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 409

Complication Management of a
Socket Shield Case After
6 Years of Function

Otto Zuhr, DMD1 Maintaining soft and hard tissues

Philip Staehler, DMD2 around dental implants after tooth
Markus Huerzeler, DMD, PhD3 extraction is a very challenging task
in dentistry. A certain amount of
volumetric change in the horizon-
tal and vertical dimension seems
Maintaining soft and hard tissues around dental implants after tooth extraction inevitable.1,2 The buccal area of an
is one of the major challenges in implant dentistry. After tooth extraction, the extraction socket is subject to the
subsequent loss of bone and soft tissue is inevitable due to the partial resorption most bone loss, and a bone loss of
of the buccal bone plate. The recently described socket shield technique addresses
up to 4 mm of the buccal plate was
the problem by maintaining the buccal piece of the tooth in the extraction
socket in order to preserve the buccal bone. As with every new technique, demonstrated in 42% of reported
specific complications, like infection of the buccal piece of the tooth, can occur. cases.3 Although this is mostly not
Herein, the authors present a clinical case that developed a complication with a problem concerning the mere im-
the socket shield technique and the consequential surgical management. plant survival, it can have a strong
Int J Periodontics Restorative Dent 2020;40:409–415. doi: 10.11607/prd.4648 impact on the surrounding soft tis-
sue, especially in the esthetic zone,
where satisfactory pink esthetics will
then be compromised.4,5
As Araújo et al6 showed in 2005,
immediate implant placement alone
does not affect the resorption of the
buccal bone. To prevent the inevita-
ble remodeling process after tooth
extraction and implant placement,
several ridge preservation tech-
niques have been described, and
the different techniques were ana-
lyzed by a systematic Cochrane lit-
erature review in 2012.7 The authors
were not able to provide reliable an-
Private practice Huerzeler/Zuhr, Munich, Germany; Department of Periodontology,
1
swers to the question of how to stop
Johann-Wolfgang-Goethe University Frankfurt, Frankfurt, Germany.
2Private practice Huerzeler/Zuhr, Munich, Germany.
the resorption of the buccal lamella
3Private practice Huerzeler/Zuhr, Munich, Germany; Department of Operative Dentistry and and the following defect formation
Periodontology, Albert-Ludwigs-University Freiburg, Freiburg, Germany. of the soft tissue situation.7 In 2014,
Lin et al8 revisited the literature from
Correspondence to: Dr Otto Zuhr, Rosenkavalierplatz 18, 81925 Munich, Germany.
Email: o.zuhr@huerzelerzuhr.com
1990 on and compared six of the
major techniques to prevent buc-
 Submitted September 20, 2019; accepted November 17, 2019.
 ©2020 by Quintessence Publishing Co Inc. cal bone resorption in immediate

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410

Case Report

In 2011, a 60-year-old patient pre-

a b
Fig 1  (a) Frontal view of the clinical situation before the extraction of tooth 21 (FDI
system). (b) Radiograph taken before implant placement.
implants: palatal/lingual implant
position, platform-switched abut-
ments, bone grafts between the im-
plant and the buccal bone, flapless
approach, connective tissue grafts,
and immediate provisionalization.
Only the palatal/lingual placement
of the implant was able to reduce
the mucosal recession with a high
level of reliability in the immediate-
ly placed implant.8 The rest of the
techniques showed conflicting re-
sults, and no technique could com-
pletely stop the resorption process
that leads to recession.9,10 After a
recession has formed, it seems very
challenging to achieve a complete
reconstruction of the defect.11
In 2010, Hürzeler et al12 ad-
dressed the underlying problem of
resorbing the buccal bone directly
by proposing to keep the buccal
part of the tooth to be extracted in
place.12 In a 5-year follow-up clinical
study, minimal changes of the peri-
implant soft tissue were depicted
using this new technique.13 At the
same time, the approach was less
invasive than other augmentation
techniques and a high esthetic score
was reported. In the last years, a va-
riety of different studies and case
reports using the same or modified
socket shield techniques have been
published with promising results.14–31
However, there are reports
of complications, such as resorp-
tion of the shield.30,32 In these two
published cases, resorption of the
remaining dentine was confirmed.
Neither working group initiated any
therapy, and the incidents did not
affect the success of the implants.
In the following case report, though,
surgical intervention was necessary
because of patient complaints and
clinical deep probing depth with
bleeding on probing. It was obvious
that after 6 years, the shield became
mobile after successful implantation
with the socket shield technique. The
shield needed to be removed and
a guided bone regeneration tech-
nique was applied to overcome the
complication on this implant in the
esthetic zone. The 1-year follow-up
after the complication management
demonstrated a stable situation.
sented with a vertical fracture of the
endodontically treated maxillary left
central incisor (Fig 1). A treatment
plan was developed to proceed
with extraction utilizing the socket
shield technique for immediate im-
plant placement.
After medical information and
discussion of treatment alterna-
tives, the patient decided for an
immediate implant in combination
with the socket shield technique.
The tooth was decoronated, further
split using carbide burs as well as a
straight desmotome (Deppeler) and
partially extracted. The buccal root
plate was left in place as a shield.
The bone walls of the alveolae were
thoroughly cleaned with the help
of an excavator. Afterwards, a 5.0
× 14.0–mm implant (SPI implant
system, Thommen Medical) was in-
serted using the Chiropro L implant
handpiece (Bien Air) and a manual
torque driver (SPI implant system,
Thommen Medical). Immediate pro-
visionalization was performed, and
the provisional crown was taken out
of occlusal contact (Fig 2).
The healing process passed
without any problems. Five months
later, impressions were taken and
the final restoration was placed by
the referring dentist (Fig 3).
In 2012 the patient returned for
checkup, impression-taking, and
photos. The situation was stable
and there were no clinical signs of
infection or other posttherapy com-
plications (Fig 4).
In 2017, the patient was referred
to the practice again with problems

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 411

a b
Fig 2  Occlusal view after (a) shield preparation and (b) implant placement. Fig 3  Emergence profile after 5 months of
healing.

a b
Fig 4  (a) Frontal and (b) occlusal views 1 year after implant crown placement.

around the implant in the maxillary
left incisor. The shield around the
buccal aspect of the implant was
mobile and a deep, 8-mm buccal
probing depth could be detected.
The incisal edge of the implant
crown was in a lower position com-
pared to the adjacent tooth, sug-
gesting an ongoing vertical growth
of the neighboring tooth (Fig 5a).
It was decided to perform sur-
gery to remove the shield with the
surrounding inflammation and fill the
defect with a bovine bone material
(Bio-Oss, Geistlich). At first a sulcu-
lar incision was performed extend-
ing from tooth 11 to tooth 24 (FDI
system). The papillae needed to be
sharply dissected in order to gain
enough sight for the surgery and
carefully remove the mobile shield.
The mobile shield was reduced in
height coronally with a diamond
bur, allowing the subsequent re-
moval with a straight desmotome
(Deppeler). The remaining buccal
bone could be preserved, and the
defect was thoroughly cleaned using
curettes and an airflow device with
erythritol powder (Perioflow and Air-
flow, EMS). Afterwards, the defect
was filled with bovine bone particles
(Bio-Oss, Geistlich Pharma) up to the
top of the buccal wall. To thicken the
tissue and to achieve a more secure
coverage of the defect, an autoge-
nous connective tissue graft for cov-
erage was taken from the tuberosity.
The graft was meticulously deepithe-
lialized using a blade and half split in
the middle to achieve a better adap-
tation over the defect. These surgical
steps are demonstrated in Figs 5b to
5e. The flap was repositioned and
sutured with a 7/0 suture (Seralene
DS 15, Serag-Weissner). The patient
was instructed to refrain from clean-
ing in the surgical area and instead
rinse three times daily with a 0.12%
chlorhexidine liquid until removal
of the sutures. The healing process
was uneventful, and the sutures were
taken out 7 days later.
In 2019, 12 months after the cor-
rection, the patient was examined
and a stable situation was observed.
No inflammation or mobility was
seen. The soft tissue around the im-
plant showed a recession, and the
papilla adjacent to tooth 11 was re-
duced in height. Scar tissue around
the implant could be observed.
Radiographs showed no irregu-
larities around the implant, and the
patient did not report any complica-
tions (Fig 6).

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412

anterior-caudal direction for life-

time.33 The clinical 6-year follow-up
(Fig 5a) depicts the anterior-caudal
growth in the presented case. The
natural tooth (no. 11) is in a more
coronal position than the adjacent
implant. Looking at the reentry situ-
ation (Fig 5b), it can be noticed that
the shield moved coronally until
it contacted the crown on the im-
plant. It seems that the shield was
prepared too short in an apico-
a
coronal direction (Fig 2a). Therefore,
the shield was not locked with ei-
ther the implant threads or with an
ingrowth of bone, ankylosing the
shield. Hence the shield acted like a
natural tooth, in terms of vertical dis-
placement, by following the growth
of the maxilla. Since the implant
b c was ankylosed, the shield came into
contact with the implant-retained
crown after some years of function.
This allowed bacteria to migrate into
the space between the implant and
the shield. The resulting inflamma-
tion was the reason for the patient’s
visit to the office. It needs to be
emphasized that, according to the
d e
initial publication of Hürzeler et al,12
Fig 5  (a) Six years after treatment, the patient returned with an apico-coronal displacement the thin buccal bone plate could be
of tooth 11 and a slightly inflamed situation around the implant. (b) After elevating a
flap, the mobile shield could be seen in contact with the crown on the implant. (c) Only a completely preserved over 6 years
small amount of the implant surface was exposed. (d) The defect was filled with bovine despite the inflammation. In order
bone particles (Bio-Oss, Geistlich). (e) The bovine bone particles were covered with an
autogenous connective tissue graft from the tuberosity.
to prevent this kind of complication,
either a tight contact between the
implant and buccal root plate should
be favored or the shield should be
Discussion ever, certain problems have been prepared long enough in the apico-
reported in the literature and ad- coronal direction that it allows the
The socket shield technique in the dressed by some authors.30,32 The bone to grow between the implant
esthetic zone shows promising re- presented case demonstrated a way surface and the shield, for an anky-
sults in maintaining the soft and to address a possible complication. losis between implant and shield.12
hard tissues around implants and The presented complication can The subsequent ankylosis keeps the
providing a possible solution for a by hypothesized. It is well known shield from moving along the direc-
reliable esthetic outcome.14–31 How- that the maxilla does grow in an tion of the skeletal growth.

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 413

a b

Fig 6  (a) Frontal, (b) occlusal, and (c) radio­graphic views 12 months after surgical intervention.

In the literature today, there is
only a small amount of data avail-
able for complications with the
socket shield technique. Prior to
the first publication of the socket
shield technique, Davarpanah and
Szmukler-Moncler published a case
series of five patients with a total of
five implants, where the authors tried
to avoid the traumatic extraction of
ankylosed teeth by leaving remnants
of the root in place before placing
the implant.32 Although they did not
exactly follow the later-published
concept of the socket shield tech-
nique, the implications in terms of
development of complications are
comparable to the complications in
the socket shield technique. In their
case series of five patients, one pa-
tient developed a small resorption
of the remaining dentine plate, but
this did not affect the overall implant
success after a follow-up period of 49
months. The authors attributed the
complication to an occlusal overload.
Another overall successful case
report of the socket shield technique
by Cherel and Etienne showed an
exposed dentine fragment in the
emergence profile when placing the
final crowns after 4 months of imme-
diate provisionalization and implant
placement.18 The dentine fragments
exhibited no signs of mobility or
surrounding inflammation and thus
were rated as a success.
Siormpas et al reported one
failure in their retrospective analysis

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414
of 46 implants over a period of up
to 60 months.30 The patient initially
presented with an extensive apical
defect in the maxillary central inci-
sor that was treated by extracting
the tooth and placing an immedi-
ate implant with the socket shield
technique. After a 3-year follow-
up, the apical defect radiographi-
cally showed uneventful healing,
but a 1.5-mm apical resorption of
the shield was observed. The cone
beam computed tomography scan
at the 48-month follow-up revealed
no progress in resorption. The
functional and esthetic implant suc-
cess was not impaired due to that
event.
In 2015, Lagas et al reported
in a case series of 16 patients (one
implant per patient) the failure of a
shield in one patient. The patient
presented with a mobile dentine
shield, which was removed. In a
second surgical procedure, a con-
nective tissue graft was used to cor-
rect the defect, and a satisfactory
esthetic outcome was observed.
The authors attribute the complica-
tion to insufficient removal of res-
toration material in the previously
partially extracted tooth.34
A systematic literature review
by Gharpure and Bhatavadekar also
had the intention to identify pos-
sible complications in the socket
shield technique.35 In their review,
four histologic studies and 19 clini-
cal studies were included, most of
them case presentations with one
implant placed. The authors of the
literature review found an overall
complication rate of around 25%
(total: n = 33) in implants placed
with the socket shield technique in
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clinical cases and a complication
rate of up to 83% (total: n = 58) in
implants placed in animal studies.
At this point, it needs to be em-
phasized that the systematic review35
did not differentiate between the
originally published socket shield
technique and the T-Belt technique.
Out of 58 published failures of im-
plants in preclinical studies, 54 were
not treated with the original pub-
lished socket shield technique. The
failure rate in animal studies with the
socket shield technique seems to be
very low.
The 19 clinical studies in the
review35 reported 33 out of 136 im-
plants as failures. A closer look at
the underlying data reveals that 10
out of the 26 implants had a bone
loss of 1.3 ± 0.2 mm at 6 months.
All of these implants come from the
Troiano et al study31 and were not
placed with the socket shield tech-
nique but with the T-Belt technique.
The other 16 implants classified as a
failure of bone loss showed a bone
loss of around 0.8 mm after 3 to 24
months. It remains a point of discus-
sion whether this amount of bone
loss is to be classified as a failure.
Another 7 failed implants showed
shield exposure, deep probing
depths, and deficiency of alveo-
lar ridge. Taking out the implants
placed with the T-Belt technique,
the complication rate is down to
17%, or 23 out of 136 implants.
Gharpure and Bhatavadekar35
also stated that a small number of
studies reported the majority of
failed implants in the socket shield
technique, and they derive that this
could be traced back to a certain
amount of technique sensitivity.
Except for the four studies re-
porting failures in the socket shield
technique and the systematic lit-
erature review by Gharpure and
Bhatavadekar,35 there are no further
reports of complications in socket
shield therapy. In the majority of the
cases, no additional treatment was
necessary, which was agreed on fol-
lowing consequent follow-ups. In
one case, surgical intervention was
performed and a satisfactory es-
thetic result was achieved.34
Conclusions
This case presentation shows that
a long-term failure in the socket
shield technology can occur, but the
complications are manageable. It is
obvious that this is an evolving tech-
nique with a learning curve. To con-
sistently apply this technique within
the implant therapy, more research
and more clinical control studies are
needed in order to mitigate the risk
of possible failures. Identifying pos-
sible risk factors and complications
with the socket shield technique is
essential for its successful applica-
tion in today’s implant therapy.
Acknowledgments
The authors declare no conflicts of interest.
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