Selective Preservation of Tooth (SPOT): A Step-by-Step Protocol for a Precise, Reproducible, Socket-Shield Technique.

The socket-shield technique is a clinical procedure aimed at preventing both hard- and soft-tissue collapse following immediate implant placement. The technique can be challenging as multiple factors influence the precision of this treatment. Selective preservation of tooth (SPOT) is a standardized, reproducible tooth-guided preparation protocol for achieving a socket shield and for immediate post-extraction implant site preparation and placement. SPOT emphasizes the utilization of osseodensification burs in both forward (ie, clockwise) rotation, to allow for simultaneous precise root apex removal and shield preparation, and reverse (ie, counterclockwise) rotation, to allow for implant site preparation with further compaction-autografting of bone and dentin, thereby improving implant primary stability and its subsequent early healing. This article presents SPOT in a step-by-step protocol for socket-shield and implant site preparation with immediate post-extraction implant placement. The article describes the stepwise application for single-rooted teeth.

Management of hyperplastic tissue response following connective tissue grafting.

OBJECTIVE: While connective tissue graft shrinkage is a well-documented post-transplantation reaction, there is a literature gap concerning hyperplastic tissue response. Despite its infrequent occurrence, investigation is warranted due to its capacity to compromise esthetics, disrupt lip dynamics, and promote food retention. Moreover, efforts to mitigate hyperplastic tissue response often prove challenging, and there is a potential risk of exacerbating gingival tissue rebound. CLINICAL CONSIDERATIONS: This report presents a potential solution to managing tissue overgrowth after connective tissue grafting in five clinical cases. The patients underwent corrective surgery involving internal excision of excessive tissue while preserving the overlying mucosa. The surgical approach was tailored to excise hyperplastic tissue with minimal trauma, aiming to optimize esthetic outcomes. Subsequent follow-up assessments spanning 1-5 years demonstrated stable results, with no indications of relapse or recurrence of tissue overgrowth. CONCLUSIONS: Within the limitations of this case series, surgical internal excision holds promise as a viable treatment modality for addressing post-transplantation hyperplastic tissue response. CLINICAL SIGNIFICANCE: This case series addresses the challenge of uncontrolled tissue overgrowth following connective tissue grafting, a concern for which previous attempts have proven unsuccessful. Internal in-toto excision emerges as a promising approach for effectively eliminating overgrown tissue, offering potential advancements in the clinical management of this complication.

Socket Shield Complications: The Management of Internal Shield Exposure. A Multicenter Case Series.

The socket shield technique has been proposed as a surgical method to prevent the collapse of the buccal plate following tooth extraction, leading to excellent soft tissue stability and long-term esthetic outcomes. Despite its success, this technique is still not without potential risks. One of the most common complications is internal exposure of the socket shield, which can present as inner soft tissue inflammation with or without exposure of a portion of the shield. This case series discusses this complication's etiology, diagnosis, treatment, management, and prevention. Data from 10 patients with 12 internally exposed sites are presented.

Effects of socket-shield therapy on inter-implant papilla preservation between upper central and lateral incisors: A case series with 3-5 year follow-up.

OBJECTIVE: Despite significant progress within implant prosthetic therapy, preserving the papilla between two adjacent implants in the esthetic zone, particularly between central and lateral incisors, remains challenging. This case series aims to report a papilla preservation approach between adjacent upper central-lateral incisor implants using the socket-shield technique. CLINICAL CONSIDERATIONS: Six patients with natural dentition received unilateral adjacent central-lateral incisor implants with different socket shield configurations. The esthetic outcomes were clinically assessed after 3-5 years of follow-up. Post-operative papilla fill was evaluated on intraoral images compared to baseline characteristics and the contralateral papilla. Papilla height was preserved in all cases, with minimal alterations observed. CONCLUSIONS: Within the limitations of the present case series, the socket-shield technique demonstrated favorable outcomes in preserving the papilla between adjacent upper central-lateral incisor implants in the midterm follow-up. Clinical studies are warranted to validate these results. CLINICAL SIGNIFICANCE: The socket-shield technique seems promising in preserving the inter-implant papilla between adjacent central-lateral incisor implants.

Bone Shell Technique with Relocated Crestal Ridge Segment for Anterior Horizontal Mandibular Ridge Atrophy: A Case Series.

Horizontal and vertical ridge augmentation via the bone shell technique provides predictable outcomes. The external oblique ridge is the most-used donor site for bone plate harvesting, followed by the mandibular symphysis. The lateral sinus wall and the palate have also been described as alternative donor sites. This preliminary case series reports a bone shell technique that used the coronal segment of the knife-edge ridge as a bone shell in five consecutive edentulous patients (20 sites) with severe mandibular horizontal ridge atrophy and adequate ridge height. The follow-up period was 1 to 4 years. The average horizontal bone gains at 1 mm and 5 mm below the newly formed ridge crest were 3.6 ± 0.76 mm and 3.4 ± 0.92 mm, respectively. Ridge volume was sufficiently restored in all patients to enable implant placement in a staged approach. In 2 of the 20 sites, additional hard tissue grafts were required at implant placement. The advantages of utilizing the relocated crestal ridge segment are as follows: The donor and recipient sites are the same, no major anatomical structures are compromised, periosteal releasing incisions and flap advancement are not required for primary wound closure, and the risk of wound dehiscence is minimized due to reduced muscle tension.

VISTA Approach in Conjunction with Enamel Matrix Derivative, Corticocancellous Bone, and Connective Tissue Graft for Periodontal Defect Surgery: A Case Series.

The biggest challenge during periodontal regeneration in the anterior region is the prevention of soft tissue recession. Minimally invasive surgeries, particularly papilla preservation techniques and soft tissue augmentation, may significantly reduce such postoperative soft tissue recession. This article presents the vestibular incision subperiosteal tunnel access (VISTA) approach for periodontal regeneration in the anterior region. A subperiosteal tunnel prepared from a single vertical vestibular incision adjacent to the defect is used for debridement, application of enamel matrix derivative, defect grafting with corticocancellous tuberosity bone, and insertion of the connective tissue graft. Evaluation of six cases with up to 6 years of follow-up showed improvements in all clinical parameters. The probing pocket depth improved from 8.2 ± 0.75 mm initially to 2.7 ± 0.52 mm at follow-up, clinical attachment level improved from 8.5 ± 0.83 mm initially to 2.7 ± 0.52 mm at follow-up, and midfacial gingival recession of 1 mm at two sites was corrected. The papillae were stable at all sites, with an average distance of 4.8 mm from the incisal edge to the papilla tip. This technique seems to be a promising approach for achieving both esthetic and functional goals of periodontal regenerative surgery. However, experience in performing microsurgeries and harvesting tuberosity tissues may be a limitation.

Clinical outcomes of retention of the buccal root section combined with immediate implant placement: A systematic review of longitudinal studies.

INTRODUCTION: Immediate implant placement in conjunction with partial extraction therapy has been shown to result in functional osseo- and dento-integration with partial preservation of the periodontal ligament (PDL) in humans. Strategic buccal root retention for PDL preservation is a biologically driven procedure that maintains alveolar ridge dimensions and esthetics, while allowing for implant placement. The aim of this study was to conduct a systematic review of longitudinal clinical outcomes of PDL-mediated ridge preservation in conjunction with implant placement in adults, compared with conventional immediate implant placement with total extractions. The primary outcome for this study was marginal bone level (MBL) changes after strategic buccal root retention implant placement techniques. MATERIALS AND METHODS: To address a predefined PICOS question, a systematic search of randomized clinical trials and cohort studies with at least 10 participants per group and a minimum 12-month follow-up was conducted. A two-phase systematic selection strategy, data extraction, and risk of bias assessment, was performed independently and in duplicate. Randomized trials were quantitatively analyzed in a meta-analysis. RESULTS: Ten human studies fulfilled the predefined criteria and were included; three clinical trials and seven cohort studies, for a total of 506 patients and 587 implants. PDL-mediated implant placement of single-rooted periodontally healthy teeth was found to reduce marginal peri-implant bone loss and buccal plate changes as compared to conventional immediate implants across studies, while implant survival and success rates were comparable between the two procedures. A meta-analysis found that bone changes were significantly less when retention of the buccal root section was performed as compared to total extractions (standardized mean difference: [-4.53, -0.11]); the three clinical trials were, however, largely heterogeneous (I2 : 93.1%; Q = 28.98, p < 0.001). CONCLUSION: Strategic retention of the buccal root section has a benefit in terms of dimensional ridge stability over conventional immediate implantation when implemented in carefully selected cases of single-rooted teeth.

The socket shield technique with proximal extensions for single-rooted teeth.

The conventional socket shield (SS) design extends from the mesiolabial to the distolabial line angle. C-shaped SS, L-shaped SS, and proximal SS designs have proximal extensions that help to maintain the hard and soft tissue in the interproximal areas. This is beneficial for implant sites adjacent to an existing implant or an edentulous space. The most common complication of the socket shield technique (SST) is internal shield exposure. Due to anatomical features such as a scalloped ridge shape and an oval socket shape of some teeth, the risk of complications such as internal shield exposure, inadvertent SS displacement, and fracture of the SS during implant insertion is greater in proximal shield areas. The present article describes guidelines for case selection for proximal shield extensions, along with SS preparation and the selection of implant and prosthetic components.

Immediate ridge reconstruction with a composite tuberosity graft after removal of failing implants.

BACKGROUND: When a dental implant is discovered to be failing, the implant must be removed, resulting in a defect. Immediate reconstruction of the defect using an autogenous composite tuberosity graft has been reported following the removal of a single implant. Ridge reconstruction after the removal of more than one failing dental implant poses an even greater challenge, given the substantial loss of hard and soft tissue. To the author's knowledge, this is the first report to describe the use of an autogenous composite tuberosity graft for the reconstruction of hard and soft tissue for multiple sites. METHODS AND RESULTS: Three patients with failing implants and ridge defects received a composite tuberosity graft comprising the bone, periosteum, connective tissue, and epithelium of the maxillary tuberosity for simultaneous hard and soft tissue reconstruction. Bone from the maxillary tuberosity was positioned between the bony borders of the defect or fixed buccally to augment the ridge. Smaller bone pieces from the tuberosity were used to fill the gaps. The soft tissue portion of the graft was allowed to heal spontaneously, thus eliminating the need for further surgery to increase keratinized gingiva and vestibular depth. All sites recovered uneventfully, and the ridge dimensions were re-established. CONCLUSION: For patients with sufficient tuberosity bone volume, using a one-piece composite tuberosity bone graft appears to be a promising approach for rebuilding the ridge in a single surgery. KEY POINTS: Why are these cases new information? Large hard and soft tissue defects are reconstructed immediately after the removal of one or more failed implants. Keratinized gingival width and vestibular depth are improved. What are the keys to the successful management of these cases? Cone-beam computed tomography for tuberosity and defect evaluation Careful handling of tuberosity bone Proper graft shaping Composite tuberosity graft fixation Fixed provisional prosthesis for grafted area protection What are the key limitations to the success of these cases? Unavailability of tuberosity A technique-sensitive approach.

Human Histologic Analysis of Implant Osseointegration in a Healed Site Grafted with Nondemineralized Autologous Tooth-Derived Graft Material.

Autologous tooth-derived grafts (ATDGs) have gained popularity as bone substitute biomaterials, owing to their promising healing dynamics in vivo and to patient preference for repurposing hopeless teeth. Nonetheless, concerns exist regarding the biologic response of these ATDGs in preparation for implant placement and subsequent osseointegration. After 12 weeks of extraction socket healing, an implant with an acid-etched surface was placed using osseodensification osteotomy preparation and was retrieved after 16 weeks of integration. Histologic analysis revealed ≥ 64% of direct bone-to-implant contact at multiple regions of interest along the implant surface. Residual dentin particles were scarce and were never found in contact with the implant, suggesting that the ATDG did not interfere with implant osseointegration. Despite the overall trabecular structure of the adjacent maxillary bone with large marrow spaces, the implant surface was delineated with a continuous dense mineralized zone (thickness of 2 to 5 cell layers) with vital osteoblasts in the lacunae. These results suggest that the healing dynamics of ATDG are well aligned with implant osseointegration dynamics.

Effectiveness of Autologous Tissue Grafts on Soft Tissue Ingrowth in Patients Following Partial Root Extraction with Socket Shield: A Retrospective Analysis of a Case Series.

PURPOSE: There is little knowledge about healing patterns for the socket with an intentionally retained root fragment: a socket shield. The clinical observation is soft tissue ingrowth next to the socket shield. The aim of this study was to evaluate the effectiveness of autologous grafting matrices in preventing soft tissue ingrowth. MATERIALS AND METHODS: Patient data from a private clinic were searched for sockets with a socket shield left to heal with blood clot or grafted with autologous materials: autologous platelet-rich fibrin (PRF), scraped particulate bone, cortical tuberosity bone plate, or particulate dentin and covered with PRF membranes. The included sites were exposed by the flap 4 months after the first surgery, and soft tissue ingrowth depth and width next to the root fragment were measured by a scaled probe and documented. RESULTS: Evaluation of 34 sites showed the greatest depth of soft tissue ingrowth in the nongrafted sockets (6.0 ± 0.0 mm). Grafting with PRF plugs (depth of 2.3 ± 0.2 mm) or particulate bone (depth of 2.7 ± 0.6 mm) decreased soft tissue ingrowth. Grafting with particulate dentin or cortical tuberosity bone plate resulted in a soft tissue ingrowth depth of only 1 mm, yielding the best clinical outcome. Radiography confirmed those findings. CONCLUSION: Autologous dentin particulate or tuberosity cortical bone plate is most effective for preventing soft tissue ingrowth.

Buccal Sliding Palatal Pedicle Flap Technique for Wound Closure After Ridge Augmentation.

One standard approach for wound closure after ridge augmentation is coronal flap advancement. Coronal flap advancement results in displacement of the mucogingival junction and reduction of the vestibulum. In the maxilla, a buccal sliding palatal flap can be applied for primary wound closure after ridge augmentation. The dissected part of the palatal connective tissue is left exposed, thus eliminating or reducing the amount of the coronal flap advancement respectively and increasing the amount of keratinized gingiva. In combination with guided soft tissue augmentation, this flap design enables a three-dimensional peri-implant soft tissue augmentation.

Maintenance of Alveolar Ridge Dimensions Utilizing an Extracted Tooth Dentin Particulate Autograft and PlateletRich Fibrin: A Retrospective Radiographic ConeBeam Computed Tomography Study.

This study utilized radiographic comparative analysis in order to evaluate dimensional ridge changes four months after tooth extraction and immediate grafting with mineralized dentin particulate autograft and chopped plateletrich fibrin. Fiftyeight extraction sockets with up to 2 mm of missing buccal bone in the coronal aspect compared to the lingual bone were included. Graft material was covered with either a plateletrich fibrin membrane or collagen sponge with no effort to achieve primary closure. The dimensional changes of the ridge were assessed on conebeam computed tomography (CBCT) images acquired prior to extraction and four months later. The reduction in the buccal bone plate thickness 1 mm, 3 mm, and 5 mm below the buccal crest was -0.87 ± 0.84 mm, -0.60 ± 0.70 mm, and -0.41 ± 0.55 mm, respectively. The mean ridge width changes 1 mm, 3 mm, and 5 mm below the crest were -1.38 ± 1.24 mm, -0.82 ± 1.13 mm, and -0.43 ± 0.89 mm, respectively. The average midbuccal bone height gain was +1.1%, while the midlingual height gain was 5.6%. A mineralized dentin autograft with plateletrich fibrin is effective in preserving postextraction alveolar ridge dimensions.

Modified IVAN Technique: Long-Term Follow-Up of 20 Cases Over 2 to 11 Years.

When natural teeth fail, frequently there is a loss of hard and soft tissue. This may complicate subsequent dental implant placement by creating insufficient bone to house the implant. This also occurs when the tooth has been missing for an extended period, especially in the premaxilla, where the bone is less dense and often lacks sufficient volume of facial bone. Site reconstruction to accommodate implant placement often requires both hard and soft tissue augmentation. The modified interpositional vascularized augmentation neogenesis (mIVAN) technique achieves the desired treatment goals in both delayed and immediate placement scenarios. The technique will be discussed as well as the long-term follow-up on 20 cases.