Combined Buccal and Proximal Socket shield
59 yer old healthy male with failing mandibular anterior teeth. In this case a combined socket (SS) shield was done utilizing buccal shield (Baumer et al. Clin Implant Dent Relat Res 2013) for the conventional root and Proximal Socket Shield (PSS) for a root with a buccal fracture. Proximal socket shield (Kan and Rungcharassaeng IJPRD 2013), should be considered when the PET concept comes into play. The Kan article suggests that the proximal shield should occupy the complete length of the root, remain 2.0 mm supra-crestal, follow the outline of the tooth and be uniform thickness of 1.5-2.0 mm to provide strength and durability, but also thin enough to not interfere with the implant placement. The article recommends tapered implants. Contraindications for PSS include roots that are less than 6.5 mm wide, significantly tapered or tilted roots. These conditions may interfere with proper shield preparation and implant placement.
Multiple options presented with recommendation to remove teeth numbers 24 and 26 retaining the socket shields, dual zone grafting, simultaneous enucleation of the cyst with grafting of the bony crypt, and delayed loading. After decorination, tooth number 24 was noted to have a vertical fracture through the buccal plate. Tooth number 26 was noted to have a mesial fracture. The shields were prepared to the level of the osseous crest, removing the fractured lines. Astra 3.0 x 15 mm implants were placed using Versah drills in clockwise rotation. Implants were placed to approximately 2 mm below the osseous crest. Dual zone grafting was done and PME’s were placed. The radicular cyst was then accessed from the buccal aspect utilizing an incision at the muco-gingival junction. The cyst was removed and the bony crypt cleansed. The defect was then grafted with sticky bone from the L-PRF protocol utilizing Miner-Oss. Several fibrin clots were positioned both vertically and horizontally to isolate the defect. The interproximal tissues between the implants were elevated slightly to allow positioning of the vertically positioned fibrin. Comments Welcome!!