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British Journal of Oral and Maxillofacial Surgery 59 (2021) 1227–1232

Evaluation of alveolar process resorption after tooth

extraction using the socket shield technique without
immediate installation of implants: a randomised controlled
clinical trial
Getúlio Batista de Oliveira a , Iêda Margarida Cruzoé Rebello b , Kátia Montanha Andrade a ,
Nara Santos Araujo a , Jean Nunes dos Santos c , Patricia Ramos Cury d,∗
a Post-graduate Program in Dentistry and Health, School of Dentistry, Federal University of Bahia, Salvador, Brazil
b Division of Dentomaxillofacial Radiology, School of Dentistry, Federal University of Bahia, Salvador, Brazil
c Division of Oral Pathology, School of Dentistry, Federal University of Bahia, Salvador, Brazil
d Division of Periodontics, School of Dentistry, Federal University of Bahia, Salvador, Brazil

Accepted 1 April 2021

Available online 8 April 2021

Abstract

Our aim was to evaluate resorption of the alveolar ridge using the socket shield technique (SST) without immediate placement of dental
implants. This randomised controlled clinical trial included 27 patients: 14 maxillary non-molar teeth were partially extracted using the SST
(test group) and 13 were extracted using a minimally traumatic extraction approach (control group). Alterations in height and thickness of the
alveolar ridge were evaluated by cone beam computed tomograms taken immediately after, and 100 days after, surgery. Minor resorption was
observed in the height of the buccal and palatal plates, without intergroup difference (p ≥ 0.10). The test group showed significantly better
preservation of the buccal-to-palatal crest dimension (p ≤ 0.05). In the control group, preservation of buccal plate thickness was significantly
greater (p ≤ 0.05), but intragroup vertical resorption of the buccal plate and reduction in the buccal-to-palatal crest distance were greater (p
≤ 0.05). The SST without the immediate placement of implants showed greater preservation of the buccal-to-palatal crest dimension and
lower preservation of buccal wall thickness compared with minimally traumatic extraction. In addition, it provided superior maintenance of
the baseline buccal wall height. The modified SST is a promising approach, but factors that interfere with the results should be investigated.
© 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

Keywords: alveolar ridge preservation; minimally traumatic extraction; socket shield technique; tooth extraction

Introduction
Alveolar ridge resorption following tooth loss is a conse-
quence of the healing process. The alveolar ridge width
∗ Corresponding author at: Division of Periodontics - Faculdade de Odon-
tologia, Avenida Araújo Pinho, 62, Canela 40110-150, Salvador/Bahia,
Brazil. Tel.: + 55 (71) 3283-8970; Fax: +55 (71) 3336-5776.
E-mail address: patricia.cury@ufba.br (P.R. Cury).
can reduce by up to 50% in the first year after tooth loss,
with two-thirds of this reduction occurring within the first
three months.1,2 Different approaches cannot prevent bone
loss despite the application of sophisticated and high-cost
techniques.3 Even an immediate implant may fail to prevent
undesirable remodelling of the tooth socket bone walls.4
Retention of decoronated roots has been shown to pre-
serve the alveolar bone at the extraction site via maintenance
of the periodontal ligament.5 The socket shield technique

https://doi.org/10.1016/j.bjoms.2021.04.001
0266-4356/© 2021 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
1228 G.B. de Oliveira et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 1227–1232
(SST) was proposed on the basis of this concept. Accord-
ingly, a buccal root fragment was intentionally retained at the
time of tooth extraction in one beagle dog, functioning like a
shield, and an immediate implant was then placed palatal to
this fragment. Four months later, on the buccal side, the tooth
fragment was attached to the buccal bone plate by a physio-
logical periodontal ligament and the alveolar bone crest was
free of any resorption processes. In contrast, new formation
of woven bone was observed.
All clinical human studies currently available on this tech-
nique involve implant placement immediately after partial
tooth extraction.6–9 However, in many clinical situations,
immediate implant placement is not indicated due to high aes-
thetic demand10 or expected lack of primary implant stability.
The only case report assessed alveolar bone preservation in
three clinical cases in which the vestibular root fragment was
left in the socket without immediate implant installation. Dur-
ing re-entry for implant installation, new bone formation was
visually confirmed.11 Therefore, the objective of this study
was to evaluate alveolar ridge preservation using the SST
without immediate dental implant placement. The hypothe-
sis was that this modified SST would promote better alveolar
ridge preservation in comparison with minimally traumatic
tooth extraction.
Material and methods
This study was approved by the Ethics Committee in
Research (Federal University of Bahia, Brazil (Process:
55523516.0.0000.5024) and registered in The Brazilian Clin-
ical Trials Registry (5194). The patients signed a written
informed consent form.
Experimental design
The study was conducted as a randomised controlled clinical
trial with a parallel design and 1:1 allocation rate, comparing
alveolar ridge preservation using the SST without immediate
dental implant placement (test group) and a minimally trau-
matic dental extraction technique (control group). A single
site was treated in each patient. The patients were randomly
assigned to the test or control group.
The primary outcomes were changes in the height and
thickness of the buccal plate and in the width of the alveolar
process (buccal-to-palatal crest distance) at 100 days after
surgery. The secondary outcome was the change in height of
the palatine plate.
Study population and randomisation
Patients referred to the School of Dentistry at the Federal
University of Bahia for extraction of non-molar upper teeth
(premolars, canines, or incisors) between 2017 and 2018 were
screened for eligibility.
Adult patients were recruited if they met the following
inclusion criteria: absence of alveolar bone loss in the area of
tooth extraction, absence of periodontal diseases, and pres-
ence of attached gingiva and adjacent teeth. Exclusion criteria
were infection or buccal dehiscence in the area of interest,
regular use of medications, pregnancy/lactation, smoking or
other drug addiction, and diabetes or any other systemic dis-
ease.
The sample size was calculated based on a pilot study in
10 patients. A sample size of 19 patients/group was estimated
to detect a mean difference of 50% in primary outcomes
(height of the buccal plate and width of the alveolar process),
assuming a mean (SD) of 0.8 (0.44) mm, power of 80%, and
significance level of 5%.
One hundred and fifty-five consecutive subjects were
screened, and 31 were selected (Fig. 1). Patients were given
a number from 1 to 31 and were randomly assigned to the
control or test groups. Sixteen patients were allocated to the
control group, and fifteen to the test group. During surgery,
one patient was excluded due to the presence of a premolar
with two roots and the other due to the absence of the buccal
plate, both from the control group. At the moment of statis-
tical analysis, one case from each group was excluded, since
they were single cases in the mandible. Therefore, 27 patients
were included in the final analysis: 14 in the test group and
13 in the control group.
Randomisation was performed using a shuffled deck of
cards (even = test group, odd = control group). Opaque
envelopes were assigned to each subject and were opened dur-
ing the surgery after removing the tooth crown. The patients
and the examiner of the tomographic images were blinded
to the allocation. The surgeon was informed of the patient’s
allocation at the moment of partial or total tooth extraction.
Cone beam computed tomography (CBCT) measures
CBCT scans were taken immediately after extraction and 100
days later (K9000; Carestream Health Inc). The acquisition
protocol was based on the manufacturer’s recommendations
and the patient’s clinical indications.12 All measurements
were performed by a single trained examiner (CS 3D Imag-
ing Software, Carestream Health Inc). The intra-examiner
concordance coefficient was less than 0.8.
First, one tooth adjacent to the extracted tooth was chosen
as a reference and was centred in the axial, coronal, and sagit-
tal sections of the CBCT images. Subsequently, the following
references were created using a coronal slice (Fig. 2A): line
A: vertical line the centre of the reference tooth, according
to its long axis; line B: horizontal line perpendicular to the
vertical line, starting at the cementoenamel junction of the
reference tooth and extending over the extraction area; line
C: horizontal line parallel to line B and 10 mm from it. All
measurements were made at the centre of the buccal and/or
palatine wall. In the sagittal slice, the distances between line
C and the buccal wall crest (buccal wall height) and the pala-
tine wall crest (palatal wall height) were measured (Fig. 2B).
 G.B. de Oliveira et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 1227–1232 1229

Fig. 1. Flow diagram of patient enrollment, allocation, follow up, and analysis.

Fig. 2. Cone beam computed tomograms.

A: coronal slice. Vertical line (line A) at the centre of the reference tooth, according to its long axis; first horizontal line (line B) perpendicular to line A, starting
at the cementoenamel junction of the reference tooth and extending over the extraction area; second horizontal line (line C) parallel and 10 mm from line B.
B: sagittal slice. Buccal (BH) and palatal wall heights (PH).
C: axial slice. Buccal wall thickness (BT) and buccal-to-palatal crest distance (BPD).

In the axial slices at 1, 3, and 5 mm from line B, linear mea-
surements of the thickness of the buccal wall, and the distance
between the buccal and palatal plates (buccal-to-palatal crest
distance) were obtained (Fig. 2C).
Surgeries
The tooth crown was worn with a wheel-type burr using a
high speed handpiece next to the bone level. In the test group,
a long flame burr was used to make a longitudinal cut in
the root in the distal mesial direction, slightly inclined to
the buccal, to separate the root into two fragments (buccal
and palatal). The palatal fragment of the root was carefully
dislodged with a periotome then removed. The buccal root
fragment was retained. The alveolus was treated with abun-
dant irrigation with saline. Then, the buccal fragment of the
root was inspected to assess the degree of mobility, which
should not be detectable. The buccal fragment was worn with
a long-stem spherical drill to a concave form between 1.5 to
2.0 mm thick (measured using a periodontal probe), and was
reduced to the level of the bone. The original buccal bone
level was preserved. In the control group, the whole root was
removed using a periotome.
In both groups the internal epithelium of the gingival sul-
cus was removed with a wheel-type diamond burr. A 2-3
mm thick epithelialised graft was removed from the palate
region near the extraction using a 6 or 8 mm circular scalpel,
and sutured with nylon thread with single interrupted sutures.
After 7 and 14 days, the sutures were removed from the palate
and extraction area, respectively.
Before surgery, all patients were prescribed 8 mg dexam-
ethasone and 2 g amoxicillin. A bonded provisional fixed
1230 G.B. de Oliveira et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 1227–1232

Table 1 distance in the test than in the control group at the 1 mm and
Baseline demographic and clinical characteristics for each group. Data are 3 mm points (p ≤ 0.05), but the thickness of the buccal wall
number unless otherwise stated.
showed a better outcome in the control group (p ≤ 0.05). The
Test group Control group p value other differences were not statistically significant (p ≥ 0.10)
(n = 14) (n = 13)
(Table 2)
Mean (SD) age (years) 41.64 (13.29) 42.31 (7.93) 0.88a Comparing the initial and final measurements within the
Sex:
Female 9 9 0.79b
test group, no statistically significant difference was observed
Male 5 4 (p ≥ 0.13). On the other hand, in the control group, there was a
Tooth: loss of height of the buccal plate, loss in the buccal-to-palatal
Anterior 6 5 0.56b crest distance, and a slight gain in the thickness of the buccal
Premolar 8 8 plate (p ≤ 0.05).
a : t test.
b : Fisher’s exact test.

prosthesis was installed immediately after surgery. After the Discussion

surgery, the patients used 0.1% chlorhexidine solution mouth-
wash every 12 hours for 14 days.
Statistical analysis
The similarity between the groups in age, sex, and tooth posi-
tion was assessed using the t test or Fisher’s exact test. The
homogeneity of variance was verified, and then comparisons
between the baseline and final measurements were performed
using a paired t test, and between the test and control groups
using the Student’s t test. The level of significance was set at
p ≤ 0.05.
Results
All tooth extractions were indicated due to advanced caries
lesions, and except for one, all teeth had endodontic treat-
ment. No clinical complication was recorded during the
surgeries or during the follow-up period, and no fracture of
the buccal bone was observed.
The groups were homogeneous in relation to age, sex, and
clinical characteristics (p ≥ 0.56) (Table 1).
In intergroup comparisons, the heights of the buccal and
palatal walls showed slight resorption with no significant
differences between the groups (p ≥ 0.10). There was a
significantly lower reduction in the buccal-to-palatal crest
To our knowledge, this is the first randomised clinical trial
to evaluate dimensional alterations in the alveolar process
after tooth extraction using the SST without immediate dental
implant placement. The minimally traumatic dental extrac-
tion technique was used as a control. Three important findings
were obtained: the height of the buccal and palatal walls
showed resorption with no difference between the groups,
but the resorption of the buccal wall was significant only in
the control group; the buccal-to-palatal crest distance was
better maintained in the test group than in the control group;
and the thickness of the buccal wall showed better results in
the control group than in the test group. Therefore, the ini-
tial hypothesis that the SST promotes better alveolar ridge
preservation than minimally traumatic extraction has been
partially confirmed.
In the present trial, there was no difference in resorp-
tion of the height of the buccal and palatal walls between
groups, but in the control group only resorption in the buccal
wall was significant when baseline to final values were com-
pared. The resorption observed in the present test group was
similar to that reported previously after immediate implant
installation with SST (between 0.2 and 0.8 mm),6–9 suggest-
ing that implant installation does not have an impact on the
preservation of alveolar bone when SST is used. The control
technique associated with a gingival graft, which was used
in both groups, may explain the small difference between the

Table 2
Mean (SD) values (mm) and of the differences between the final and initial measurements of the test and control groups, and intragroup and intergroup statistical
significance.
Dimension Test group Control group p value
Height of buccal bone wall −0.15 (1.30) −0.95 (1.12)* 0.10
Height of palatal bone wall −0.91 (2.24) −1.20 (1.96) 0.73
Thickness of buccal bone wall (mm):
1 −0.07 (0.62) 0.65 (1.15)* 0.05
3 0.06 (1.10) 1.02 (1.15)* 0.04
5 0.03 (0.80) 1.77 (2.61)* 0.03
Buccal-to-palatal crest distance (mm):
1 −0.98 (2.32) −3.13 (3.15)* 0.05
3 0.74 (2.95) −1.22 (1.58)* 0.04
5 −0.41 (2.20) −0.81 (2.03) 0.63
∗ p ≤ 0.05 comparing initial and final measurements.
 G.B. de Oliveira et al. / British Journal of Oral and Maxillofacial Surgery 59 (2021) 1227–1232
groups. In the control group, the loss of the crest level was
around 1 mm, which was lower than the 1.74 mm previously
reported,13 and was likely to be due to the use of the free
gingival graft covering the extraction orifice.14
In the present test group, greater preservation of the
buccal-to-palatal crest distance was detected. A case report
with three patients in which the SST was performed with-
out implant placement, reported that the residual ridge
was clinically preserved six months after SST. However,
no measurement was obtained.11 When immediate implant
installation was associated with SST, a more pronounced
reduction of the buccolingual width (2.79 mm) has been
reported.13
For the buccal wall thickness, the results were statisti-
cally superior in the control group. However, the difference
between the groups was about 0.5 mm, which might be not
clinically significant. This may have been associated with
surgical trauma or inflammation associated with partial tooth
extraction in the test group. A loss of 0.02 mm of the buc-
cal wall thickness has also been reported four months after
the SST associated with immediate implantation, which was
similar to the current study.8 The remaining studies on SST
did not evaluate the thickness of the buccal wall.6,7,9,11
Considering the high costs of the grafting materials,
the SST offers a significant advantage in terms of cost-
effectiveness. Regarding its disadvantages, the sensitivity of
the technique is the most important, and extensive preclini-
cal training is required.11 Another drawback is the strict case
selection for the SST. It is not indicated in teeth that are in
areas showing alveolar bone loss, infection, or those with an
absence of attached gingiva.
The important strengths of the present trial were its design,
the similarity between the groups, and the fact that it was
the first trial to evaluate the effect of the SST by itself, as
no biomaterial or implant was used. An additional strength
was the use of CBCT scans for bone measurement, which is
a non-invasive technique and shows high accuracy to hun-
dredths of millimeters for linear bone measurements. Values
obtained from CBCT did not differ from direct measurement
using a high precision digital caliper.15,16 Fixed provisional
protheses were installed after tooth extraction to avoid migra-
tion and drift of the reference teeth adjacent to the extraction
area, and to ensure the smile aesthetics. Among the limita-
tions of this study, the small sample size and the short follow
up might be considered. Thus, future well-designed prospec-
tive randomised controlled studies with a larger sample, and
assessment of the long-term stability of the outcomes and the
factors that may have an impact on the results, are required.
Conclusions
The SST showed greater preservation of the buccal-to-palatal
crest distance. However, preservation of the thickness of the
buccal bone wall was lower compared with minimally trau-
matic extraction. There was no difference between groups
1231
with regard to the height of the buccal and palatal bone
walls, but resorption was significant only in the control group.
Therefore, after confirmation of the long-term stability of
the outcomes, this technique could be indicated for cases in
which immediate implant placement is not recommended due
to high aesthetic demands, or when primary implant stability
is unlikely to be reached.
Conflict of interest
We have no conflicts of interest.
Ethics statement/confirmation of patients’ permission
This study was approved by the Ethics Committee in
Research (Federal University of Bahia, Brazil (Process:
55523516.0.0000.5024) and was registered in The Brazil-
ian Clinical Trials Registry (5194). Yes I have the patients’
consent.
Funding
This work was supported by the Brazilian National Council
for Scientific and Technological Development for the finan-
cial support (CNPQ) (No. 303861/2018-5).
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