 ).
Intraoral scan of a fractured, nonrestorable maxillary right central incisor, previously treated with root canal therapy 10 years earlier.
Sagittal CBCT view showing the radial root plane with measurements of the residual root length (alveolar crest to apex), alveolar crest to nasal crest distance, and bucco-palatal width at the alveolar crest.
An interdisciplinary consultation was conducted, and the patient was presented with comprehensive treatment options, including orthodontic therapy and full-mouth rehabilitation. However, the patient elected to focus solely on managing tooth #8 at this time.
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Preoperative cone beam computed tomography (CBCT) evaluation is essential for planning the SS preparation and implant placement. On the sagittal CBCT section, the sagittal root position was determined according to Kan and colleagues Measurements included the residual root length from the alveolar crest to the apex, the distance from the alveolar ridge to the nasal crest, and the bucco-palatal width of the alveolar crest ( Fig. 2 ).
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The root was initially trimmed to the level of the marginal gingiva ( Fig. 3 ).
Fig. 3 Occlusal view of the fractured maxillary central incisor submerged to the gingival level.
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A pilot drill was used to prepare the root canal trajectory, which was subsequently widened with osseodensification burs (Versah, Jackson, MI).
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The root was sectioned mesio-distally ( Fig. 4 ), and the palatal root fragment was carefully extracted.
Fig. 4 Root was sectioned mesio-distally following root canal trajectory preparation; the buccal root fragment was trimmed to the crestal level. A gingival protector was used to safeguard soft tissues. Note the thinning of the coronal shield portion.
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The remaining shield was trimmed to a 1.5 to 2 mm thickness, ensuring complete removal of the apex and any periapical chronic inflammatory tissue.
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The shield was further reduced to the level of the crestal bone, and the coronal portion was thinned to allow sufficient restorative space.
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The implant was placed in a lingualized position, with its platform positioned 1.5 mm apical to the shield midfacial, and the gap between the implant and shield was grafted ( Figs. 5 and 6 ).
Fig. 5 Placement of a 3.5 × 13 mm Megagen AnyRidge implant. Buccal gap grafted with a 50/50 mixture of cortico-cancellous bone allograft. Chamfer preparation of the coronal shield portion created prosthetic space.
Fig. 6 Immediate postoperative sagittal CBCT showing graft material in both the apical and buccal gap areas.
Given the patient’s deep bite and history of bruxism, a subgingival healing protocol was chosen despite a good primary implant stability ( Figs. 7 and 8 ). After 12 weeks, an implant-supported provisional crown was delivered ( Fig. 9 ). A customized abutment was designed, maintaining a minimum 2 to 3 mm distance from the shield. The “copy-paste” crown design protocol was utilized, following the methodology described by Agnini and Coachman ( Fig. 10 ).
Socket closure was achieved with platelet-rich fibrin (PRF) membrane and cyanoacrylate adhesive.
An Essix retainer was delivered. Due to occlusal considerations, an immediate implant-supported provisional crown was not placed.
A printed provisional crown was delivered 12 weeks postimplantation to condition peri-implant soft tissues.
A digital design file (3Shape software) shows customized abutment fabrication. Mesiodistal and bucco-palatal dimensions were designed to minimize shield exposure risk. The crown design was edited using the “copy-paste” technique.
The peri-implant tissues remained stable 1.5 ( Fig. 11 A and B ) and 4 years posttreatment ( Fig. 12 A and B ), with the papillae filling the interproximal spaces. The 4-year CBCT represents ideal SS shape and prosthetic space radiographic dimensions ( Fig. 13 ).
( A , B ). Final restoration (lithium disilicate, E.max) at 1.5-year follow-up. ( A ) Frontal view, maintenance of papillae fill. ( B ) Lateral view, maintenance of papillae, and facial ridge contour.
( A , B ). Final restoration at 4 years ( A ) Frontal view ( B ) Lateral view—both demonstrating the peri-implant tissue stability.
The final CBCT shows optimal shield dimensions according to the PET protocol: SS is reduced to the alveolar crest. Shield width is 1.5 to 2.0 mm, and the length is 2/3 of the length of the residual root. Buccal gap 1–1.5 mm. The chamfer prepared in the coronal SS portion provides the restorative space.
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