Socket shield technique: A systematic review of human studies

A Strip Free Gingival Graft and a Xenogeneic Collagen Matrix to Increase Keratinized Tissue After Vertical Bone Augmentation

After vertical bone augmentation (VBA) surgery, loss of both keratinized tissue (KT) and vestibule depth (VD) take place. This article evaluated KT gain, patient satisfaction, and aesthetic outcomes after a modified apically repositioned flap (ARF) in combination with a strip-free gingival graft (FGG) harvested from the palate and a xenogeneic collagen matrix (XCM) to correct mucogingival distortion (MGD) after VBA. This technique minimizes patient morbidity by reducing the need for extensive masticatory mucosa grafts. The study included 12 patients with ≤3 mm KT after vertical augmentation procedures. Keratinized tissue gain and tissue thickness were measured. Patient morbidity and aesthetic outcomes were also evaluated. Twenty-four months after surgery, significant VD gain was observed, obtaining a vertical KT augmentation of 5.38 ± 2.06 mm, although tissue thickness increase was only 0.42 ± 0.42mm. Regarding patient satisfaction, aesthetic results evaluating tissue color and texture were satisfactory; the pain was slight, obtaining a score of 2.10 ± 1.13 out of 10, measured using a Visual Analogue Scale (VAS). The present retrospective case series study shows that using an apically repositioned flap combined with a strip FGG and an XCM might offer a valid means of achieving KT gain.

Use of Injectable Platelet-Rich Fibrin Accompanied by Bone Graft in Socket Endurance: A Radiographic and Histological Study

Background Ridge preservation became a crucial dental health issue and strategy to keep away from ridge defacement after post-tooth loss. The recent scientific evolution of platelet-rich fibrin (PRF) comprises a parenteral formulation of PRF. The combined allograft for socket preservation gives benefits. In this study, bone allografts, demineralized freeze-dried bone allografts (DFDBA) and freeze-dried bone allografts (FDBA) are used in a 30:70 ratio alone or in combination with injectable PRF (I-PRF) for socket preservation. Methods This study is a radiographic and histological examination conducted on 60 participants aged between 19-65 years. Participating patients agreed voluntarily that they would not bear any fixed prosthesis for the next nine months and plan for implanted teeth placement, including multi-rooted mandibular molars denticles. Both groups received atraumatic extraction; then, the socket was preserved with bone allograft alone in the control group and bone allograft mixed with I-PRF, forming sticky bone, in the experimental group. Clinical, radiological, and histological assessments were taken at the inception stage, three months, six months, and nine months. A multivariate regression model and a generalized estimating equation (GEE) model were used to analyse the effects of these changes on outcomes. Results In all the parameters, the test group indicated a good amount of bone growth with increasing intervals of time for bone height radiographically with statistically significant difference present (p<0.05) and histologically after nine months when socket site grafted with bone graft in combination with I-PRF. Conclusion This study's results demonstrated that I-PRF possesses the potential to regenerate and heal in the tooth-extracted socket. This study further recommends the implementation of I-PRF in safeguarding and conserving the raised rim of the tooth. Future research should take place on the osteogenic capability of I-PRF in more comprehensive ridge accession surgical procedures and additional expanding and improving capacities in periodontal reconstruction.

Effect of the use of platelet concentrates on new bone formation in alveolar ridge preservation: a systematic review, meta-analysis, and trial sequential analysis

OBJECTIVES

To investigate the histomorphometric changes occurring in alveolar ridge preservation (ARP) based on the use of different plasma concentrates (PCs) in randomized clinical trials (RCT). There is controversy whether the placement of PCs in ARP is effective in the formation of new bone.

MATERIALS AND METHODS

A systematic review search was conducted in PubMed, Scopus, Web of Science, and Cochrane Database to answer the PICO question: In patients undergoing tooth extraction followed by ARP, do PCs alone in the post-extraction socket in comparison with spontaneous healing improve new vital bone formation percentage in histomorphometric analysis after more than 10 weeks? The risk of bias was assessed and a meta-analysis was conducted.

RESULTS

Of 3809 results, 8 studies were considered suitable for inclusion. A total of 255 teeth were extracted in 250 patients. Regarding the PCs used, ARP was performed with platelet- and leukocyte-rich fibrin (L-PRF) in 120 sockets, and with pure platelet-rich plasma (P-PRP) in 31 sockets and 104 sockets were controlled. PCs improved new bone formation in ARP with respect to the spontaneous healing group (SMD = 1.77, 95%C.I. = 1.47-2.06, p-value < 000.1). There were no differences between the different PCs (L-PRF and P-PRP).

CONCLUSION

The results of this meta-analysis support the efficacy of the use of PCs in new bone formation in ARP. With respect to the different types of PCs studied, no differences were observed.

CLINICAL RELEVANCE

When planning implant surgery after tooth extraction, treatment with PCs should be considered for ARP. Any PC increases new bone formation compared to spontaneous healing.

Digital workflow for image-guided immediate implant placement by using the socket-shield technique and custom abutment in the esthetic area

Marginal bone loss around immediately placed implants may compromise esthetic outcomes in the anterior maxilla. The relatively recent socket-shield technique of partial extraction therapy has been described as being useful to maintain the structure of peri-implant tissues. The present technique report introduced a digital workflow to perform image-guided implant placement after partial extraction therapy. In this technique, digital 3-dimensional images are used to plan and orient the flapless surgical procedure and to digitally design a custom abutment based on the natural emergence profile as segmented from the tooth to be extracted.

Minimally invasive management of a socket shield technique complication: A clinical report

The socket shield technique has been used to optimize the esthetic outcome of anterior immediate implant treatment. However, complications have been reported, including internal or external shield exposure, implant failure, and infection. The key to the surgical management of shield exposure is to avoid a full-thickness flap because of the risk of losing soft tissue volume. For this patient, a flapless approach was used to extract the exposed root shield, followed by a simultaneous connective tissue graft. A satisfactory esthetic outcome was observed at the 20-month follow-up after the surgical intervention.

The Effect of Terra-Cortril as Local Pain Medication on the Healing Process of a Fresh Extraction Socket: A Retrospective Cohort Study

(1) Background: Use of Terra-Cortril may reduce pain and discomfort after tooth extraction. It is widely used among dentists, especially for third molar extraction and for treatment of dry socket. Only few case reports described unsuccessful healing with formation of myospherulosis. (2) Aim: The primary objective of this retrospective cohort study was to compare the occurrence of unsuccessful healing between extraction sockets locally treated with Terra-Cortril (TC) (exposure cohort) and extraction sockets subjected to unassisted healing (non-exposure cohort). The assessment of the three-dimensional morphology of the bone was a secondary objective. (3) Material and methods: The records of patients who had one or more extractions between 1 January 2020 and 1 July 2021 followed by implant placement in one private practice were retrieved and data were extracted. At the time of implant placement, practitioners established, both clinically and radiographically, if the healing was successful or unsuccessful. Explanatory demographic as well as clinical variables were extracted from patient files, checked and supplemented by contacting patients in cases of missing data. (4) Results: 69 patients were included who had, in total, 99 extractions. The exposure cohort included 55 sites, while the non-exposure cohort included 44 sites. A total of 56 sites demonstrated successful healing, and 53 showed unsuccessful healing. The regression model identified TC as a significant predictor (p = 0.014) for unsuccessful healing with an odds ratio of 2.86. Sites treated with Terra-Cortril had a significantly greater bone defect at level -1 mm, level -3 mm, and level -5 mm from the bone crest, and significantly greater maximal vertical and horizontal bone defects. At sites where Terra-Cortril was used, significantly more surgical consequences were reported (70.91% vs. 18.18%, p < 0.001). (5) Conclusions: fresh extraction sockets treated with Terra-Cortril increased the likelihood of unsuccessful healing with an odds ratio of 2.86. The greater defect size leads to significantly more limitations when planning implants at sites previously treated with TC.

Autogenous particulated dentin for alveolar ridge preservation. A systematic review

PURPOSE

This review aimed to investigate the clinical outcomes of autogenous particulated dentin (APD) used for alveolar ridge preservation (ARP), evaluating volume gain, histologic/histomorphometric data, and associated complications.

MATERIAL AND METHODS

The review followed PRISMA guidelines and was registered in the International Prospective Register of Systematic Reviews (PROSPERO). An automated search was made in four databases (Medline/Pubmed, Scopus, Web of Science, and Cochrane Library) supplemented by a manual search for relevant clinical articles published before March 10th, 2022. The review included human studies of at least four patients in which extraction and subsequent ARP were performed in a single surgery. Both comparative studies and studies that assessed ARP with APD exclusively were admitted. The quality of evidence was assessed with the Cochrane bias assessment tool, the Newcastle-Ottawa Quality Assessment Scale, and the Joanna Briggs Institute Critical Appraisal tool.

RESULTS

Eleven studies fulfilled the inclusion criteria and were included for descriptive analysis, with a total of 215 patients, and 337 alveoli preserved by APD, spontaneous healing (blood clot), or other bone substitutes, obtaining comparatively less vertical and horizontal resorption when APD was used.

CONCLUSIONS

After dental extraction, autogenous dentin was effective in terms of volume maintenance, showing promising results in histologic/histomorphometric analysis, and a low complication rate. Nevertheless, few comparative studies with comparable parameters have been published and so more research providing long-term data is needed to confirm these findings.

Evaluation of soft tissue and labial plate of bone stability with immediate implant in direct contact versus gap with socket shield: A randomized clinical trial with 1 year follow-up

OBJECTIVE

In the anterior region, the resorption of the buccal plate of bone after tooth extraction leads to contraction of the overlying soft tissues, resulting in an esthetic problem. In the socket shield technique, the buccal root section of the tooth is maintained, to preserve the buccal bone for immediate implant placement. The aim of this randomized clinical trial was to investigate the effect of leaving a gap or not between implant and retained root fragment on bone dimensions and soft tissue esthetics.

METHODS

This was a two armed parallel group randomized clinical trial with allocation ratio 1:1. Patients were eligible in case they needed immediate implant replacing teeth in esthetic zone with sufficient buccal bone support. CBCT was performed immediately after the intervention and 12 months later.

RESULTS

Forty six patients (26 females and 20 males) were enrolled in the study with 23 of them placed in contact with shield and 23 were placed palatal leaving a gap to graft with a xenograft. After 12 months, excellent soft tissue stability was reported (mean pink esthetic score at placement group A: 12.00 ± 1.60 after 12 months 12.90 ± 1.69, group B 12.62 ± 2.07 and after 12 months 12.38 ± 2.20) Using both surgical techniques. Radiographic crestal bone level changes mean for group A was -0.26 ± 0.52 and for group B -0.34 ± 0.31. There was a strong positive correlation between clinical and radiographic bone width values which was statistically significant (r = 0.782, p < 0.001). Width and thickness of keratinized gingiva showed no significant difference between values measured in both groups. Nonsignificant difference between studied groups according to the labial plate of bone clinical and radiographic changes after immediate implantation.

CONCLUSION

Within the limitations of this study, the present data seem to support that the clinical outcome of the socket shield technique with immediate implant placement placed in contact or leaving a gap gave excellent esthetic results.

Dimensional Changes in the Alveolus after a Combination of Immediate Postextraction Implant and Connective Grafting and/or Socket Shield Technique

Immediate implant placement protocols after dental extraction have enabled a reduction in surgical phases. This procedure has increased patient satisfaction and similar survival rates to late implant placement procedures. However, placing an implant immediately after dental extraction does not counteract the physiological remodeling of alveolar bone. For this reason, additional surgical techniques have been developed, such as the placement of a connective tissue graft (CTG) or the socket shield technique (SST). Dimensional changes in the peri-implant tissues were observed after placement of immediate implants following the extraction and CTG and/or SST. A total of 26 surgical interventions were carried out in which dimensional change variables of peri-implant tissues were analyzed. The preoperative state and immediate postoperative situation were compared with the situation after one year. Measurements were taken at 3, 5, and 7 mm from the gingival margin and analyzed in this CBCT radiological study (Planmeca Promax 3D). The implant platform was used as a reference point for the measurement of changes in alveolar crest height. One year after performing either of the two techniques (CTG and/or SST), a significant increase in the gingiva thickness and vestibular cortex occurred at 5 mm (0.65 ± 1.16 mm) and 7 mm (0.95 ± 1.45 mm) from the gingival margin. Additionally, an increase in thickness of palatal bone was registered at 3 mm (0.48 ± 0.90 mm). The graft placement group showed an increase in thickness of peri-implant tissue in the vestibular area after one year, although CTG and SST groups were clinically similar. The implementation of SST revealed promising results regarding the buccal thickness of hard and soft tissues after one year. A significant increase in vestibular cortical bone thickness, as well as the overall mucosa thickness and buccal bone at 3 mm from the gingival margin, was observed. A significant reduction in the distance from the bone crest to the platform was detected in both techniques. Both techniques (CTG and SST) are appropriate to provide sufficient volume to peri-implant tissues in the vestibular area of anterior maxillary implants. Some limitations were detected, such as the lack of an aesthetic analysis or small sample size, so results should be interpreted with caution. Future studies are necessary to further evaluate the long-term predictability of these techniques.