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.

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.

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.

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.

In seiner klassischen Form erstreckt sich ein Socket Shield von der mesio- zur distolabialen Kante des Zahns. C-förmige, L-förmige und approximale Socket-Shield-Designs besitzen approximale Extensionen, die den Hart- und Weichgewebeerhalt in den Approximalbereichen unterstützen. Dies bietet besondere Vorteile für Implantatstellen neben einem bereits vorhandenen Implantat oder einer Zahnlücke. Häufigste Komplikation der Socket-Shield-Technik (SST) ist die interne Exposition des Schilds. Aufgrund anatomischer ­Gegebenheiten, wie einer bogenförmigen Kammkontur und der ovalen Alveolenform einiger Zähne, erhöht sich das Risiko für eine interne Exposition, unbemerkte Verschiebung oder Fraktur des Schilds während der Implantatsetzung in den approximalen Schildbereichen. Im vorliegenden Beitrag werden Richtlinien für die Indikation der approximalen Schildextension, die Socket-Shield-Präparation sowie die Auswahl der Implantat- und prothetischen Komponenten vorgestellt.

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.

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. Keywords: bone graft, case report/series, dentin graft, platelet-rich plasma, socket shield, soft tissue ingrowth

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.

Bei fortgeschrittenem Attachmentverlust muss auf der Basis mehrerer Parameter entschieden werden, ob die Erhaltung eines Zahns oder die Entfernung und eventuell der Ersatz durch ein Implantat die besseren Alternativen darstellen. Insbesondere im ästhetisch relevanten Bereich müssen verschiedene Therapien hinsichtlich der Möglichkeit des Gewebeerhalts und/oder -gewinns sowie das Risiko eines Gewebeverlusts abgewogen werden. Bei dem hier dargestellten Patientenfall mit generalisierter schwerer chronischer Parodontitis erfolgte nach einer antiinfektiösen Initialtherapie eine regenerative Chirurgie am Zahn 15. Um ein ästhetisch akzeptables Ergebnis in Regio 11 zu erreichen, war ein interdisziplinäres Vorgehen erforderlich. Hierfür wurde der Zahn zunächst langsam orthodontisch extrudiert. Acht Wochen nach der Zahnentfernung, mit chirurgischer Weichgewebepräservation, wurde ein Implantat in Kombination mit Knochenregeneration (guided bone regeneration = GBR) und vaskularisiertem Bindegewebetransplantat eingesetzt. Keywords: Parodontologisch-implantologische Therapie, regenerative parodontale Therapie, orthodontische Extrusion