J Stomatol Oral Maxillofac Surg 124 (2023) 101469

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Technical Note

Dual-guide template−guided socket-shield preparation and immediate

implantation in maxillary anterior region implant surgery
Changfu Xiea, Endian Sua, Mingdong Yana, Jingjing Huanga, Xiaoan Yea, Gusheng Luob,
Weiliang Wua,*, Jianyong Ruana,*
a
Department of Oral Implantology II, School and Hospital of Stomatology, Fujian Medical University, Fuzhou 350001, China
b
Zhongshan Hospital (Xiamen), Fudan University, Xiamen 361000, China

A R T I C L E I N F O A B S T R A C T

Article History: For immediate implants in the anterior region, the socket-shield technique has received much attention in
Received 11 December 2022 recent years. However, this technique is technically sensitive and root preparation is difficult. It is also diffi-
Accepted 11 April 2023 cult to obtain the ideal three-dimensional position for implant placement in the anterior region. This paper
Available online 13 April 2023
reports a clinical case in which socket-shield preparation and implant cavity preparation were performed
with the aid of a dual guide in implant surgery. The dual guide surgical preparation technique was used to
Keyword:
reduce the difficulty of socket-shield preparation and to achieve restoration-orientated implant placement
Immediate implant
with satisfactory clinical results.
Socket-shield technique
Dual-guide template
© 2023 Elsevier Masson SAS. All rights reserved.

1. Introduction During the ‘socket-shield’ technique, the treatment of the root

fragment is critical to its success. In previous studies [5,8−12], there
Most teeth in the anterior maxilla have a thin labial bone plate, was some agreement on the length, thickness and neck profile of the
consisting mainly of bundled bone. Following tooth extraction, the residual root fragment when performing the socket-shield procedure
alveolar bone is subject to different degrees of resorption and the that could increase the risk of postoperative complications if the pro-
thinner the labial bone wall, the more severe the atrophy of the alve- file was not properly prepared. Additionally, excessive alveolar bone
olar bone width [1]. In this case, the implant may not be placed in the grinding and perforation of the labial bone wall can occur due to lim-
ideal three-dimensional position. With immediate implants, although ited visualisation, and it is difficult to be sure of the shape of the pre-
they have the advantages of being minimally invasive and time-sav- pared root. So, the socket-shield technique is a highly technically
ing, it is difficult to avoid the resorption of the labial bundle bone sensitive procedure. Accordingly, the focus of this study was on how
after extraction [2]; this causes the collapse of the gingival contour to trim the root with more certainty. The digitally-assisted design of
and results in aesthetic defects. The complete preservation or recon- the double-guide preparation technique and the use of a convention-
struction of peri-implant soft tissue remains a major challenge for ally equipped implant guide kit provided good guidance for both root
oral implantology. trimming and implant cavity preparation, resulting in a good surgical
In 2010, Hu € rzeler et al. published the first study on the ‘socket- outcome.
shield’ technique [3]. This preserves the root-periosteal-bundle bone
complex on the labial side of the edentulous area, maximising the
2. Technique
stability of the original hard and soft tissue in this area. A histological
study by Schwimer et al. showed that new bone filled the gap
A 55-year-old, healthy, non-smoking male fractured a crown on
between the root fragment and the implant and that the new bone
his maxillary left central incisor while biting a hard object three days
had a concentric structure in which osteocytes were visible [4]. The
ago. Clinical evaluation revealed multiple oblique fracture lines on
results of this randomised controlled study showed the advantages
the maxillary left central incisor and a 3 mm sub-gingival fracture
of the socket-shield technique compared to conventional immediate
line on the labial aspect. As shown in Fig. 1, the patient had a low
implants in terms of maintenance of bone volume and aesthetic
smile line and normal vertical overlap. The preoperative 3D cone
results [5−7].
beam computed tomography (CBCT) image showed that the tooth
was root-canal treated without any periapical involvement. The labial
* Corresponding authors.
bone wall was complete but thin, at less than 1 mm. The retained root
E-mail addresses: [email protected] (W. Wu), [email protected] length was approximately 7 mm, which was too short to support
(J. Ruan). crown restoration. After discussing possible treatment options, a

https://doi.org/10.1016/j.jormas.2023.101469
2468-7855/© 2023 Elsevier Masson SAS. All rights reserved.
C. Xie, E. Su, M. Yan et al. Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101469

Fig. 1. A,B, Clinical intraoral examination before surgery. C, Preoperative smile view. D,E, Radial plane views and transverse views of radiograph examination before surgery.

decision was made to replace this tooth with an implant-supported CBCT data to design the surgical template for root preparation and
restoration. To obtain a good aesthetic result, the use of a root shield implant placement using 3Shape software. As shown in Fig. 2, the
with immediate implantation was recommended. implant placement direction and depth were first determined
Preoperatively, three-dimensional images of the entire dentition according to the expected position of the future restoration, so that it
were obtained by intraoral scanning. These were combined with could be penetrated from the palatal side of the restoration and have

Fig. 2. A, Preoperative digital data of maxilla and simulating future restoration. B, C, Implantation guide planning. D, Socket-shield guide planning. E, Simulating shield preparation.
F, Association between implant and socket shield(red).

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C. Xie, E. Su, M. Yan et al. Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101469

Fig. 3. A, Socket-shield guide in position. B, Guided drilling on root. C, Occlusal view after drilling. D,E, Root cut mesiodistally into buccal and palatal parts. F, Removing the palatal
parts, G, Implant placement guide in position. H, Guided osteotomy drilling for implant placement. I, Osteotomy prepared. J,K, Implant placement. L, Bio-oss bone powder implanta-
tion into the buccal jump gap. M, Healing abutment placement . N, O, Postoperative cone beam computed tomography images.

sufficient retention. Thus, the first guide was designed. Then, the buccal jump gap. A large-diameter healing abutment was screwed
shape of the reserved root piece was designed based on the position in to close the extraction wound.
of the implant and the restoration. The second guide was designed by 3 month later, impressions were taken, and temporary resin
the placement of drill pins step by step to a thickness of 1.0 mm, in crown restorations were provided for gingival shaping. After two
most of the tooth on the labial side. Both guides were designed to be adjustments with temporary resin crowns, the gingival plasticity was
tooth-supported, thus ensuring their stability. satisfactory. The final restoration was completed using a porcelain
Intraoperative, as shown in Fig. 3, after local anaesthesia (Prima- abutment with an all-ceramic restoration, with palatal penetration
caine Adrenaline, 1.7 mL), the root was prepared under the guidance and screw retention (Fig. 4).
of the socket-shield guide template. Sterile saline coolant was used The gingiva was stable with good aesthetic results at the six-
during the entire drilling procedure. After being drilled to a diameter month postoperative review (Fig. 5).
of 3.5 mm, the root was divided into buccolingual and lingual halves
with a long-handled fissure drill (HP-701; SS White Dental) and 3. Discussion
then the palatal side was divided into proximal and distal mesial
parts. The palatal side was extracted with a minimally invasive Immediate implants can shorten the duration of the patient’s
jaw. The remaining tooth fragment was refined to 1.0 mm above edentulism and maintain a good soft tissue profile. However, the thin
the alveolar bone. The implant osteotomy was then prepared bone wall of the upper anterior teeth, which is prone to resorption,
with the implant placement guide template and the implant poses greater uncertainty for immediate implantation in the upper
(3.3 £ 12 mm; Straumann BLT, RoxolidSLActive) was placed. Bio- anterior region. Although some studies have concluded that there is
oss bone powder (Geistlich, Switzerland) was filled into the less collapse of the labial bone wall in the anterior region when the
3
C. Xie, E. Su, M. Yan et al. Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101469

Fig. 4. A, Digital design of interim restoration. B, Interim restoration. C, Interim restoration positioned. D, Definitive restoration. E, Frontal smile view after definitive restoration
placement. F,G, Intraoral views.

labial bone wall is thicker than 1 mm, few people meet this condition In a study on root fragment preparation, Tan et al. found a nega-
[13]. To avoid affecting the aesthetic results of implants, scholars tive correlation between bone resorption and root thickness when
have proposed various techniques to avoid the collapse and resorp- the root shield thickness was between 0.5 and 1.5 mm [17]. It has
tion of the labial alveolar bone. also been suggested that a root shield thickness of 1 to 2 mm is ideal
The socket-shield technique allows for better maintenance of to meet both strength and space requirements [18], while Huang et
the lateral labial bone wall. Due to the preservation of the blood al. indicated that a root shield length of 4 to 6 mm was best [19]. In
supply from the periodontium in the lateral labial bone plate, terms of the root fragment height, Ba €umer et al. prepared the coronal
good postoperative indicators in terms of lateral labial bone surface of the root shield to 1 mm above the level of the labial bone
width, bone height and marginal bone changes were found [14]. but identified that the tip should not be overly sharpened [5]. On the
A study by Bramanti et al. reported that the postoperative aes- other hand, Gluckman et al. concluded that having the root shield
thetic area exhibited a more natural contour appearance due to flush with the alveolar ridge prevented root fragment fracture or cor-
the stabilisation of the bone level, without the need for additional onal displacement, thus avoiding root shield exposure [12]. Both
lateral labial soft tissue grafting—a good aesthetic result [15]. resulted in good clinical results.
However, there are also some postoperative complications with In the aesthetic zone, to maintain the blood supply and soft tissue
socket-shield surgery. Gluckman et al. noted that exposure within morphology of the alveolar fossa, full flaps are not recommended.
the root shield was amongst the most significant complications However, root shields are prepared in a freehand situation and the
that occurred; this was closely related to the preparation of the operator must stop frequently to check the depth and angle of the
root piece [16]. root division and to verify complete root separation [8]. Due to the
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C. Xie, E. Su, M. Yan et al. Journal of Stomatology oral and Maxillofacial Surgery 124 (2023) 101469

Fig. 5. A, Six-month follow-up after definitive restoration delivery. B, Nine months postoperative cone beam computed tomography image.

limited surgical field-of-view and the variations in root anatomy, Consent for publication
complications such as excessive root abrasion, root shield loosening
and dislodging—causing bone openings or injury to adjacent teeth All authors read and approved the final manuscript.
and poor 3D orientation of the implant— make the root shield tech-
nique a challenging and time-consuming technique [12]. Therefore, Declaration of Competing Interest
new technical tools are required to assist in performing this tech-
nique. Disclosures: The authors declare that they have no competing
Intraoral scanning was used to obtain information about the interests.
patient’s intraoral dentition and occlusion. By combining this with
CBCT data, an appropriate restoration profile was designed. The res-
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