The socket shield technique used in conjunction with immediate implant

placement in the anterior maxilla: a case series

Vinh Giap Nguyen, DMD MSc*

Dennis Flanagan, DDS MSc^
John Syrbu, DDS†
Thomas T. Nguyen, DMD MSc FRCD(C)‡

*
Private Practice in Brossard, QC, Canada
^
Private Practice, Groton, CT, USA
†
Department of Family Dentistry, University of Iowa College of Dentistry and Dental Clinics,
Iowa City, IA, USA
‡
Division of Periodontology, Department of Oral Medicine, Infection and Immunity, Harvard
School of Dental Medicine, Boston, MA, USA

Key words: dental implants, immediate implant, esthetic, bone regeneration, socket shield
technique, partial extraction therapy

Corresponding author:

Dr. Thomas T. Nguyen

Harvard School of Dental Medicine

188 Longwood Avenue

Boston MA 02115

[email protected]

Word count: 1,025

Figures: 13

Tables: 1

References: 16
This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1002/cap.10087.

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Short title: Socket shield technique in the anterior maxilla

Summary of key findings: The socket-shield technique produces virtually no change in the
hard and soft tissue dimensions with relatively minimal invasive surgical interventions and
shorter treatment time.

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This article is protected by copyright. All rights reserved.
Abstract

Introduction: Bone remodeling after tooth extraction and immediate implant placement will

occur nonetheless and as a result, additional hard and soft tissue augmentations are often

necessary to compensate for the loss of alveolar ridge dimension. The socket shield

technique has shown encouraging clinical results in maintaining original ridge morphology

and thus may be used as an alternative protocol for the conventional immediate implant

placement in the esthetic zone.

Case series: The authors report three cases of socket shield technique used in conjunction

with immediate implant placement in an anterior maxilla. The patients were followed for a

period of 2 to 6 years, and the evolution of the soft and hard tissue surrounding the implants

were documented.

Conclusions: The socket-shield technique produces virtually no change in the hard and soft

tissue dimensions with relatively minimal invasive surgical interventions and shorter

treatment time.

Background

The advantages of immediate implant placement include less extensive surgical

1-4
interventions, reduced treatment time, lower treatment cost, and less patient morbidity. A

predictable protocol for long-term success and aesthetic outcomes has been proposed

which includes atraumatic extraction,5 palatal implant placement,2 sub-crestal placement,6

smaller implant diameter,7 platform switch design,8 and buccal soft tissue augmentation.9 In

addition, concomitant grafting the buccal gap and immediate provisionalization, has a

positive impact on the crestal bone and soft tissue profile, according to a study by Tarnow et

al. in 2015.10 Despite the excellent outcome, immediate implant placement still has some

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drawbacks. Bone remodeling after extraction will occur regardless of the immediate

placement of a dental implant. Preservation of gingival morphology and ridge dimension is

possible only when additional hard and soft tissue procedures are applied to compensate for

labial bone modeling post-extraction.9,10,11

Although more long-term evidence is needed, the socket shield (SS) technique has clinically
12-14
shown promise in maintaining original ridge morphology. In this technique, the root of the

tooth is sectioned in such a way that a thin fragment of root, or a “shield”, is left attached to

labial bone while the remainder of the root is completely removed. As the labial periodontal

attachment is left undisturbed, no osteoclastic activity appears to be triggered labial to the

shield. An immediate implant may be placed without additional bone or soft tissue graft.

Clinical Presentation, Management, and Outcomes

All three cases of SS technique were performed at the author’s private practice in Montreal

QC between 2012 to 2016. The patients were followed for a period of 2 to 6 years, and the

evolution of the soft and hard tissue surrounding the implants were documented. All patients

exhibited an excellent periodontal condition with periodontal indexes falling within normal

limits. Using a straight fissure surgical bur* with a high speed hanpiece, the root fragments

were prepared and left attadched to the facial bone plate while the remainder of the roots

were elevated and removed. The shields were left 1mm coronal to the buccal bone margin

as describeb by Bäumer et al. All the immediate implants were placed 2mm subcrestal, in

* Messinger, Centenniel, CO, USA

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the palatal position and no bone graft was placed in the buccal gap. Ridge mapping

templates were used to record before and after ridge dimensions (Table 1). No

complications have been recorded and the patients reported minimal discomfort. All

participants provided informed written and verbal consent prior to treatment.

Case 1

A healthy 72-year-old female patient was seeking implant treatment to replace her fractured

maxillary left central and lateral incisors. The teeth were deemed non-restorable and

required removal of the roots. The patient consented for immediate implant treatment using

the SS technique. The shields were prepared (Fig.1a) and osteotomies done to receive 3.5 x

13mm implants.# Two splinted acrylic screw-retained crowns were installed as immediate

non-functional- occlusion provisional prostheses. The final impression was taken at 4

months post-op and individual screw-retained ceramic crowns were delivered. Six years

after the insertion of the final prostheses, the SS procedure appears to preserve not only the

buccal marginal bone but also the inter-implant papilla. (Figs. 1b and 1c).

Case 2

A vertical root fracture necessitates the removal of the maxillary lateral incisor of an 87 year-

old male patient. An immediate implant combined with the SS technique was done. A

3x15mm implant# was inserted (Fig. 2a). The final impression was taken at 4 months post-op

# Nobel Active, Nobel Biocare, Kloten, Switzerland

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and a screw-retained crown was delivered (Fig. 2b). Five years after the prosthetic insertion,

hard and soft tissue appear very stable (Fig. 2c).

Case 3

A healthy sixty-two-year-old female patient with a high smile line selected an immediate

implant treatment option using the SS technique to replace her maxillary left central incisor

due to a vertical root fracture (Fig. 3a). The SS preparation and immediate implant

placement were done following the same protocol described in previous cases. A 3.5 x

13mm implant# was placed to obtain a 35 N/cm torque and an average ISQ of 65 (Fig. 3b). A

screw-retained provisional crown was fabricated chairside and installed at the same

appointment. Four months after the implant placement, the final impression was taken and a

screw-retained crown was delivered (Fig. 3c). Well preserved hard and soft tissue profiles

are observed 2 years after the prosthetic insertion (Figs. 3d and 3e).

Discussion

Although most studies on the SS technique have been presented as case series12-14, a

recent larger retrospective study has shown encouraging results15. In the SS technique, the

root fragment appears to prevent the modeling of the labial bone plate and thus the original

buccolingual dimension of the socket is not altered. The small diameter implants and palatal

placement were chosen to allow approximately 1mm clearance between the implant and the

root fragment. This clearance allows bone forming on the buccal aspect of the implant and

also to prevent inadvertent pressure on the root fragment. While it is recommended that a

#Nobel Active, Nobel Biocare, Kloten, Switzerland

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bone graft material should be utilized to fill the labial gap of the conventional immediate

implant cases16, such a practice is not essential in the narrower labial gap of the SS

placement. While it is recommended that a bone graft material should be utilized to fill the

labial gaps of immediate implants that are wider than 2mm, gaps narrower than 2mm are

observed to heal spontaneously.16 In accordance with this observation, such a practice was

not essential in the narrower labial gap of the SS placement in all our three cases. The

buccal bone plate does not appear to be altered in the presence of the shield. It is therefore

up to the surgeon’s discretion whether to graft the buccal space.

Conclusion

The present clinical case series shows that the SS technique produces virtually no change in

the hard and soft tissue dimensions with relatively minimal invasive surgical interventions

and shorter treatment time. The technical protocol, modeled after the immediate implant

placement, appears to provide excellent aesthetic outcomes and stable short-term results.

More evidence is, however, required for the long-term efficacy of the SS technique.

Summary

Why are these cases new This case series showed that the SS technique

information? produces virtually no change in the hard and soft

tissue dimensions with relatively minimal invasive
surgical interventions and shorter treatment time.

What are the keys to  Thorough planning is crucial when using the SS
successful management technique.

of these cases?  Cone beam computed tomography (CBCT) is

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 necessary in order to appreciate root position in
relation to the existing alveolar bone.

What are the primary  The socket shield is a very technique sensitive
limitations to success in procedure and requires a significant learning
curve and practice.
these cases?
 Careful case selection is essential to perform this
technique successfully.

Conflicts of interest

The authors reported no conflicts of interest related to this case series.

References
1. Fugazzotto PA. Treatment options following single-rooted tooth removal: a literature
review and proposed hierarchy of treatment selection. J Periodontol 2005;76:821-
831

2. Chen ST, Buser D. Clinical and esthetic outcome of implants placed in post
extraction sites. Int J Oral Maxillofac Implants 2009;24 (Suppl):186-217

3. Romanos G, Froum S, Hery C, Cho SC, Tarnow D. Survival rate of immediately vs

delayed loaded implants: Analysis of the current literature. J Oral Implantol
2010;36(4):315-324

4. Weigl P, Strangio T. The impact of immediately placed and restored single-tooth

implants on hard and soft tissues in the anterior maxilla. Eur J Oral Implantol. 2016;9
Suppl 1(2):89-106

5. Oghli AA, Steveling H. Ridge preservation following tooth extraction: a comparison

between atraumatic extraction and socket seal surgery. Quintessence
Int. 2010;41(7):605-9

6. Su C, Fu J, Wang H. The role of implant position on long term success. Clin Adv
Perio. 2014; 4:187-193

This article is protected by copyright. All rights reserved.

 7. Galindo-Moreno P, Nilsson P, King P, et al. Clinical and radiographic evaluation of
early loaded narrow-diameter implants: 5-year follow-up of a multicenter prospective
clinical study. Clin Oral Implants Res. 2017;28(12):1584-1591

8. Pieri F, Aldini NN, Marchetti C, Corinaldesi G. Influence of implant-abutment interface

design on bone and soft tissue levels around immediately placed and restored single-
tooth implants: a randomized controlled clinical trial. Int J Oral Maxillofac
Implants. 2011;26(1):169-78

9. Grunder U. Crestal ridge width changes when placing implants at the time of tooth
extraction with and without soft tissue augmentation after a healing period of 6
months: report of 24 consecutive cases. Int J Periodontics Restorative
Dent. 2011;31(1):9-17

10. Tarnow DP, Chu SJ, Salama MA, et al. Flapless postextraction socket implant
placement in the esthetic zone: part 1. The effect of bone grafting and/or provisional
restoration on facial-palatal ridge dimensional change-a retrospective cohort study.
Int J Periodontics Restorative Dent. 2014;34(3):323-31

11. Rungcharassaeng K, Kan JY, Yoshino S, Morimoto T, Zimmerman G. Immediate

implant placement and provisionalization with and without a connective tissue graft:
an analysis of facial gingival tissue thickness. Int J Periodontics Restorative
Dent. 2012;32(6):657-63

12. Siormpas KD, Mitsias ME, Kontsiotou-Siormpa E, Garber D, Kotsakis GA. Immediate
implant placement in the esthetic zone utilizing the "root-membrane" technique:
clinical results up to 5 years postloading. Int J Oral Maxillofac Implants.
2014;29(6):1397-405

13. Abadzhiev M, Nenkov P, Velcheva P. Conventional immediate implant placement

and immediate placement with socket-shield technique – Which is better. Int J of Clin
Med Res. 2014;1(5):176-180

14. Bäumer D, Zuhr O, Rebele S, Hürzeler M. Socket Shield Technique for immediate
implant placement - clinical, radiographic and volumetric data after 5 years. Clin Oral
Implants Res. 2017;28(11):1450-1458

This article is protected by copyright. All rights reserved.

 15. Gluckman H, Salama M, Du Toit J. A retrospective evaluation of 128 socket-shield
cases in the esthetic zone and posterior sites: Partial extraction therapy with up to 4
years follow-up. Clin Implant Dent Relat Res. 2018;20(2):122-129

16. Paolantonio M, Dolci M, Scarano A, d'Archivio D, di Placido G, Tumini V, Piattelli A.

Immediate implantation in fresh extraction sockets. A controlled and histological
clinical study in man. J Periodontol. 2001;72(11):1560-71

Figures legends

Fig.1a Root fragments just before the final shaping

Fig.1b A periapical radiograph taken at 6 years after the insertion of the final crowns
on implants

Fig. 1c Volumetric analysis between the digital scans of the pre-op and 6-year post-op
dental casts shows little dimension alteration

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Fig.2a Socket shield preparation and immediate implant placement

Fig.2b A radiograph at 5 years after the prosthetic insertion

Fig.2c A CBCT image at 5 years after the prosthetic insertion

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 Fig.3a Frontal image. Vertical root fracture of the maxillary left central incisor

Fig.3b Immediate implant position

Fig.3c Frontal view of the crown 3 years after the prosthetic insertion

Fig.3d Occlusal view of the crown 3 years after the prosthetic insertion

Fig.3e A CBCT image at 3 years post-op

Table 1. Pre- and post-operative volumetric changes

Bony ridge
Case # Tooth number Soft tissue ridge width (mm) width (mm)

Pre-op Post-op △ Pre-op Post-op △

1 9 9.1 9.0 -0.1 7.5 7.3 -0.2

1 10 8.3 8.2 -0.1 6.3 6.0 -0.3

2 10 8.8 8.8 0.0 5.9 6.1 0.2

3 9 9.7 9.7 0.0 7.3 7.3 0.0

Mean RP 9.0 8.9 -0.1 6.8 6.7 -0.1

SD 0.6 0.6 0.1 0.8 0.7 0.2

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