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Table of Contents
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 38-41

Incorporating the socket-shield technique in the esthetic treatment of a patient's smile: A case report with 2-year follow-up

Private Practice, Mafra, Portugal

Date of Web Publication13-Apr-2018

Correspondence Address:
Dr. Dárcio Luis Fonseca
Beclinique, Rua Serpa Pinto 75 r/c, 2640- 534 Mafra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/GFSC.GFSC_1_18

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The socket-shield technique has demonstrated promising histological and clinical results. Osseointegration has been reported to occur successfully with this technique, with added benefit of preserving the tissues buccofacial to an immediate implant. The present case report describes a modification of the socket-shield technique. Clinical and radiological examination at 25-month follow-up confirmed positive midterm esthetic results with high pink and white esthetic scores. Based on the clinical experience with this technique, it is the author's opinion that the socket-shield technique may well be the future accepted norm that best fulfills the goals of immediate implant treatment to offset buccofacial tissue recession and ridge collapse.

Keywords: Immediate implant treatment, partial extraction therapies, socket shield

How to cite this article:
Fonseca DL. Incorporating the socket-shield technique in the esthetic treatment of a patient's smile: A case report with 2-year follow-up. Int J Growth Factors Stem Cells Dent 2018;1:38-41

How to cite this URL:
Fonseca DL. Incorporating the socket-shield technique in the esthetic treatment of a patient's smile: A case report with 2-year follow-up. Int J Growth Factors Stem Cells Dent [serial online] 2018 [cited 2022 Aug 14];1:38-41. Available from: https://www.cellsindentistry.org/text.asp?2018/1/1/38/230070

  Introduction Top

Dimensional changes of the alveolar ridge following tooth extraction remain a persistent challenge in implant treatment.

Numerous studies report the buccal bony plate, particularly compromised following tooth extraction as a result of the loss of the attachment apparatus and subsequent loss of the socket's bundle bone.[1],[2],[3],[4],[5],[6] The resultant hard- and soft-tissue deficiencies may preclude ideal, restoratively driven implant treatment, predispose to peri-implantitis, and esthetic failure of treatment.[1],[2],[3],[5],[7],[8],[9],[10],[11],[12]

To either offset ridge loss or overcome the drawbacks of its collapse, several techniques have been proposed, including minimally-traumatic tooth extraction, ridge preservation by socket grafting, immediate implant placement with provisionalization, augmentation of the hard- and soft-tissues, and so forth. However, each of these has their own benefits as well as limitations.[4],[5],[6],[9],[10],[11]

Thus, the concept of partial extraction therapy (PET) has been introduced as an attempt to preserve the patient's tooth or part thereof with its attachment apparatus intact.

Among this group of treatments, the socket-shield technique first reported by Hürzeler et al. proposed the intentional preparation of a single-rooted tooth and immediate implant placement palatal to it, “shielding” the buccofacial ridge from resorbing and receding.[3]

Histological results in the animal model have demonstrated successful osseointegration of the implant with what appears to be coronal support of the buccofacial ridge – the periodontium healthy with its attachment to the prepared root portion intact.[2],[3],[10],[11] Human histological reports have similarly attempted explaining the outcome of an implant at retained tooth roots or portions thereof. The possibility for the bone to form and integrate between root dentin and the implant surface in a human has been confirmed by Schwimer et al.[13]

Langer et al. had reported that detrimental outcomes are possible when the mistaken, unintentional placement of an implant into infected root remnants may occur.[14] Yet, there is a distinction between such a scenario and the explicit, planned placement of an implant adjacent to prepared socket shield. More to this, the largest single cohort of patients consecutively treated with the socket-shield technique at up to 4-year follow-up has been reported with results comparable to conventional implant treatment – both immediate and delayed.[11]

Hereafter a case is reported, modifying the socket-shield technique, and incorporating it into esthetic, prosthetic veneer treatment of a patient's smile.

  Case Report Top

A 65-year-old female patient was referred for the treatment of a heavily restored and failing upper central incisor tooth [Figure 1]a,[Figure 1]b,[Figure 1]c,[Figure 1]d].
Figure 1: (a and b) Pretreatment view of the smile before the treatment. Note the spaces between central incisors and abrasion of teeth incisal edges. (c) front view of the horizontal fracture. (d) Socket shield. (e) Periapical X-ray of the socket shield

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The patient had high functional and esthetic demands, pertaining specifically to a diastema present at the upper central incisors, and a malpositioned lower incisor tooth.

The patient opted against orthodontic correction, and prosthetic treatment was decided on. Bonded porcelain prosthetic veneer treatment was planned for the upper anterior teeth and the lower malpositioned incisor. Following a thorough examination of the patient (clinically, radiographically) an immediate implant with a socket shield was decided on for the failing upper central incisor.

Before implant surgery, a provisional restoration was fabricated from the existing crown. The socket shield was prepared as previously described Gluckman et al., 2017, by decoronation, followed by mesiodistal sectioning of the tooth root by long-shank bur and high-speed handpiece in its longitudinal orientation. The separated palatal portion was removed, flapless, and the socket thoroughly debrided and rinsed [Figure 1]c. The facial root portion was then prepared, thinning to approximately half its residual thickness, into a concave shape, and reducing its coronal portion to bone level.

The implant osteotomy was then prepared palatal to the socket shield and implant inserted as per accepted immediate implant protocol (Essential cone 4.5 mm × 12 mm, Klokner) and an insertion torque of 45Ncm was confirmed [Figure 2]a and [Figure 2]b. The buccal gap was grafted with a xenograft bone substitute (Cerabone, Botiss), thereby modifying the socket shield as it was originally described by Hürzeler et al. The implant was immediately provisionalized with a screw-retained crown, free from occlusion [Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f. The patient attended regular follow-up visits, and at the 4-month implant maintenance visit and crown removal, the clinical presentation of the peri-implant soft tissue was healthy and ideal in its presentation [Figure 3]a,[Figure 3]b,[Figure 3]c. At approximately postplacement, all indirect restorations were delivered (porcelain veneers and implant crown) [Figure 3]d,[Figure 3]e,[Figure 3]f and [Figure 4]a, [Figure 4]b. The patient was pleased with the outcome and positive functional and esthetic goals were realized. At 16-month follow-up, the peri-implant soft-tissue contours remained comparable to the neighboring central incisor, and no noticeable tissue recession or complication was observed [Figure 4]c,[Figure 4]d,[Figure 4]e. Later at the 25-month follow-up visit, clinical and radiological examinations verified that the hard- and soft-peri-implant tissues remained healthy and stable, with high pink esthetic scores and white esthetic scores [Figuter 5]a,[Figuter 5]b,[Figuter 5]c,[Figuter 5]d,[Figuter 5]e.
Figure 2: (a) Final implant position. (b) Periapical X-ray of the implant placed using the socket-shield technique (#11). (c) Transfer impression coping during surgery. (d) Provisional restoration, using the real tooth crown. (e) Provisional crown was placed to support the marginal soft tissues. (f) Periapical X-ray with the provisional crown

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Figure 3: (a) Four-month follow-up. Note that scalloped anatomy is preserved between the central incisors. (b) Occlusal view, 4 months later, showing no sign of inflammation in fragment remnants. (c) Veneeres preparations- Frontal view. (d) Final smile, close-up frontal view. (e) Right lateral close-up view. (f) Left lateral close-up view

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Figure 4: (a) Occlusal view of the upper arch with final restorations in place. (b) Final periapical X-ray of the implant supported crown (#11) and cemented veneers (#21). (c) Sixteen-month follow-up, close-up right view of the final restorations. (d) Sixteen-month follow-up. The patient smile frontal view. (e) Sixteen-month follow-up, close-up left view of the final restorations

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Figure 5: (a) Twenty-five-month follow-up, close-up frontal view of the anterior teeth. (b) Right lateral view, close-up at a 25-month follow-up period. (c) Occlusal view of the upper arch at a 25-month follow-up period. (d) CBCT image of the #11, at a 25-month follow-up. Notice the correct implant position and its relation to the vestibular bone and soft tissues. (e) X-ray of the #11, at a 25-month follow-up period

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  Discussion and Conclusion Top

The growing body of literature on the socket-shield technique is ever more supportive of its potential to preserve tissues buccofacial to an immediately placed dental implant. Although it is widely accepted in implant dentistry that correctly adhering to treatment indications and proper case selection and treatment planning are fundamental to treatment success. The socket-shield technique is no different. Guidelines for the socket shield as previously reported are to be adhered to, including the exclusion of significant root fractures through the facial portion of the planned socket shield, a complete absence of buccofacial bone over the socket shield, active periodontitis, and so forth.[1],[5],[12] Clinicians considering this treatment must note the need for the proper instrumentation and technique. In the absence of these, compounded by inexperience, the risks are notably higher.

In the case reported here, despite the medium to thick gingival phenotype, the patient presented with recession at the adjacent teeth, possibly due to some bone loss as seen in the initial radiograph. In such a case, it would be even greater importance to maximally preserve the tissues in lieu of extensive augmentation procedures later on.

With regard to a minor modification of the technique, in the case reported here, the buccal gap was grafted. At the time of placement, the gap was measured to be 1.5 mm in width and non- or slow-resorbing xenograft material selected to graft with. This differs from the original technique reported by Hürzeler et al., who in fact proposed the application of an enamel matrix derivative to the internal surface of the socket shield. This step has wholly been omitted in the technique as we know it today. Moreover, Mitsias et al. also prescribed not grafting the buccal gap in a similar technique, known as the root membrane technique. It is this author's recommendation in keep with Gluckman et al. to graft the gap, unless the implant is too close to the socket shield precluding the introduction of material safely into this space.

  Conclusions Top

Within the limitations of a single case report, after a 25-month follow-up period, stable esthetic and functional results were maintained. This report demonstrates the potential benefits of the technique in routine immediate implant placement, especially esthetically challenging scenarios, when proper case selection and planning are carried out.

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.

  References Top

Gluckman H, Du Toit J, Salama M. The socket-shield technique to support the buccofacial tissues at immediate implant placement. Int Dent Afr Ed 2015;5:3.  Back to cited text no. 1
Bäumer D, Zuhr O, Rebele S, Schneider D, Schupbach P, Hürzeler M, et al. The socket-shield technique:First histological, clinical, and volumetrical observations after separation of the buccal tooth segment – A pilot study. Clin Implant Dent Relat Res 2015;17:71-82.  Back to cited text no. 2
Hürzeler MB, Zuhr O, Schupbach P, Rebele SF, Emmanouilidis N, Fickl S, et al. The socket-shield technique: A proof-of-principle report. J Clin Periodontol 2010;37:855-62.  Back to cited text no. 3
Glocker M, Attin T, Schmidlin R. Ridge preservation with modi ed “Socket-shield” technique: A methodological case series. Dent J 2014;2:11-21.  Back to cited text no. 4
Gluckman H, Du Toit J, Salama M. The pontic-shield: Partial extraction therapy for ridge preservation and pontic site development. Int J Periodontics Restorative Dent 2016;36:417-23.  Back to cited text no. 5
Cherel F, Etienne D. Papilla preservation between two implants: A modified socket-shield technique to maintain the scalloped anatomy? A case report. Quintessence Int 2014;45:23-30.  Back to cited text no. 6
Wadhwani P, Goel S, Tiwari S, Syed S, Paul T, Komal A. Socket shield technique: A new concept of ridge preservation. Asian J Oral Hlth Allied Sc 2015;5:55-8.  Back to cited text no. 7
Chen ST, Wilson TG Jr., Hämmerle CH. Immediate or early placement of implants following tooth extraction: Review of biologic basis, clinical procedures, and outcomes. Int J Oral Maxillofac Implants 2004;19 Suppl: 12-25.  Back to cited text no. 8
Petsch M, Spies B, Kohal RJ. Socket shield technique for implant placement in the esthetic zone: A Case report. Int J Periodontics Restorative Dent 2017;37:853-60.  Back to cited text no. 9
Mitsias ME, Siormpas KD, Kotsakis GA, Ganz SD, Mangano C, Iezzi G, et al. The root membrane technique: Human histologic evidence after five years of function. Biomed Res Int 2017;2017:7269467.  Back to cited text no. 10
Gluckman H, Salama M, Du Toit J. Partial extraction therapies (PET) part 2: Procedures and technical aspects. Int J Periodontics Restorative Dent 2017;37:377-85.  Back to cited text no. 11
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 2017;19:1-8.  Back to cited text no. 12
Schwimer C, Pette GA, Gluckman H, Salama M, Du Toit J. Human histologic evidence of new bone formation and osseointegration between root dentin (Unplanned socket-shield) and dental implant: Case report. Int J Oral Maxillofac Implants 2018;33:e19-23.  Back to cited text no. 13
Langer L, Langer B, Salem D. Unintentional root fragment retention in proximity to dental implants: A series of six human case reports. Int J Periodontics Restorative Dent 2015;35:305-13.  Back to cited text no. 14


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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