病例報告 Case Report
即拔即種併用Socket Shield Technique：臨床特殊案例報告
簡介： 拔牙後伴隨而來的牙周萎縮是植牙領域的一大挑戰，主要發生在唇側及頰側造成美觀上的問題，對於thin biotype 的病人這無異是雪上加霜，一直以來許多專家、學者試圖對此找出解決方案，然而至今為止並沒有任何研究報告指出有任何方法能夠完全避免拔牙窩吸收。2010 Hürzeler以及 Zuhr發表的論文提出一個新術式，在拔牙過程中保留牙根頰側的牙周韌帶，無損頰側骨板血流供應的狀況下達到術後組織吸收最小化。本文提出五個socket shield technique的臨床案例，說明術式的方法， 臨床上需要注意的地方以及案例癒後追蹤。
材料與方法： 在本篇案例報告中，收集的案例為前牙區單顆必須拔除且沒有感染的壞牙。壞牙在切除牙冠部分之後直接使用鑽針穿過牙根做植牙洞的鑽備。接下來用高速鑽針將牙根切割成兩半，移除顎側部分。頰側部分的牙根用高速鑽針修短至1.5 mm低於齒齦邊緣，植入人工牙根之後裝上臨時牙冠，待三個月骨整合完成再做正式假牙。
結果： 本篇的五個案例中有兩個發生牙齦發炎的情況。其中一例導因於正式假牙裝戴過程中瓷牙冠過度擠壓使得牙根斷裂，另一例可能與沒有清乾淨的臨時黏膠有關， 兩個牙齦發炎的案例在使用雷射治療之後得到控制。所有的案例中植牙根都存活（survive），除了案例四所有的牙齦幾乎沒有發生萎縮。
結論： 治療過程中如果能夠注意到所有細節，即拔即種併用socket shield technique應用在前牙美觀區是一個成功率很高的術式。
關鍵詞：即拔即種，socket shield technique，牙科雷射
Immediate Implant Placement with Socket Shield Technique: A Case Series
Hung-Chieh Lu, DDS
- President of Asia Pacic Laser Institute
- Board director of Taipei Congress of Oral Implantologists
- Board director of Academy of Taiwan Cosmetic and Implant
Introduction: Tissue recession after tooth extraction is one of the main challenges in Implant Dentistry. It occurs mostly in labial and buccal side, which in turn cause esthetic problem. This situation is even more worse in patient with thin biotype. For that, many eorts were done aempting to overcome the post extraction resorption, however complete preservation of extraction socket has not been documented yet. At 2010, Hürzeler and Zuhr et al. published a paper suggested that preserving the buccal portion of the root during tooth extraction can keep the blood supply to buccal bone plate intact, which will lead to reservation of the buccal structure. e following case report presents ve consecutive cases demonstrate the procedure of Socket Shield technique, the concept behind, and prognosis of treatment.
Materials and Methods: In this case series, single anterior hopeless tooth without infection was selected. Following decoronation of the tooth, implant bed preparation was done with direct drilling through the root. Next, the root was sectioned into two pieces carefully with high speed bur, and lingual portion was removed. en, the buccal portion of the root was adjusted until 1.5mm below gingiva margin , aer that the implant was placed. Patient wear temporary crown for 3 months during healing stage and come back for nal impression.
Result: Gingiva inammation occurred in two of the ve cases, among them, one was caused by socket shield fracture during permanent crown installation, another one might be caused by excessive temporary cement. Gingiva inammation of these two cases were solved by dental laser decontamination. All the gingiva tissue of ve cases have almost no recession except case 4, and all the implant survived.
Conclusion: Immediate implant placement simultaneous with socket shield technique may be a predictable procedure for anterior esthetic implant case as long as all the key points are well executed.
Key words: Immediate implant placement, socket shield technique, dental laser
Immediate implant placement saves lots of time when comparing with delay implant placement or stage approach, which usually cost extra 6 to 8 months for bone healing and graft maturation. However, the biggest shortage of conventional immediate implant placement is unpredictability due to the risk of recession. Back to 1960, Almer et al. studied ridge recession aer tooth extraction, they observed the change of ridge contour through radiographic images1. At 2005, Araújo and Lindhe et al. they observed ridge alteration following tooth extraction in histology analysis of dog model and pointed it out that in phase I of ridge resorption, the bundle bone was resorbed, and replaced with woven bone2. Since the crest of buccal bone wall was comprised solely of bundle bone, this modeling resulted in substantial vertical reduction of the buccal crest2. Lost of vertical high in anterior teeth may cause asymmetry of dentition and possible esthetic disaster. Although esthetic may not be the point of concern in posterior, recession in the posterior region may cause food trapping and possibly lead to periodontal disease. In order to overcome the diminishing tissue volume following extraction, many treatment techniques have been described in literatures such as socket preservation3, ice cream cone technique4, block graing5, socket seal technique6?etc. Up to date, a complete preservation or entire regeneration of extraction socket have not been documented yet. Since destruction of blood supply from periodontal ligament play a main role in buccal bone plate resorption, it can be assumed that root retention may have an inuence on the occurring resorption process7. (Hurzeler and Zuhr et al. 2010) In their study, they presented a clinical case report together with a histology assess of one beagle dog, and the histology result showed retaining buccal aspect of the root in conjunction with immediate implant placement has the following effects: 1. well preservation of periodontal ligament and the blood vessel. 2. no modeling of buccal bone plate. 3. bone tissue formation in between implant and dentin. At 2014, Siormpas and Mitsias et al. published a retrospective study, they collected data from 46 patients, each patient had single hopeless anterior tooth treated with socket shield technique, followed time from 24 to 60 months8. The results showed the mean crest bone loss on the medial and distal aspect of implants was 0.18 ± 0.09 mm and 0.21 ± 0.09 mm. All implants successfully maintained osseointegration at the end of follow up period. They concluded that the socket shield technique is a safe treatment modality that yield high implant success rates. Now a day, almost all available papers gave recognition for socket shield technique, however there are not sufficient evidence for supporting this technique as our daily clinical practice. No paper describes the possible clinical situation occurred during the treatment procedure or clinical prognosis. In this case series, we show the cases with implant infection during healing period, root shield fracture aer implant loading, root shield exposure, and the way we solved the situation. Hope our case report gives dentist who is interested about this technique some awareness and may be come out with beer solutions.
Medical history: A 75 years old man, no smoking and no known medical condition.
Extra-oral examination: Patient has medium smile line, no abnormality was found.
Intra-oral examination: Tooth number 21 fracture. e fracture line extend to the root portion with pulp exposure. Aside from tooth fracture, a stula was found.
Radiographic examination: Periapical radiolucent
Diagnosis: Traumatic tooth fracture, hopeless tooth.
Treatment plan: Prevention of ridge resorption with socket shield technique in conjunction with immediate implant placement. e procedure is described in gure 1.
Medical history: A 74 years old lady, no smoking, with controlled diabetes
Dental history: Tooth number 21 had class 3 composite resin lling long time ago.
Extra oral examination: Patient has high smile line, no abnormality was found.
Intra oral examination: Secondary caries underneath the old class 3 composite resin restoration extend to the root of tooth number 21.
Radiographic examination: Large extensive caries
Diagnosis: Extensive caries with poor prognosis.
Treatment plan: Socket shield technique in conjunction with immediate implant placement. e procedure is described in gure 2.
Medical history: 66 years old man, no smoking, no known medical condition.
Dental history: Tooth number 13 had class 3 composite resin restoration.
Extra oral examination: Patient has medium smile line, no abnormality.
Intra oral examination: Old composite resin restoration no longer exist, the secondary caries extend into root canal.
Radiographic examination: Large extensive caries almost hollow out the whole tooth.
Diagnosis: extensive caries with poor prognosis.
Treatment plan: Socket shield technique in conjunction with immediate implant placement. e procedure is described in gure 3.
Medical history: 55 years old lady, no smoking, no known medical condition.
Dental history: Tooth number 11 had post crown restoration.
Extra oral examination: Patient has high smile line, no abnormality detected.
Intra oral examination: Old crown fall down and root fractured due to caries underneath the crown.
Radiographic examination: Increased radiopaque in the apical area, no sign of infection.
Diagnosis: Caries underneath the crown and root fracture.
Treatment plan: Socket shield technique in conjunction with immediate implant placement. e procedure is described in gure 4.
Medical history: A 54 years old lady, no smoking, no known medical condition.
Dental history: Tooth number 11 had old crown restoration
Extra oral examination: Patient has high smile line, no abnormality detected.
Intra oral examination: Old crown fall down and tooth fractured due to caries.
Radiographic examination: No sign of infection, normal periodontal condition
Diagnosis: Caries underneath the crown and crown fracture.
Treatment plan: Socket shield technique in conjunction with immediate implant placement. e procedure is described in gure 5.
Insufficient amount of hard and soft tissue has challenged dentist for a long time, many regeneration techniques, or preservation techniques, and plenty of graing materials on the market, all of these only declare the truth that none of them really has superior capability of stoping the nature of physical resorption. Socket shield techniques, ever since it was described at 2010 it aracted huge aention, and many modified techniques had been published, the concept behind is simple, preservation of blood supply from periodontal ligament by keeping the root portion and it seems working pretty well. Aside from no biomaterial is necessary to incorporate with, the operation procedure is not too much dierent from dentist's daily practice. Section tooth, extracting root fragment, osteotomy and implant placement, all of aforementioned treatments are not dicult tasks for an experienced clinician who practice implant dentistry. However, there is no long term clinic follow up yet, neither any clinic trial. e case report from our clinic is the first one talking about clinic problems occurred during treatment and possible solutions. Amount five cases, two of them had infection, however it does not mean infection is the main problem for this technique. In case 2, the gingiva inflammation occurred after crown loading, we saw gum swelling and bleeding, and upon probing we discovered fracture of root shield. e permanent crown probably slight bigger than the root shield and caused fracture, the fracture line in turn offered a recess for bacteria invasion. Since the fracture fragment was small and lose, we removed the fragment in order to eliminate the recess and irradiated with laser9. (Aoki et al. 1996, Bactericidal effects of erbium YAG laser on periodontopathic bacteria) Problem was solved, and we learned a lesson that beer not to make the root shield too thin, root shield that is thiner than 1 mm is prone to fracture. In case 5, symptom of infection began as granulation tissue over growth from the lingual side of gingiva margin, and this was found at 4th weeks of follow up visit. Aer removing the temporary crown, we carefully probing around the implant, the pocket was found at distal buccal side. In the early stage of osseointegration, peri-implantitis is not a common situation, excessive temporary cement may be the cause of inflammation in case 5, and since osseointegration was not completed at 4th week, traditional curettage should not be the choice of treatment, that is why we use laser to treat the infection, for laser is able to clean the implant surface without direct contact. In case 1, temporary crown was installed right after implant placement, and the occlusal contact was took off by leaving 1 mm clearance. However, patient came back with mobile implant at the second week follow up. It happen that sometimes patient does not pay aention and bite on the implant which is still under healing. In this case, we explained to the patient that wearing temporary crown may cause delay healing of the implant due to unaware occlusal over loading. Knowing the possible risk of failure osseointegration, patient chose to have implant heal on time rather than having a temporary crown. "since I am 75 years old, and having a family already, esthetic is no longer my first priority" said the patient. So we removed the temporary crown, carefully examined the tissue condition, torqued down the implant with 30 newton and le it heal undisturbed. Aer 3 months of uneventful healing, patient came back for impression taking and permanent crown fabrication. In case 4, gingiva recession occurred at distal buccal side, and buccal shield exposed. When we ground off the exposed root shield we saw remaining cement in between root shield and prosthesis. e remnant cement probably the cause of recession, so we will remove the cement and wait for a period of time then go ahead to perform semilunar incision technique for covering recession area. From the experiences of all clinic cases, we can say that there are some important things we need to pay more aention for a successful socket shield technique. First, the case selection, tooth with periodontitis or uncontrolled infection is not indicated for this technique, keeping the contaminated root can cause implant infection and peri-implantitis, and eventually become a more dicult situation. Second, know the length of root. Doesn't matter use CT-SCAN or panoramic radiograph, it will help the surgeon to be sure that he or she is thinning the root shield instead of bone tissue ird, keeping the inter proximal portion of the root will help to preserve the interdental papilla, the sharpey's ber holding the papilla to the cervical portion of root, once the root is lost papilla will prone to shrink. Fourth, sucient thickness of the root shield can prevent fracture, and if root shield fracture does occur, it is suggested to grind off the fracture line, that way, the risk of bacteria invasion through fracture line can be eliminated10. As for implant position, following the esthetic guide line and place implant lingually, and if there is gap between implant and root shield, leave it without any grafting material. Last but not least, it is never over emphasize the importance of pretreatment planning on the computer.
Socket shield technique is safe, easy to learn and promising. However, preparation of the root shield is delicate and play an important role. So far, there is no sufficient evidences to support this technique as clinical daily practice, long term follow up and large scale clinical trial research is needed.
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- Araújo, M. G. & Lindhe, J. Dimensional ridge alterations following tooth extraction. An experimental study in the dog. Journal of Clinical Periodontology 32,212-218 2005.
- Stefan Fickl, Oo Zuhr, Hannes Wachtel, Christian F. J. Stapelt, Jamal M. Stein, Markus B. Hürzeler. Dimensional changes of the alveolar ridge contour after different socket preservation techniques. Clinical Periodontology 35,906-913; 2008.
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- Peter N. Demmas, George C. Sotereanos. Closure of alveolar clefts with corticocancellous block grafts and marrow: A retrospective study. Journal of Oral and Maxillofacial Surgery 46,682-687; 1988 .
- Landsberg, Cobi J. Socket seal surgery combine with immediate implant placement: A novel approach for single-tooth replacement. International Journal of Periodontics & Restorative Dentistry. 17,140-149; 1997.
- Hürzeler MB, Zuhr O, Schulbuch P, Rebele SF, Emmanouilidis N, Fickt S. The socket-shield technique: a proof-of-principle report. Journal of Clinical Periodontology. 37,855-862; 2010.
- Konstantinos D. Siormpas, Miltiadis E. Mitsias, Eleni Kontsiotou-Siormpa, David Garber, Georgios A. Kotsakis. Utilizing the "Roor-Membrane" technique: clinical results up to 5 years postloading. International Journal of Oral and Maxillofacial Implants 29,1397-1405; 2014.
- Yoshinori Ando, Akira Aoki, Hisashi Watanabe, Isao Ishikawa. Bactericidal effect of Erbium YAG laser on periodontopathic bacteria. Laser in Surgery and Medicine 19,190-200; 1996.
- Daniel Bäumer, Oo Zuhr, Stephan Rebele, David Schneider, Peter Schupbach, Markus Hürzeler. The socket-shield technique: first histological, clinical, and volumetrically observations after separation of the buccal tooth segment - A pilot study. Clinical Implant Dentistry and Related Research. 17,71-82; 2015.