Lupine Publishers | Is Alveolar Ridge can be Completely Preserved by Socket Shield Technique (SST)? A Case Series

 Lupine Publishers | Journal of Surgery & Case Studies

Abstract

Background:Tooth extraction is usually followed by partial resorption of the residual alveolar ridge. Different techniques such as ridge preservation procedure have been proposed to maintain the ridge dimension. However, applying these methods to extraction sockets could not completely preserve the coronal part of facial bone walls, which were comprised almost entirely of bundle bone.

Aim: To assess the effectiveness of partially tooth extraction (SST) for completely preservation of alveolar ridge.

Materials and Method: Case series study, which includes 6 participants medically fit, undergoes extraction of Non-restorable teeth, which doesn’t have any periapical or periodontal pathology. After clinical and radiographical assessment, computed tomography (CBCT), indicated insufficient width of buccal bone plate therefore socket shield technique was planned for simultaneous immediate implant placement with immediate provisionalization in area between the maxillary first premolars. Initial follow up after two weeks then after 2 months final restoration by screw retained crowns inserted, after 6 and 12 months of loading follow up by using CBTC, for evaluation bone remodelling and clinical evaluation of soft tissue changes around implants.

Result: Two weeks follow up revealed the healing was uneventful, and after 6 and 12 months the clinical and (CBCT) revealed, that retaining root fragment adjacent to the buccal crestal bone and placing an implant engaged to the palatal socket wall immediately are able to maintain the contour of the ridge. And the implant can achieve osseointegration without any inflammation at Periimplant tissue and also soft tissue contour preserved.

Conclusion: within limitation of this study we can conclude, after one year follow up, SST can prevent soft and hard tissue changes can be happens during healing of alveolar socket after tooth extraction. However the using SST as routine clinical practice stile need to higher level of evidence.

Abbreviations: SST: Socket Shield Technique, RST: Root Submergence Technique

Introduction

Literature has reported after tooth extraction, the alveolar bone undergoes a remodeling process, which leads to approximately 3.87 mm of horizontal ridge reduction and 1.67mm of vertical ridge reduction in the 6-12 months following extraction, primarily in the initial 3 months [1]. Conversely, the loss of a tooth triggers a remodeling reaction as part of the healing process, involving various degrees of alveolar bone resorption, especially affecting the buccal lamella: The bundle bone is primarily vascularized by the periodontal membrane of the tooth. Therefore, this part of the alveolar bone is compromised by the extraction, to such an extent that the buccal lamella is insufficiently nourished, leading to its total or partial resorption [2]. A higher degree of resorption is to be expected in the presence of flap formation, thin soft tissue biotype and prominent roots, especially with frontal teeth in buccal position [1,3]. These resorption processes complicate dental rehabilitation, particularly in connection with implants [4]. Immediate implant placement does not necessarily prevent resorption of the alveolar ridge [5]. A variety of ridge preservation techniques using tissue and augmentative materials have been proposed in the literature [6]. It has also been suggested that resorption of the buccal bundle bone can be avoided by leaving a buccal root segment (socket shield technique) in place, because the biological integrity of the buccal periodontium (bundle bone) remains untouched. This method has also been described in connection with immediate implant placement [7]. Clinical Concept, Procedures and Indications With the root submergence technique (RST), submucosal root retention can virtually eliminate bone resorption [8]. Based on this concept, the retention and stabilization of the coronal and buccal bundle bone and the retention of the periodontal membrane by retaining a coronal tooth fragment (so-called “socket shield”) [6]. Therefore, potential indications for such techniques include their use as part of the (delayed) late implantation approach or the optimization of pontic support in crown-bridge reconstructions or to improve the prosthesis base for removable dentures [7].

Figure 1: Socket Shield Technique by immediate implant placement.

A step-by-step illustration of the proposed procedure: Firstly, the hopeless tooth is split supragingivally, the crown fragment is carefully dislocated and removed using a suitable instrument. Then, the root is separated vertically in a ratio between 1:3 and 2:3. The smaller, buccal root fragment is retained and the larger lingual root fragment is removed in a manner that spares bone and soft tissue to the greatest possible extent. The height of the buccal socket shield is reduced to the level of the bone. Simultaneous immediate implant placement Figure 1. After the procedure, patients rinse with 0.2% Chlorhexidine mouthwash two to three times daily for one minute over a period of at least ten days. During this time, mechanical oral hygiene is avoided in the affected area and only restarted after the follow-up examination. Anti-inflammatory drugs (e.g., Amoxicillin 500mg tid) are prescribed as needed. Each patient was informed verbally and in writing about the treatment and the materials used as well as the associated pre-and post-operative risks and gave their written consent to the use of the collected data and photos.

Figure 2: Treatment procedure for case 1.

Case Presentations

Case 1

Medical history: A 45-year-old woman, non-smoker with noncontributory medical history. Extra-oral findings: The patient’s facial features were symmetrical with average smile lines. On inspection and palpation, no abnormalities detected. Intra-oral findings: Non-restorable tooth #23, which doesn’t has any periapical or periodontal pathology. Clinical and radiographical assessment, computed tomography (CBCT), indicated insufficient width of buccal bone plate. Treatment plan: partial root extraction of tooth #23, prevention of alveolar ridge resorption using the socket shield technique, simultaneous immediate implant placement (Straumann 4.1x12 RN) with immediate provisionalization crown. Initial follow up after two weeks, then after 2 months final restoration by screwretained crown inserted. After 6 and 12 months of loading follow up by using CBTC, for evaluation bone remodeling and clinical evaluation of soft tissue changes around implants. The treatment is depicted in Figure 2.

Case 2

Medical history: A 35-year-old man, smoker with noncontributory medical history. Extra-oral findings: The patient’s facial features were symmetrical with average smile lines. On inspection and palpation, no abnormalities detected. Intra-oral findings: Non-restorable tooth #24, which doesn’t has any periapical or periodontal pathology. Clinical and radiographical assessment, computed tomography (CBCT), indicated insufficient width of buccal bone plate. Treatment plan: partial root extraction of tooth #24, prevention of alveolar ridge resorption using the socket shield technique, simultaneous immediate implant placement (Straumann 4.1x10 RN) with immediate provisionalization crown. Initial follow up after two weeks, then after 2 months final restoration by screwretained crown inserted. After 6 and 12 months of loading follow up by using CBTC, for evaluation bone remodelling and clinical evaluation of soft tissue changes around implants. The treatment is depicted in Figure 3.

Figure 3: Schema of a Student Scientific Society structure.

Figure 4: Professor SHOR GV (1812-1944) - well known Pathologist - with students at a meeting of the student scientific circle of Pathologic Anatomy in the 30-ties.

Case 3

Medical history: A 37-year-old woman, non-smoker with noncontributory medical history. Extra-oral findings: The patient’s facial features were symmetrical with average smile lines. On inspection and palpation, no abnormalities detected. Intra-oral findings: Non-restorable tooth #21, which doesn’t has any periapical or periodontal pathology. Clinical and radiographical assessment, computed tomography (CBCT), indicated insufficient width of buccal bone plate. Treatment plan: partial root extraction of tooth #21, prevention of alveolar ridge resorption using the socket shield technique, simultaneous immediate implant placement (Straumann 4.1x10 RN) with immediate provisionalization crown. Initial follow up after two weeks, then after 2 months final restoration by screwretained crown inserted. After 6 and 12 months of loading follow up by using CBTC, for evaluation bone remodelling and clinical evaluation of soft tissue changes around implants. The treatment is depicted in Figure 4.

Discussion

Post extraction ridge collapse with degrees of alveolar resorption has been extensively documented in the literature. These hard and soft tissue defects can negatively affect ideal planned implant placement with a potential for esthetic failure [9]. Bundle bone arises from a functionally loaded PDL and is lost following extraction, resulting in an almost certain collapse of the buccofacial tissues [10]. Ideally, a method for the prevention of alveolar ridge resorption should be a cost-effective and minimally invasive, with only minimal material requirements. However, these criteria are not entirely met by any of the methods available today. Moreover, the goal of complete preservation of the alveolar ridge after tooth extraction has not even been reached with sophisticated techniques [11]. First reported in 2010 the SS technique had progressed from concepts introduced in the 1950s that the retention of a tooth limits tissue alterations following extraction. The submergence of tooth roots was introduced originally to preserve alveolar ridge volume beneath removable full prostheses [12,13]. The retention of tooth roots in the alveolar process can preserve the ridge tissues Histologically this was demonstrated by Hürzeler and coworkers. The buccal plate crest showed an absence of osteoclastic activity an absence of active remodelling [14]. The histological analysis suggests that the buccal bone plate was preserved. Therefore, it may be speculated that this technique may have the potential to avoid the marked resorption of the buccal bone plate after tooth extraction [15]. The clinical outcome of Hürzeler and coworkers’ report presented the successful osseointegration of an implant placed simultaneous to the SS technique and a restoration with aesthetics indistinguishable from the adjacent maxillary central incisor. Whilst the authors reported preservation of the buccofacial tissues, it should be noted that absolute preservation has not yet been shown.

The authors later reported a mean of 1 mm horizontal loss after final restoration, Chen and coworkers reported 0.72 mm of buccal resorption [16,17]. Retaining the buccal aspect of the root in conjunction with immediate implant placement is a viable technique to achieve osseointegration without any inflammatory or resorptive response [15]. It needs to be highlighted that the presented partial extraction is technique-sensitive and associated with the risk of displacement of the buccal root fragment, or even the buccal lamellar bone. Already at the time of extraction, the root fragment should be reduced along its vertical axis to the level of the height of the alveolar ridge to prevent perforation of the buccal mucosa during the healing period. Should the root fragment become exposed despite this preventative measure, height reduction and tissue freshening can be performed during follow-up visits [7]. The SS technique offers a promising solution to the difficulties encountered when managing the post-extraction tissues. This case series of immediate placement simultaneous to the SS technique is among the first to demonstrate with a 1 year follow up successful preservation of post-extraction tissues coinciding with successful restorative implant treatment.

Conclusion

Within limitation of this study we can conclude, after one year follow up, SST can prevent soft and hard tissue changes can be happens during healing of alveolar socket after tooth extraction. However the using SST as routine clinical practice stile need to higher level of evidence.

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Lupine Publishers | Scientific Student Societies: A Way of Scientific Research Vocations Boosting

 Lupine Publishers | Journal of Surgery & Case Studies

Abstract

Born in Russia at the end of the XIXth century the Scientific Student Societies have developed a rather original way of initiation and involvement of the young in the scientific research during High School and University cursus. All through the XXth century and up to now, they have given several generations of Russian scientists an adequate pre formation consisting not only of skill acquisition in their future speciality but also in planning, realization and organization of scientific research and sharing of its results. Their popularity was also due to the high degree of initiative and autonomy left to the students.

Abbreviations: SSS: Scientific Student Societies

Introduction

In our days, when most of young people with a diploma of physician are no more inspired by a scientific career possibility, and though Occidental World has general negative opinion about Russia and its institutions, it is not forbidden to exhume some moments which have proved efficacy and may be useful for.com now. Such an interesting institution (from my point of view) was the Scientific Student Societies (SSS) [1], existing in all the High Schools and Universities, but may be especially activated in Medicine Faculties. They were created in the end of XIXth century by famous scientists such as VI Vernadski (Figure1) and his colleagues in Sankt Petersburg (1882) and in the beginning of the XXth century by NE Jukovski (Figure 2) in Moscow (1909) [1-4]. In the 30-ies they were reactivated and widespread through all the country. After the 2nd World War, SSS were also working in the other countries of the “East Bloc”. The links and experience exchanges were current between them (International meetings and conferences, scientific information share, student exchanges and so on). Presently in the XXIth century they have not disappeared: “NIRS” - student scientific research work - remains a preoccupation of the academic staff in Universities and High Schools as well as different Ministries of the Russian Federation. Student scientific associations still exist, may be a little modified, sometimes independently as “Meridian”, “Luch” (that means ray or beam). Books including scientific articles written by students are still published [5-7], regional and national competitions are organized.

Figure 1: Vladimir Vernadski (1863-1945) famous chemist and mineralogist, creator of the first student scientific circles in Russia.

Figure 2: Monument to NE Jukovski (1847-1921) - The “Father of Russian Aviation” - in the Entry Square of the Petrovski Palace (Aviation school) in Moscow.

Description and Commentaries

The SSS aims were: to popularize scientific research among students, to find out the most talented among them and to help them to develop towards an eventual scientific career. It was also a mean for students to acquire deeper knowledge in one or several disciplines and to choose their future speciality. The Student Scientific Circles eventually provided the departments with qualified helpers, as a just return for the teaching staff mobilisation during the young researcher’s formation. The structure schema of the SSS is presented in Figure 3. At the basis level was the Circle. As soon as they wanted, students were invited to join a student scientific circle by the department of their choice and to begin their initiation according to their trends with one of the assistant or docent. At this level, the students learned step by step how to manage scientific literature, to review it, to deepen their knowledge’s in the chosen subject, to acquire technical skills and, last but not least, to participate to the research of their mentor/supervisor, or even to start their own investigations on their personal research topic.*NB. The work performed within the SSS activity differed from end of cycle obligatory works, but the members of SSS were allowed to include their personal data in the end of cycle work, if it was adequate. The students - members of a circle - elected their president - responsible who organized periodic reunions for reviewing the work performed by the circle members. During these meetings experienced assistants and docents or professors were invited to present lectures or demonstrations helping the students to assess the peculiarities and the research specifics of the discipline (Figure 4). The best student ‘works were selected and recommended for reporting at Faculty and inter Faculties student scientific conferences.

Figure 3: Schema of a Student Scientific Society structure.

Figure 4: Professor SHOR GV (1812-1944) - well known Pathologist - with students at a meeting of the student scientific circle of Pathologic Anatomy in the 30-ties.

The next level was Faculty and University or High School Scientific Student Society. The department circles joined forming faculty and institute Student Scientific Societies (SSS), which were gathered as University or High School SSS. They were handed by students and only supervised by a responsible chosen among docents and professors of the Faculty. Students elected their president and delegates for contacts with other faculties, institutes of the country and of foreign countries. They organized faculty conferences, Inter-faculty scientific sessions. Their activity was financed either by the Professional Union of their School or by the University budget. The most promising students - members of SSS were further recommended for scientific work either in the department where they started their work, or in Scientific Research Institutes and other High School Faculties (according to the young specialist’s will and the possibilities of the aforementioned institutions). The Ministries took into account the SSS activity of the young specialist when his future was considered after the end of his cursus. Besides career start consideration, other awards were current: scientific books, scientific travels, being the co-author of a “chief’s paper, and so on. So the students made acquaintance not only with the individual searching process itself (Figure 5), but also with elements of organizing scientific research, co-operative investigation, discussion and peer evaluation of its results both by other students and by the Faculty staff scientists. Students also learned to communicate at different levels and, if they wanted, to prepare themselves to a scientific career. If not, nevertheless the aptitudes obtained during their work in the SSS was precious for their further professional activity: acquaintance with special literature research methods, reviewing and critics of scientific publications, acquisition of some technical skills, capacity to plan scientific research and organize scientific meetings.

Figure 5: Students at Research work in a Technical High School in the 80-ies.

It is estimated that about 20% of the students attended the SSS. Among them about 30% have presented a valuable work (compilation, fundamental or applied research). Most of the exmembers of SSS have pursued a career in the previously chosen specialty. In Russia, all through the years 1930-1990 and up to now most of those who have followed a successful scientific or pedagogic career, were ancient members of the SSS. (That does not mean that without SSS a scientific career was not possible). Many of the students, even foreigner hosts, who have passed through this “school” have been later eminent scientists of their countries (for instance: Academician VI Shumakov - the first Director of the Transplantation Institute in Moscow, Professor VM Filipov - present Rector of the Russian University od People Friendship; Professor R Roman Ramos - Dean of the Medicine Faculty of the Mexico Autonomous University)

Conclusion

The SSS have given several generations of motivated Russian scientists an adequate pre formation consisting not only of skill acquisition in their future speciality (especially precious in surgical disciplines) but also in planning, realization and organization of scientific research and share of its results. This was capital for a developing country and remains important nowadays. The large autonomy and initiative given to the students in the SSS has certainly contributed to their popularity and success. This experience ought to be adapted to the conditions of our present society development and could enhance individual initiative and motivation, as well as collective research organization. It ought to be included into Faculties staff task and financing.

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