Q U I N T E S S E N C E I N T E R N AT I O N A L

PERIODONTOLOGY

Fabrice Cherel

Papilla preservation between two implants:

A modified socket-shield technique to maintain the
scalloped anatomy? A case report
Fabrice Cherel, DDS, MS1/Daniel Etienne, DDS, MS1

A scalloped anatomy maintained between two adjacent to preservation of interproximal root fragments. Clinical results
crowns supported by immediate implants is presented in this at 11 months after implant placement are presented.
clinical case. This is a modified concept of the socket-shield (Quintessence Int 2014;45:23–30; doi: 10.3290/j.qi.a30765)
technique, which allows preservation of the papilla due in part

Key words: implant esthetics, papilla preservation, socket shield

Simultaneous removal of multiple adjacent teeth in the tooth extraction.3 Immediate implant placement alone
anterior maxilla leads to a labial bony plate collapse as does not prevent bone remodeling and bone resorp-
well as a flattening of the interproximal bony scallop, tion,3 and clinical trials have focused on soft tissue
resulting in implant restorations with missing inter- recession that may occur after immediate placement.4,5
implant papillae. While the use of nonresorbable xenograft biomater-
This clinical case illustrates a modified concept of ial may partially compensate buccal bone resorption,6-8
the socket-shield technique,1 in the esthetic zone, to bone peak loss between two implants is not prevented.6
obtain a predictable result in implant therapy. The When the distance between two implants is less
authors’ proposed approach was the retention of the than 3 mm, development of a normal papilla is impaired
buccal root fragment of an extracted tooth in combina- and bone resorption may occur.9 In situations where suf-
tion with immediate implant placement. This approach ficient space for a papilla is present, a maximum of
allowed the buccal cortical bone to be successfully 3.5 mm papilla height is achieved. Any more ambitious
preserved. approach of papilla preservation or papilla creation
It is well known that bone resorption and soft tissue between two implants is at high risk of failure. On the
retraction occur following tooth extraction.2 Systematic other hand, in case of a single tooth replacement, the
reviews demonstrate that the alveolar ridge undergoes papilla level can be maintained by the proximal peri-
a mean horizontal reduction of 3.8 mm and a mean odontium (bone and soft tissue) of the adjacent teeth.10
vertical reduction of 1.24 mm within 6 months after The use of remaining roots was widely imple-
mented during the 1970s to restrain bone crest resorp-
1
Private practice, Paris, France.
tion. After 10 years of observation, submerged roots
have maintained the alveolar process under removable
Correspondence: Dr Fabrice Cherel, 24 Rue St Petersbourg, 75008,
Paris, France. Email: paro_implant@hotmail.fr prosthesis.11

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a Fig 1b Preoperative radio-

Fig 1a Preoperative view of the hopeless maxillary central inci- graph of the hopeless maxil-
sor with a buccal fistula on the right central incisor. Scars from lary central incisor with peri-
previews periapical surgery are seen. b apical infections.

Formation of a new attachment may occur over port immediately after extraction has been sug-
submerged sectioned teeth (root submergence tech- gested.15
nique, RST).12 This study, apart from showing bone Given all the information above, we have applied
regeneration predictability in intrabony defects around the socket-shield technique on two adjacent hopeless
submerged roots with the exclusion of epithelium cells, teeth. However, instead of buccal root retention, proxi-
has demonstrated an absence of resorption, ankylosis, mal root fragments were left intact to preserve the
and a lack of pulp necrosis in 30 roots within 9 patients. papilla bone peak, in combination with immediate
This RST was also proposed to preserve the alveolar implant placement and immediate provisionalization.
bone frame and assist in the creation of an esthetic
result in adjacent multiple-tooth-replacement cases.13
A beagle dog histomorphometric analysis has been
CASE REPORT
performed after retaining the buccal aspect of the root A 40-year-old patient who was a heavy smoker (more
in combination with an implant placement.1 There was than 20 cigarettes a day), was referred for the replace-
no incidence on osseointegration and no buccal tissue ment of the two maxillary central incisors. Preoperative
alteration. A human clinical study is ongoing and seems clinical and radiographic images showed nonrestorable
to be promising (Rebel SF, EAO Scientific Annual meet- teeth due to recurrence of periapical infections and
ing, Glasgow, 7 to 9 Oct 2010). root fracture. Cervical discoloration indicated poor oral
In a periodontally healthy patient, the volume of the health and a heavy smoking habit. Despite previous
buccal tissue can be stabilized and esthetics can be endodontic surgery, prognosis was hopeless due to a
maintained by using bone substitutes and connective short root, a recurrent apical infection, and a root frac-
tissue grafting,14 although no technique can guarantee ture on the maxillary right central incisor. The teeth had
the preservation of a papilla bone peak between two a triangular shape with a medium to thin periodontal
implants. Within the esthetic zone, it is a challenge to biotype, as determined by transparency of a periodon-
restore two adjacent implants. Success is not predict- tal probe inserted in the sulcus, but the smile line was
able due to a high risk of failure, especially at the papilla low. There was no attachment loss (Fig 1).
level. Considering the clinical situation, smoking habit,
However, for a single implant with a single-stage and patient’s desire, our concerns were to reduce the
approach, the obtained interproximal tissue level is risk of complications by soft tissue management and
comparable to pre-implantation, and mechanical sup- address the need for bone reconstruction.

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Fig 2 Occlusal view after removal of crowns: a Fig 3 Frontal view with a scalloped anatomy.
root fracture is observed on the distobuccal angle
of the right central incisor.

Fig 4 Conservative extractions: vertical Fig 5 Mobilization and subtotal extrac- Fig 6 A root fragment with its apex is
radicular sections in order to preserve the tion of the roots. removed.
buccal plate and the interdental papillae.

After nonsurgical therapy by scaling and root plan- The mesial coronal parts of the roots were left intact
ing with oral hygiene instructions, on the day of sur- while the apex of each root was meticulously removed.
gery the patient received 2 g amoxicillin 1 hour before It was important that there were no loose remnants left
intervention, a preoperative chlorhexidine mouth rinse, (Figs 5 and 6).
and 1 g amoxicillin 6 hours after surgery to reduce the Granulation tissue was removed and the alveolar
risk of infection. Local anesthetic was injected into the bone was disinfected with iodine socket rinse (Beta-
oral mucosa and palatally (2% mepivacain with epi- dine). Both implant sites were prepared slightly on the
nephrine 1:100,000). palatal side of the bottom of the socket. Conical
After the removal of the crowns, a vertical root frac- implants (Nobel Active system, Nobel Biocare) were
ture was clearly visible. Note the scalloped margin and placed completely within the confines of the socket
the presence of an interdental papilla (Figs 2 and 3). using the sterile surgical technique prescribed by the
Roots were sectioned in three parts without flap manufacturer (Figs 7 and 8).
elevation (Fig 4). Only the mesial part of the roots was Implant shoulders were positioned laterally 1.5 to
preserved in order to maintain the papilla of the central 2 mm from the adjacent teeth, 3 mm apical to the
incisors. The distal papilla was efficiently preserved due anticipated gingival margin, and 1 mm apical to the
to the presence of the roots of the lateral incisors and height of the most coronal wall of the alveolus.
their healthy periodontium. Implants were inserted with a 45 Ncm torque to obtain
an optimal primary stability.

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Fig 7 Osteotomy are prepared towards Fig 8 Implants are placed horizontally at Fig 9 Deproteinized bovine bone min-
the palate of the extraction sockets. 3 mm from the buccal plate with an axis of eral is layered into the gap between the
emergence toward the cingulum. alveolar buccal bone and implants

Fig 10 Impression taking by using trans- Fig 11 Occlusal view with healing abut- Fig 12 Direct implant screw-retained
fer impression coping during surgery. ments in contact close to the remaining provisional crowns.
fragments after impression.

Fig 13 Mesial concavity to avoid any pres- Fig 14 Three hours later, the provisional Fig 15 Three months after surgery, heal-
sure over the fragment. crowns were placed to support the mar- ing was completed, with good soft tissue
ginal soft tissues. integration and no signs of inflammation.

A nonresorbable bone substitute (deproteinized An impression with Impregum (3M Espe), was taken
bovine bone mineral, DBBM; Bio-Oss, Geistlich) was to produce provisional crowns (Figs 10 and 11), and the
placed to fill the gap between the implant and the buc- collagen sponge was changed.
cal plate (Fig 9). A collagen sponge (Hemocollagene, Provisional crowns were made with a concavity on
Septodont) was trimmed and packed around the base the subgingival mesial part to avoid any pressure on
of the impression coping to protect the bone substi- the root fragment (Figs 12 and 13). They were placed a
tute, especially during impression. few hours after surgery, with a slight pressure to sup-

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Fig 16 At 3 months, the

periapical radiograph
shows a satisfactory bone
density around the
implants. Note the absence
of radiolucency between Fig 17 A scalloped anatomy is preserved between the two
the root fragments and the implants. Note how the interdental papillae fill the entire embra-
implant surface. sure space.

Fig 18 Fragment remnants can be Fig 19 Procera zirconia (Nobel Biocare) Fig 20 Abutment connection to implants
observed with no sign of inflammation. abutments with a mesial concavity. 4 months after implantation. These sup-
Note that tooth coloration is due to a port the buccal soft tissue with controlled
heavy smoking habit. pressure.

port the soft tissues (Fig 14). The occlusion was on both sides, when the crowns were removed
adjusted to clear all contacts in maximum intercuspa- (Fig 18). The fragments could not be mobilized with a
tion and in lateral and protrusive excursions. Any occlu- probe.
sal contacts during centric and eccentric movements Full zirconia abutments (Nobel Procera, Nobel Bio-
on the provisional restoration were eliminated. care) were tried in (Figs 19 and 20). The same concavity
The patient was instructed to consume a soft diet was produced mesially and the rest of the emergence
and to avoid placing food in the surgical area during profile of the abutment was shaped to support the soft
the first 6 weeks as well as to rinse twice daily with 0.2% tissue (Fig 21). The definitive abutments were screwed
chlorhexidine digluconate. to the implant, and the definitive full ceramic crowns
After 4 months of healing, provisional crowns were were cemented onto the abutments (Dr Alexandre
well integrated in healthy periodontal tissue. Radio- Boukhors, Meudon). Marginal mucosa was clinically
graphic control and clinical examination of the torque healthy (Fig 22). The periapical radiograph 1 month
resistant value indicated that osseointegration was after crown cementation showed a satisfactory rela-
achieved (Fig 15). tionship between the platform and the bone level of
Complete preservation of the papilla was observed the distal aspect of the alveolus (Fig 23).
clinically and the bony peak was maintained radio- At 3 and 6 months after crown cementation (7 and
graphically (Figs 16 and 17). 10 months respectively after implant placement), clin-
A small part of the coronal aspect of the remain- ical and radiographic parameters were optimal: the
ing root was still apparent through the mucosa bed interproximal papilla, the gingival buccal margin levels,

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Fig 21 Occlusal view, showing a satisfactory buccal soft tissue Fig 22 Final restorations with full ceramic crowns 1 month after
bulk. crown cementation (5 months after implantation). The morphology
is similar to that of the natural teeth with an interimplant papilla.

Fig 23 Periapical radiograph 1

month after crown cementation, 5
months after implant placement.
Note the adaptation of the subgingi-
val part of the abutment (prosthetic Fig 24 Frontal view 11 months after implant placement. Note
support). the stability of the soft tissue.

a b
Figs 25a and 25b Occlusal (a) and palatal (b) view 11 months after implant placement. Note coloration on the palatal aspect of the
crown due to the smoking habit.

Figs 26a to 26c Radiographs 11 months

a b c after implant placement.

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and the interproximal bone level showed no change periodontal plastic surgery as well as peri-implant tis-
over this period of time. The situation 11 months after sue reconstruction should be avoided if possible. 21 Our
implant placement is shown in Figs 24 to 26. patient did not agree on abstinence at this time, and
with a thin and scalloped mucosa,22 there was a high
risk of developing papillae recessions and buccal reduc-
DISCUSSION tion following a surgical procedure with flap elevation
This clinical case deals with some complicating factors and tissue manipulation.4 Therefore the chosen proto-
such as periapical infection, smoking, and root fragments, col for this case was a noninvasive technique with a
which may be considered risks for immediate implants. reduced morbidity.
Clinical data available on immediate implant place- In an animal study on dogs, 16 roots were sub-
ment in chronic periapically infected sites suggest that merged 2 mm below the alveolar crest. After 60 days,
a history of endodontic infection is a predictive marker 62.5% of the sites had bone covering the top of the
for implant infection and failure.16 The possibility of soft submerged root. Cement and connective tissue were
and hard tissue contamination during surgery, persis- present between the newly formed bone and the root
tence of contaminants that were not seen clinically, surface.23 In a similar study on dogs, 12 roots were sub-
dimension of the lesion, and a noneffective debride- merged and at 12 weeks of healing, 8 roots were cov-
ment of the site during the surgery are critical factors ered with bone, with a vital pulp present in all of them.
that can explain implant failure. On the other hand, if an Some complications were reported, such as gingival
appropriate clinical procedure with antibiotic adminis- perforation and cyst formation.24 Human cases have
tration, meticulous cleaning, and alveolar debridement been followed when removable prostheses or fixed
is achieved, immediate implant placement in chronic partial dentures were applied over submerged roots.
periapical lesions may be performed.17 A prospective Failures increased with time, from three cases at 1 year
and randomized study of 50 patients with immediate after prosthetic delivery to 11 cases at the 4-year fol-
implants in periapically infected sites showed a predict- low-up. In 53% of the failures, an exposure of the root
able success rate of 92%.18 Considering these results, surface was seen, but without inflammation in the sur-
the replacement of two condemned teeth with a his- rounding tissue.25
tory of endodontic failure by immediate implants with Recently in implant-supported prostheses, sub-
the above requirements was a valuable option. merged roots have maintained their natural attach-
Small gaps between the implant surface and the ment apparatus at the pontic site. Roots were main-
socket walls have the potential for spontaneous heal- tained after resection and submerged with a coronally
ing.19 Larger gaps may be filled with bone substitutes, advanced mucosal flap. The alveolar bone frame was
which can be susceptible to contamination and infec- then completely preserved.13
tion. Immediate impressions after implantation may This approach is consistent with a study showing
increase the risk of infection, but they are not that the level of the papilla can be maintained by the
reported.14,15 In the present protocol, the placement of proximal periodontium,10 and confirms the possibility
a collagen sponge over the gap to avoid direct contact of maintaining a submerged root for an indefinite
with impression materials may decrease the risk of con- period.
tamination. A higher risk of failure seems to be associ- In an animal study on immediate implant place-
ated with the timing of implant placement.20 ment with or without grafting of extracted sockets with
Smoking effects are dose dependent on the reduc- DBBM, filling of the gap had a positive effect on the
tion of blood flow supplied by terminal vessels and a buccal bone thickness and the height.7 In case of facial
reduced immune response. Wound healing complica- tissue shrinkage, and if post-extraction tissue remodel-
tions often occur in heavy smokers, and complicated ing is not fully compensated by DBBM, the present ap-

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proach can be associated with connective tissue graft- 5. Sanz M, Cecchinato D, Ferrus J, Pjetursson EB, Lang NP, Lindhe J. A prospec-
tive, randomized-controlled clinical trial to evaluate bone preservation using
ing. A case series of 20 consecutive patients has shown implants with different geometry placed into extraction sockets in the max-
that connective tissue graft associated with bone graft- illa. Clin Oral Implants Res 2010;21:13–21.
6. Nevins M, Camelo M, De Paoli S, et al. A study of the fate of the buccal wall of
ing in the implant-socket gap favors stable marginal extraction sockets of teeth with prominent roots. Int J Periodontics Restora-
soft tissue conditions over a period of 2.15 years.14 tive Dent 2006;26:19–29.
7. Araújo MG, Linder E, Lindhe J. Bio-Oss collagen in the buccal gap at immedi-
Buccal root fragment retention can be an option ate implants: a 6-month study in the dog. Clin Oral Implants Res 2011;22:1–8.
that allows a preservation of facial tissues. Histologic 8. Allegrini S Jr, Koening B Jr, Allegrini MR, et al. Alveolar ridge sockets preserva-
tion with bone grafting: review. Ann Acad Med Stetin 2008;54:70–81.
evaluation on dog found newly formed acellullar 9. Tarnow DP, Cho SC, Wallace SS. The effect of inter-implant distance on the
extrinsic fibers with inserting periodontal ligament height of inter-implant bone crest. J Periodontol 2000;71:546–549.
10. Choquet V, Hermans M, Adriaenssens P, Daelemans P, Tarnow DP, Malevez C.
present along the entire inner wall of the retained root Clinical and radiographic evaluation of the papilla level adjacent to single-
fragment.1 Natural protection seems to be complete tooth dental implants. A retrospective study in the maxillary anterior region. J
Periodontol 2001;72:1364–1371.
and the absence of inflammatory reaction may be a 11. Howell F. Retention of alveolar bone by endodontic root treatment. Mexico:
determinant factor in the stability of the fragment. Seminario Annual del Grupo de Estudios Dentales USC, 23 May 1970.
12. Bowers GM, Chadroff B, Carnevale R, et al. Histologic evaluation of new attach-
However, buccal root retention fragment does not ment apparatus formation in humans. Part II. J Periodontol 1989;60:675-682.
compensate the papillae retraction following multiple 13. Salama M, Ishikawa T, Salama H, Funato A, Garber D. Advantages of the root
submergence technique for pontic site development in esthetic implant
adjacent tooth extraction, whereas it may be obtained therapy. Int J Periodontics Restorative Dent 2007;27:521–527.
with proximal root retention fragments. 14. Kan JY, Rungcharassaeng K, Morimoto T, Lozada J. Facial gingival tissue stabil-
ity after connective tissue graft with single immediate tooth replacement in
The combination of these two techniques has the esthetic zone: consecutive case report. J Oral Maxillofac Surg
allowed the full three-dimensional preservation of alve- 2009;67(Suppl 11):40–48.
15. Kan JY, Rungcharassaeng K, Lozada J. Immediate placement and provisional-
olar architecture around these two implants. ization of maxillary anterior single implants: 1-year prospective study. Int J
Oral Maxillofac Implants. 2003 Jan-Feb;18(1):31-9.
16. Ayangco L, Sheridan PJ. Development and treatment of retrograde peri-
implantitis involving a site with a history of failed endodontic and apicoec-
CONCLUSION tomy procedures: a series of reports. Int J Oral Maxillofac Implants
2001;16:412–417.
This case report indicates the feasibility of the inter- 17. Novaes AB Jr, Novaes AB. Immediate implants placed into infected sites: a
proximal shield technique. In this protocol the apex and clinical report. Int J Oral Maxillofac Implants 1995;10:609–613.
18. Lindeboom JAH, Tijiook Y, Kroon FHM. Immediate placement of implants in
the pulp have been removed to minimize the risk of periapical infected sites: a prospective randomized study in 50 patients. Oral
complication. At nearly 1 year, there was no sign of Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:705–710.
19. Chen ST, Wilson TG Jr, Hämmerle CH. Immediate or early placement of
adverse reaction. A satisfactory long-term prognosis implants following tooth extraction: review of biologic basis, clinical proced-
needs to be validated by long-term studies before this ures, and outcomes. Int J Oral Maxillofac Implants 2004;19(Suppl):12–25.
20. Esposito M, Grusovin MG, Polyzos IP, Felice P, Worthington HV. Timing of
technique can be recommended as a routine pro- implant placement after tooth extraction: immediate, immediate-delayed or
cedure. delayed implants? A Cochrane systematic review. Eur J Oral Implantol
2010;3:189–205.
21. Trombelli L, Scabbia A. Healing response of gingival recession defects follow-
ing guided tissue regeneration procedures in smokers and non-smokers. J
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