Socket-shield technique with minimally invasive osteotomy preparation as well as simultaneous sinus lift utilizing Densah Bur and platelet-rich fibrin membrane followed by immediate implant placement in a symptomatic posterior endodontically treated decayed root stumps site: A case report with 1-year follow-up : Journal of Indian Society of Periodontology

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Case Report

Socket-shield technique with minimally invasive osteotomy preparation as well as simultaneous sinus lift utilizing Densah Bur and platelet-rich fibrin membrane followed by immediate implant placement in a symptomatic posterior endodontically treated decayed root stumps site

A case report with 1-year follow-up

Deshwal, Rahul; Salaria, Sanjeev Kumar1; Dahiya, Ritu2; Deshwal, Neha2

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Journal of Indian Society of Periodontology: Sep–Oct 2022 - Volume 26 - Issue 5 - p 507-511
doi: 10.4103/jisp.jisp_699_21
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Postextraction alteration in horizontal and vertical dimensions of alveolar bone is an inescapable event, and is commonly experienced even if minimally traumatic extraction was performed; which not only interferes with implant position and size but at the same may impact the emergence profile and esthetic outcome in implant-supported prosthesis.[1] Comparative poor bone quality and deficient bone volume due to ridge resorption and sinus pneumatization following tooth extraction in the maxillary posterior region; make it quite challenging for the clinician, especially in terms of implant placement in the maxillary posterior region.[234]

Therefore, to prevent pessimistic consequences of tooth extraction, multiple treatment modalities are recommended in the web of literature but the results are still nonconclusive. Thus, the researcher might implicit that root fragment preservation with immediate implant placement might solve that issue of buccal plate resorption and concluded the same in their research too as cited and reported by Durrani et al.[5] The socket-shield technique (SST) was first of all executed by Hürzeler et al. on one beagle dog. The buccal fragment of mandibular premolar was retained 1-mm coronal to the buccal bone plate followed by immediate implant placement lingual to the retained buccal root piece with or without contact with root fragment. New cementum formation was observed in the area between the titanium implant and retained root fragment which was proven on the histological assessment of the surgical site.[6]

The present case illustrates the successful treatment outcome of single-stage surgical buccal SST with minimally invasive indirect sinus lift and immediate implant placement in an endodontically maltreated root stump site with respect to (w. r. t) tooth no. (#) 15 with 1-year follow-up.


A 66-year-old female educated patient reported to the clinical practice with chief complaint of difficulty in chewing food due to fractured tooth in the right upper jaw middle tooth for 3 weeks and demanded fixed teeth solution for the same. Tooth #15 was slightly tender on percussion and grossly carious root stumps on clinical evaluation [Figure 1a]. Patient history revealed root canal treatment (RCT) 2–3 years ago w. r. t #15 and 16. Overall oral, periodontal, and systemic health status of the patient was good clinically. Preoperative radio visual graph (RVG) was taken w. r. t #14–16 showed short root canal obturation w. r. t. #15 [Figure 1b]. The patient was disclosed in detail about the advantages and disadvantages associated with various fixed prosthetic rehabilitation procedures even after re-RCT followed by post and core and full coverage crown/fixed partial denture, including SST with or without minimally invasive sinus lift utilizing Densah Bur and platelet-rich fibrin (PRF) followed by immediate implant placement. The patient submitted the written consent in favor of the clinician suggestion to proceed for SST with/without minimally invasive sinus lift procedure followed by immediate implant placement.

Figure 1:
(a) Grossly carious root stumps of tooth #15 on clinical evaluation, (b) Radio visual graph showed short root canal obturation, (c) Gutta-purcha removal utilizing Peeso reamer, (d) Socket shield and Komet surgical kit, (e) palatal root removed with apex, and (f) showed curettage w. r. t #15, respectively


Surgery was planned as per the universal standards of surgical protocol and executed under 2% local anesthesia with adrenaline in 1:80000 concentrations. Utilizing Peeso Reamer, gutta-percha was removed [Figure 1c]. Coronal part of the root was smoothened till gingival margin. Utilizing Komet Long Shank and SST surgical kit [Figure 1d] mesiodistally root sectioning was performed. The basic principle of minimally invasive SST was followed by retaining the buccal root portion unmanipulated for buccal bone plate preservation and the palatal root portion including complete root apex was removed [Figure 1e]. Palatal root length was measured to be about 10.5 mm. Apical curettage was performed and buccal shield beveled [Figure 1f] with socket-shield round bur till alveolar crest level to accommodate future prosthesis followed by through irrigation with betadine solution. Sequential osteotomy preparation and indirect sinus lift were done by utilizing distinctive advantage of bone autografting caused by minimally invasive Densah Bur in osseodensification mode at 1200 rpm counterclockwise direction (palatal osteotomy) [Figure 2a] and sinus floor was tapped [Figure 2b] and membrane was lifted by 1–2 mm as evaluated radiographically. PRF was prepared as per Choukroun's protocol [Figure 2c]. PRF plug was pushed inside the palatal osteotomy site along with the last Densah Bur at 100 rpm which further assisted in minimally invasive sinus floor elevation [Figure 2d] and simultaneously 4 mm × 11.5 mm Osstem TSIII implant fixture was placed utilizing physiodispenser with insertion torque set at 30 Ncm followed by further insertion of exposed implant fixture threads manually using Osstem torque wrench. Insertion torque value (ITV) between 30 Ncm and 35 Ncm was achieved which was an indicator of adequate implant primary stability. Customized healing abutment was placed and RVG was taken; showed tenting effect around implant apex along with bicortical anchorage which would additionally provide increased primary implant stability [Figure 2e]. The bony jumping gap was <2 mm so only PRF sufficiently was able to reduce it. The soft-tissue jumping gap was restored with flowable composite [Figure 2f] and no sutures were applied. Postoperative oral hygiene instructions and prophylactic antibiotics and analgesics were prescribed for 5 days. The patient was recalled after 3 weeks, surgical site healed uneventfully with satisfactory soft-tissue healing [Figure 3a]. Upon 4 months recall visit, gingival tissue as well as peri-implant soft-tissue healing around gingival former [Figure 3b] and around implant collar were excellent [Figure 3c]. RVG was taken and radiographically no alterations were observed. The implant area showed radiopacity which might be suggestive that osseointegration has been achieved. Secondary implant stability was checked by performing percussion test using the back end of mouth mirror. The implant when first percussed vertically and then horizontally, a clearly ringing crystal sound was heard giving an indication of successful osseointegration. Putty impression was taken and implant analog was transferred to the impression and send to dental laboratory for screw-retained prosthesis preparation. After 7 days, porcelain fused to metal (PFM) full-coverage crown was procured [Figure 3d]. PFM was screwed at implant site [Figure 3e]. Clinically, soft-tissue healing was excellent on buccal and palatal aspects w. r. t #15 [Figure 3f] at 5 months postoperatively. Patient reported for follow-up after 1-year. Buccal and palatal architecture was well-maintained around implant as observed clinically [Figure 4a] and no bone loss was observed radiographically [Figure 4b] which was further confirmed by computerized cone-beam tomography w. r. t #15 [Figure 4c and d].

Figure 2:
(a) Palatal osteotomy w. r. t tooth #15, (b) Sinus floor was tapped with Densah Bur, (c) PRF prepared (d) PRF placed at osteotomy site, (e) implant placed showed tenting effect in the sub-sinus area, (f) showed restoration of soft-tissue jumping gap with flowable composite, PRF – Platelet-rich fibrin
Figure 3:
(a) Soft-tissue healing at 3 weeks, (b) and (c) soft-tissue healing around gingival former and around implant collar at 4 months postoperatively, (d) screw-retained PFM prosthesis, (e) PFM crown placement, (f) Buccal and palatal soft-tissue healing around implant prosthesis w. r. t #15, respectively, PFM – Porcelain fused to metal
Figure 4:
(a) Showed buccal and palatal architecture was well-maintained around implant clinically, (b) No bone loss observed on radio visual graph, (c) showed CBCT section with existence of buccal shield denoted by arrow w. r. t #15 till 1-year follow-up, and (d) CBCT section showed new elevated sinus floor denoted by arrow till 1-year follow-up, CBCT – Computerized cone-beam tomography


Postextraction reduction in alveolar ridge contour/dimension (horizontal and or vertical, flatting of interproximal bone) is an inevitable sequel which may further set hurdles for implant insertion and rehabilitation.[1] The incidence of buccal bone plate resorption is much higher in comparison to palatal and lingual bone; the reason for the same may be associated with loss of periodontal ligament due to the loss of blood supply providing nutrition to the buccal bone and the consecutive trauma in particular at the buccal bone plate.[7] To control/maintain bundle bone loss, many researchers who attempted immediate implant[8] showed a minimal loss in comparison to edentulous site treated without any immediate implants, whereas Covani and coworkers reported insignificant changes in terms of bone loss when comparison was done between edentulous sites treated with or without immediate implant as cited in the report of Ebenezer V et al.[8] Chappuis et al. proposed long-term stability for soft and hard tissues with the early placement of implants (6–8 weeks) with contour augmentation,[9] but results are still inconclusive. Few authors agreed to the inability to avoid buccal bone volume resorption and role of regenerative materials in preventing it when used with immediate implants.[1011] whereas few completely contradict the statement[9] and others partly disagreed.[12]

Therefore, looking after the advantages of SST such as predictable therapy with minimum surgical intervention required as no biomaterials are used, less duration of total treatment, and an optimum esthetic result,[613] does not appear to interfere with osseointegration and may be beneficial in preserving the buccal bone plate,[6] eliminating the need for future hard and soft tissue augmentation; SST was advised and performed in the present case.

Looking after the strong osteogenic potential of Schneiderian membrane and its periosteum-like behavior, sinus lift without grafted bone material or with autogenous PRF has been recommended by various researchers but lifting the sinus member to accommodate implant height without tearing the Schneiderian membrane is very technique sensitive and needs specialized training too to maintain its osteogenic potential.

Therefore, single-stage minimally invasive sinus lift with sole autogenous PRF following osteotomy preparation under osseodensification mode with Densah Bur was planned in the present case after going through the advantages of Densah Bur-assisted osteotomy preparation as this technique will increase the primary stability, bone mineral density, and percentage of bone at implant surface interface in comparison to conventional osteotomy drills and is easy to perform. It is hypothesized that healing process will be enhanced due to autografting of the bony matrix, cells and biochemicals along the osteotomy site with the usage of Densah Bur.[14] Densah Burs in densifying mode can breach the sinus floor without causing any perforation. The simplified minimally invasive antral membrane elevation technique is based on the application of hydraulic pressure by a viscous bone graft that acts as an incompressible fluid to atraumatically elevate the Schneiderian membrane,[15] but we have utilized PRF membrane instead of putty graft material as the Densah Bur-assisted sinus lift due to autografting was 1–2 mm, thus minimizing the need for any biomaterial. Therefore, Densah Bur was advised and utilized in the present case.

Giving due consideration to the advantages and recommendations of PRF is a three-dimensional autogenous fibrin network that promotes effective neovascularization, accelerated wound closing, and fast cicatricial tissue remodeling. Furthermore, the procedure of procurement is simple and inexpensive without any chemical adulteration as cited in the report of Salaria et al.[16] and systematic use of PRF particularly for the protection of the Schneiderian membrane as well as for the stabilization of high volume of natural bone in the sub-sinus area to the tip of the implants;[17] PRF was advised and utilized in the present case.

Implant loading was done after complete healing at 4 months in accordance with reports of Gluckman et al.[18] after verifying that adequate secondary implant stability has been achieved by clinical and radiographic analysis, further confirmed by the ringing sound heard while performing the percussion test.[19] There are various methods of assessing implant stability in literature ranging from percussion, radiography, resonance frequency analysis (RFA), reverse torque, insertion torque, and vibration in sonic and ultrasonic ranges.[20] In the present case report looking for convenience, ease and availability of armamentarium at the time of surgery, primary implant stability was measured using torque wrench. ITV achieved was in the range of 30Ncm-60Ncm which was indicative of good primary stability as suggested by Sarfaraz et al.[21] In recent years no doubt RFA technique to measure dental implant stability has attracted considerable interest but it is of great value when immediate loading is considered in the treatment plan.[22] Although ITV in the present case was sufficient to load implant immediately looking for long-term prognosis conventional delayed loading was planned and executed while opting for the most commonly and widely used methodology for checking implant stability.

At the follow-up visit, SST in the posterior region helped in maintaining the alveolar ridge, vestibular depth, and adequate width of attached keratinized tissue postoperatively as reported in the proof-of-principle report by Schwimer et al.[23] To the best of our knowledge, this was the first case report which had used combination of SST, minimally invasive sinus lift utilizing Densah Bur, and PRF-assisted Schneiderian membrane elevation with immediate implant so the direct comparison may not be available to the best of our knowledge, but outcome achieved was in accordance with the reports of Dayakar et al. who utilized SST and immediate implant.[524] Huwais et al.[14] utilized a novel osseodensification approach in implant osteotomy preparation to increase the biomechanical primary stability, bone mineral density, and bone-to-implant contact whereas Baron et al.[15] utilized minimally invasive crestal approach sinus floor elevation using Densah Burs and hydraulic lift utilizing putty graft in cartridge delivery.

The reason for the best outcome achieved in the present case may be due to the distinctive advantages of different techniques and materials utilized in the present case.


A combination of SST with Densah Bur and PRF-assisted minimally invasive sinus lift followed by immediate implant placement is an effective single-stage procedure which not only reduces the surgical insult, saves patient's time and finances but at the same time provides excellent clinical and esthetical outcome without affecting the soft as well as hard tissue around the implant site. Further long-term randomized controlled studies with more numbers of cases utilizing current radiographical and clinical parameters assessment are recommended before directly reaching the conclusion.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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Decayed tooth; Densah Bur; immediate implant; platelet-rich fibrin; sinus lift; socket-shield technique

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