الفهرس 
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Abstract
Summary
The present study aimed to evaluate the efficacy of the socket shield
technique for immediate implantation at the esthetic zone, through comparison to
the traditional conventional immediate implant technique. The study was
conducted on 20 implant sites present in patients attending the outpatient clinic,
Oral and Maxillofacial Surgery Department. The patient was presented with
remaining roots related to maxillary anterior teeth seeking extraction of the root
and immediate implant placement to restore esthetics and function.
All selected patients were informed about the details of the study and signed
informed consent. Approval of the Research Ethical Committee was taken before
starting the study. All patients were examined intra-orally by inspection to evaluate
existing alveolar ridge contour, height, and width, soft tissue attachments for any
signs of inflammation, ulceration, or scar formation, presence of existing
pathology, Palatal vault dimensions, and vestibular depth. Probing around the tooth
was performed to evaluate probing, condition of the remaining tooth structure, and
measurement of gingival sulcus depth and gingival thickness, to evaluate gingival
and periodontal condition. Patients who had mobility of the tooth or remaining root
as a result of the previously diseased periodontium or traumatic occlusion are
excluded.
The conclusion that was obvious from two pilot studies revealed that the
failure was mainly due to a lack of standardization of the root separation and
socket shielding technique which is supported by the review of the literature.
Therefore the present study was divided into two phases. The first phase was to
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standardize the technique of root division and amputation. The second phase was
to clinically assess the technique of the socket shielding.
An in-vitro pilot study was done on 10 extracted single-rooted tooth is used in
this phase; to standardize an accurate and significant technique of root separation,
whether the root was endodontically treated or not. Using Gates Glidden burs and
Peeso Reamers drills with periapical radiographs in separating the root into two
halves was a reproducible, and controllable technique with the reassurance of
reaching the root apex and complete removal of the root apex without injury to the
labial shield.
In the study group, the tooth was decoronated to the gingival level with care
taken not to damage the gingiva. This was done by using an irrigated long-shank
fissure surgical bur. The root canal was enlarged using manual files reaching
working length to size #50 using K files. Canals were further enlarged with Gates
Glidden drills to size #6 sequentially. Following canal widening with Gates
Glidden burs, Peeso Reamer drills were used directly down the root canal to the
apex. Cutting through the root with the canal as a reference point was done in
mesiodistal direction to the full working length till the root is entirely separated
into two parts (Buccal & palatal) from the coronal to the apical aspect. This was
the start of apex removal and was one of the most important steps in the technique.
Absolute care was taken not to penetrate bone or neighboring teeth mesial or
distally. A periapical radiograph was taken with a Peeso Reamer drill in the
prepared site. Once labial and palatal root halves were adequately separated, a
microperiotome instrument was inserted into the palatal periodontal ligament space
carefully displacing the palatal root section labially and retrieving it with a curved
hemostat. The labial shield was instrumented on its inner aspect with a sharp
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probe, inspecting for the absence of cracks and immobility. After reassurance the
root section is stable, any or all remnants of infection within the socket apex are to
be thoroughly curetted out, followed by a copious saline rinse. After that, the
coronal aspect of the root section was reduced and shaped to the level of the
alveolar bone crest by an irrigated large round diamond bur. The socket shield was
reduced approximately half its thickness from the root canal to its labial limit. The
coronal portion was thinner while maintaining a thicker apical root section. The
interproximal areas of the shield were prepared with a feather edge design to
facilitate the ingrowth of bone between the shield and implant surface. Again, the
socket was thoroughly rinsed with physiologic saline solution, and the root section
was inspected with a sharp probe for immobility. A periapical radiograph was
taken to visualize the complete preparation for sharp edges of the root and the
absence of any remnants in the socket.
Subsequently, the initial preparation of the implant bed was done with a
pilot drill of 2 mm according to the standard technique of implant placement, and
then the osteotomy was widened using sequential drilling according to the
manufacture instructions till the final diameter of the selected implant. The implant
drills were used through the long axis of the reaming root. The drilling was
initiated palatal to the shield leaving about 0.5-1 mm approximate gap, engaging
the palatal aspect of the root, so that the buccal aspect would remain intact
following preparation of the implant bed. A 4/13mm tapered self-threading implant
was used in conjunction with this technique as it follows the natural contours of the
mid and apical portion of the root and allows for retention of a root fragment with
enough thickness to ensure resistance to fracture. Finally, the implant was inserted
immediately to the bone palatal to the root. The implant housing was composed of
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the mesial, distal, and palatal bony walls while the buccal wall was occupied by the
retained buccal aspect of the root composed of a thin layer of dentin followed by
cementum, periodontal ligament, and bundle bone. A smart pig is then inserted into
the implant to measure the primary stability using Osstell. Finally, the smart pig
was removed, and the implant was covered by a healing collar. In the control
group, implants were inserted using the conventional immediate technique.
The post-operative assessment was done for implant stability, and after 48
hours to assess the presence of any signs and symptoms of infection or
inflammation. First, third, and sixth months postoperatively to assess implant
stability and peri-implant probing depth. Cone-beam computed tomography
(CBCT) was used immediately post-operatively and after six months for
measurement of horizontal bone loss, vertical bone loss, and measurement of bone
density.
No statistically significant differences between both groups regarding age
and sex. Before the procedures were done, a proper diagnosis was performed, and
the site was carefully evaluated. All patients in both groups were radiographically
free from pathosis.
The study group showed an insignificant increase in mean probing depth,
while the control group reported a statistically significant gradual increase in mean
probing depth. At one month, 3, and 6 months, a higher mean value was recorded
in the control group in comparison to the study group, with a statistically
significant difference between both groups.
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Both groups showed a gradual statistically significant increase in mean
Osstell Stability (ISQ) from immediately post-operatively; up to 6 months. In the
interval from immediately post-operatively to 6 months, the study group recorded a
greater percent increase, while the control group recorded a median percent
increase. However, these differences didn’t reach the level of statistical
significance.
Both groups reported a statistically significant decrease in the mean
horizontal Gap. In the interval from immediately post-operatively to 6 months, the
study group recorded a greater percent decrease, while the control group recorded a
median percent decrease, this difference between groups was statistically
significant.
Both groups showed a non-significant increase in mean vertical bone loss. In
the interval from immediately post-operatively to 6 months, the study group
recorded a percent increase, while the control group recorded a median percent
decrease. The difference between groups was statistically significant.
Both groups showed a statistically significant increase in mean bone density
immediately postoperatively up to 6 months. Immediately postoperatively, there
was no significant difference between groups (P=0.175). At 6 months, a higher
mean value (2823±603.31) was recorded in the study group in comparison to the
control group, with a statistically significant difference between both groups.
It has been concluded that the socket shield technique, eliminates the negative
consequences of bone resorption of the buccal bone plate resulting from tooth
extraction. Preserving a part of the root leads to maintaining hard and soft tissue
contours. The socket shield technique provides a perfect pleasing esthetic result with
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good function. It’s a highly promising technique in terms of maintaining pink and
white esthetics through the preservation of the interdental papilla during the
preparation of the interdental socket shield.