Title The Socket-Shield Technique Might Improve the Clinical Outcome of Immediate Implants
Clinical Question In patients that receive an immediate implant, does the "socket-shield" technique improve the implant success rate and promote better esthetic results?
Clinical Bottom Line For patients receiving an immediate implant, the socket-shield technique leaves a fragment of root structure against the buccal wall, to reduce the amount of bone loss around the implant when compared to conventional immediate placement techniques in which the complete tooth is removed. A systematic review, which included animal and human studies, provides evidence that cases using this technique have high levels of complications for the implant and implant site. However, more current randomized controlled and retrospective studies show that the socket-shield technique results in a 1- to 4-year implant success rate similar to that of conventional immediate implant placement and also produces increased bone levels and better esthetic results.
Best Evidence  
PubMed ID Author / Year Patient Group Study type
(level of evidence)
28604262Gharpure/201723 studies including 19 dogs and 144 adult humansSystematic review of non-randomized trials
Key resultsThis systematic review included case-control, histological reports, original cases and human case reports/series. Of the histological studies reviewed, common negative outcomes included: failure of implant to osseointegrate (27.27%), crestal bone loss (3.13±0.54 mm to 6.01±2.23 mm; 54.55% of cases), and a biologically weakening presence of cementum or fibrous PDL-like tissue on the implant surface (6 cases). Clinical studies revealed a mean bone loss around implants in 78.78% of reported cases. Positive findings included osseointegration and bone formation around the immediate implant. A study by Abadzhiev et al. showed the socket shield group had less bone loss and better esthetics and soft tissue volume; however, the quality assessment scale score was a 4/28.
29489581Bramanti/201840 adult patients needing anterior tooth extractionRandomized Controlled Trial
Key resultsPatients were electronically randomized into two groups (socket-shield or conventional protocol) followed by immediate implant placement after the extraction of an anterior tooth. The two groups were followed for 3 years. Inclusion criteria were teeth to be extracted due to fracture, caries, internal resorption or endodontic issues. Patients with poor oral hygiene, smokers, uncontrolled diabetes, active periodontitis, teeth with mobility were excluded as well as immediate implant torqued to less than 35 Ncm. Radiographic evaluation was performed at the time of implant placement then 3, 6, and 36 months after. This study reports no clinical complications and no implant failures. At all of the evaluated time points the socket-shield group showed a slower rate of crestal bone loss (p<0.05) compared to the control group. At 3 years the socket shield technique had 0.605±0.06 mm of marginal bone loss, whereas the conventional protocol had 1.115±0.131 mm (P=0.00014). The pink aesthetic score (PAS) evaluation revealed that the socket-shield group had an improved score at all time points that was statistically significant (p<0.05). At 3 years the socket shied technique had a PAS of 12.15±0.87 and the conventional protocol had 10.3±1.59 (p=0.00008). Overall, this randomized small sample size with very stringent exclusion criteria demonstrated improved esthetic results in the socket-shield group with comparable implant survival to the conventional protocol of extraction and immediate implant placement.
29178381Gluckman/2018128 adult patients with socket shield and immediate implant placementRetrospective Observational Study
Key resultsThis retrospective study examined 128 socket-shield cases with immediate implants placed in private practice. The patients had to be followed up for a minimum of 12 months from the placement of the implant restoration and included all treatment failures and complications of the cases studied. Twenty-five total complications were reported (19.5%) from the socket-shield technique including: 16 exposures (internally or externally), 5 implant failures, 3 sites cultivated infections, and 1 socket-shield migrated. Of the 128 implants, 123 osseointegrated with an overall survival rate of 96.1% from 1 to 4 years after being restored. The authors pointed out, however, that some of the complications with the socket shield can be avoided with new techniques of reducing the shield height to the level of the bone crest and then thinning the crestal portion to a 2 mm chamfer margin. Overall, this study included complications that have been previously reported in other studies. However, with new techniques in shaping the socket shield some complications may be avoided.
Evidence Search (Immediate[All Fields] AND ("dental implants"[MeSH Terms] OR ("dental"[All Fields] AND "implants"[All Fields]) OR "dental implants"[All Fields] OR ("dental"[All Fields] AND "implant"[All Fields]) OR "dental implant"[All Fields]) AND socket[All Fields] AND shield[All Fields]) AND ("2013/10/14"[PDat] : "2018/10/12"[PDat])
Comments on
The Evidence
Validity: The systematic review (Gharpure/2017) is based on a mixture of trials and case studies that have small sample sizes and present with varying levels of evidence. No meta-analysis was performed. The review indicates that there are multiple shortcomings with the current literature and research available on this technique. Thirteen of the twenty-three studies included a single subject, indicating that case selection bias could be present towards positive outcomes. Sixteen of the reviewed human clinical studies were only short-term studies that were 12 months or less. Due to the current discrepancy in research and literature the amount of complications or failures could be vastly under-reported in regards to the socket-shield technique. Differing results were presented with more recent studies (Bramanti/2018 and Gluckman/2018), which support that the socket-shield technique has a high success rate. These were human randomized controlled and retrospective studies; however, more evidence is required to provide strength and show reproducibility to support the argument of the success in using this technique. Perspective: Insufficient studies have been completed on this topic. More reproducible studies with a higher level of evidence need to be performed to demonstrate that the socket shield improves the clinical results of the immediate implant, and a defined protocol for the shaping of the remaining tooth portion left in the site needs to be established.
Applicability The socket shield is presented as a technique-sensitive procedure that depends on both clinician skill and proper patient selection. Criteria for patient selection should be systemically healthy non-smokers in which the tooth needing extraction is infection-free and non-mobile. The tooth to be extracted and site are the major limiting factors and need to be thoroughly examined to ensure the site is conducive to this technique.
Specialty (General Dentistry) (Oral Surgery) (Periodontics)
Keywords “Socket shield technique" AND “Immediate implant”
ID# 3336
Date of submission 11/07/2018
E-mail morrisa1@uthscsa.edu
Author Amanda Morris, DMD
Co-author(s) e-mail
Faculty mentor Richard Finlayson, DDS
Faculty mentor e-mail rsfin54@gmail.com
Basic Science Rationale
(Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?)
None available
Comments and Evidence-Based Updates on the CAT
None available