CLINICAL RESEARCH

The socket-shield technique:

a step-by-step protocol
after 12 years of experience

Philip Staehler, DMD

Private Practice, Munich, Germany

Sophia M. Abraha, DMD

Private Practice, Munich, Germany

Joel Bastos, DMD

Private Practice, Munich, Germany

Otto Zuhr, DMD

Private Practice, Munich, Germany
Department of Periodontology, Johann Wolfgang Goethe University Frankfurt, Frankfurt,
Germany

Markus Hürzeler, DMD, PhD

Private Practice, Munich, Germany
Department of Operative Dentistry and Periodontology,
Albert Ludwigs University Freiburg, Freiburg, Germany

Correspondence to: Dr Philip Staehler

Private Practice Hürzeler/Zuhr, Rosenkavalierplatz 18, Munich, Germany;
Tel: +49 89 189 1750, Fax: +49 89 189 17528; Email: p.staehler@huerzelerzuhr.com

288 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020

Abstract
The socket-shield technique, first published in 2010,
has gained worldwide scientific and clinical accept-
ance. To address possible complications with this in-
novative approach in esthetic implant dentistry, we
provide a comprehensive step-by-step protocol incor-
porating what we have learnt in the past decade. After
initial decoronation of the tooth, the implant bed is
prepared through the root of the tooth to be extract-
ed. Following extraction of the palatal root fragments,
the shield is prepared according to either a mechani-
cal or biologic ‘locking’ principle. The mechanical
The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
STAEHLER ET AL
‘locking’ comprises a direct contact between the im-
plant and the shield, whereas the biologic approach
facilitates ankylosis of the shield, preventing its coro-
nal displacement. The coronal part of the shield is
brought into a concave shape, ending up 0.5 mm cor-
onal to the buccal bone. The implant is consequently
inserted, and an individualized healing cap fabricated.
When performed according to the underlying biologic
and mechanical principles, the socket-shield tech-
nique can provide highly esthetic and predictable out-
comes.
(Int J Esthet Dent 2020;15:288–305)
| 289
CLINICAL RESEARCH
Introduction
Complete preservation or reconstruction
of the peri-implant soft tissue remains one
of the biggest challenges in implant dentist-
ry. To counteract defect formation that
negatively influences the esthetic appear-
ance of dental implants, numerous tech-
niques have been described,1 ie, hard and
soft tissue augmentation procedures, im-
mediate provisionalization, flapless implant
placement, a more palatal orientation of
the implant in the socket, and the possible
use of platform switching. Despite the pos-
itive aspects of all these techniques, the re-
ality is that optimal esthetics is only achieved
in select cases,2 as it is not possible to com-
pletely prevent or compensate for tissue
changes.1,3,4
Nowadays, it is well established that loss
of the periodontal ligament and the bundle
bone play a significant role in influencing
the resorption process that leads to peri-im-
plant soft tissue recession and esthetic de-
terioration. As those structures will be lost,
the buccal bone plate and soft tissue cover-
ing will be reduced in height because the
bundle bone extends into the tip of the buc-
cal bone wall. In the maxillary anterior, the
coronal part of the buccal lamella often
consists of bundle bone only, and therefore
its loss will lead to the complete resorption
of the buccal bone in this area.5
In 1965, Björn et al6 published the first re-
port of root submersion in humans to gain
periodontal reattachment. In 1978, Welker
et al7 were the first group to aim at prevent-
ing residual alveolar ridge reduction by the
mucosal coverage of the roots.7 Today, the
root-submergence technique has been
made popular again by Salama et al.8 The
principle behind it is simple: the preserva-
tion of the periodontal attachment, includ-
ing the cementum, periodontal ligament,
and bundle bone, prevents the resorption of
these structures.
290 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
A technique called ‘socket shield’ is
based on this principle. It was developed to
preserve healthy periodontium in the mar-
ginal area on the buccal side of the implant
by partial root retention.9 The technique
combines the advantages of incision-free
immediate implants such as a reduced
number of interventions, shortened treat-
ment time, reduced morbidity, and superior
soft tissue surface texture, with primary pre-
vention of tissue loss. Case reports and co-
hort studies on the technique have been
published in the literature and summarized
in a literature review,10 where a failure rate of
6.96% of all implants placed was reported.
Since the first publication on the sock-
et-shield technique,9 our working group has
undergone a learning curve. This article in-
tends to standardize the protocol of per-
forming the socket-shield technique. It also
addresses ways to minimize possible com-
plications with this technique, and presents
a comprehensive review of the surgical ap-
proach, incorporating what has been learnt
in the past decade.
Step-by-step protocol
The socket-shield technique is only utilized
in the zone of high esthetic relevance,
namely the maxillary anterior area from ca-
nine to canine. In the esthetically less-
demanding zones in the posterior and man-
dibular anterior area, there are well-
established implant placement concepts
available that omit the need to leave in place
parts of the tooth to be extracted.
Before the treatment, it is mandatory to
assess the patient’s medical history and oral
health status. The absence of periodontal
disease and infrabony periodontal defects
needs to be confirmed as well as radio-
graphically significant dehiscence in the
buccal bone plate of the tooth requiring ex-
traction. Clinically, there should be no verti-
cal and no subcrestal horizontal or oblique

Fig 1 Sagittal view of the mechanical Fig 2 Occlusal view of the mechanical
‘locking’ approach of the shield with the ‘locking’ approach in the interproximal area
implant in the apical area. with the implant.
fractures detectable on the facial aspect of
the tooth. Following the preoperative
analysis of the specific issues concerning
the clinical socket shield, the implant pos-
ition is digitally planned using an optical
scan and cone beam computed tomogra-
phy. The implant position itself is not influ-
enced by the application of the socket-
shield technique.
The key to the success of the socket-
shield technique is the radiographic analysis
of the implant position in relation to the
shield. Precise measurements of the hori-
zontal dimension (thickness of the shield),
the dimension of the shield interproximally,
and the vertical dimension (length of the
shield in the apicocoronal direction) are
conducted.
In our approach, the shield design re-
flects the biologic idea of preserving the
bundle bone, but nowadays also incorpo-
rates our understanding of facial growth and
the possibility of resulting complications. As
demonstrated in a recent article by Zuhr et
al,11 lifelong growth of the maxilla and the
involved teeth can result in complications
with the socket-shield technique. Therefore,
the need to prevent the antero-caudal
movement of the dentin shield compared
with the ankylosed implant is addressed by
‘locking’ the shield to the implant.
STAEHLER ET AL
Fig 3 Occlusal view demonstrating the
thinning out of the shield interproximally to
allow for better vascularization and
osteogenesis from the side.
There are two possible ways to achieve
this. The first is the preferred mechanical
principle comprising the mere ‘locking’ of
the shield with the implant threads in the
apical area. The implant shoulder should
not have contact with the shield. In the
three-dimensional analysis, the possible
mechanical ‘locking’ options can be deter-
mined. By leaving the apical part of the
shield thicker, the implant threads can ‘lock’
the shield apically (Fig 1). A variable thick-
ness of the shield can therefore be expect-
ed in this case. Another possibility of ‘lock-
ing’ the shield can be found in the
interproximal region, by leaving the shield
extended in this area (as was suggested by
Kan and Rungcharassaeng12) (Fig 2). The
contact of the implant in this area should
always be below the bone level.
The second possible way, the biologic
approach, is to create a non-inflammatory
ankylosis between the shield and the im-
plant surface, preventing future displace-
ment of the shield, as reported by Zuhr et
al.11 Therefore, the goal when preparing the
shield with this approach is to leave as much
as possible of the dentin shield in place to
facilitate ankylosis. Also, the interproximal
sides of the shield should be thinned out to
enable vascularization and the subsequent
osteogenesis with ankylosis (Fig 3).
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CLINICAL RESEARCH
Fig 4 Additional burs needed for performing the socket-shield technique.
One hour before surgery, a single-shot
oral antibiotic is administered comprising
2 g amoxicillin, or 600 mg clindamycin in
case of penicillin allergy.
The required instruments for the sock-
et-shield technique should be minimal.
Therefore, only the following instruments
are recommended in addition to those re-
quired for conventional implant placement:
■ Straight handpiece.
■ Straight desmotome (Deppeler).
■ Small Lindemann bur for angled hand-
piece (Komet Dental) (Fig 4).
■ Diamond bur for angled handpiece
(Fig 4).
■ Round carbide bur for straight handpiece
(Fig 4).
■ Round diamond bur for straight hand-
piece (Fig 4).
292 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
1. Decoronation and endodontic post
removal
The removal of the crown or other restor-
ations takes place before the surgical pro-
cedure (Fig 5). The tooth is ground down to
the level of the gingiva. Metal posts are re-
moved by cutting down the dentin mainly
on the palatal side to avoid damaging the
root on the facial aspect (Fig 6). Fiber posts
and composite fillings are removed with a
small Lindemann bur (Fig 7), following the
root canal as far to the apex as possible –
the rationale being that these materials are
hard enough to blunt the implant burs and
therefore need to be removed in advance.
2. Preparation of the implant bed
The implant bed is prepared through the
root using a 2-mm pilot drill and a surgical
guide (Fig 8). The preparation should be lo-
cated toward the palatal side of the root
(Fig 9). The intact root guarantees a stable
guidance of the bur during implant bed
preparation (Fig 10). The implant bed is
completely prepared following the specific
protocol of the implant manufacturer. As
shown in the examples of digitally planned
implant positions, the implant bed does not
follow the course of the root canal but in-
stead is palatally oriented.
 STAEHLER ET AL

Fig 5 Removal of the crown prior to surgery. Fig 6 Removal of the posts by the palatal reduction of the dentin,
saving the buccal dentin.

Fig 7 Removal of fiber posts and composite fillings with the small Fig 8 Preparation of the implant bed through the root using a
Lindemann bur. surgical template and the 2-mm pilot drill.

Fig 9 The small notch represents the middle of the palatally Fig 10 The intact root guarantees a stable guidance of the bur
oriented implant bed preparation. during implant bed preparation.

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CLINICAL RESEARCH

Fig 11 The root is separated in a mesiodistal direction using a small Fig 12 A sulcular incision is performed on the palatal side before
Lindemann bur. the extraction of the palatal root.

Fig 13 The palatal root is

removed with a desmotome.

3. Removing the palatal part of the
root and the apex
After the preparation of the implant bed, the
remaining palatal part of the tooth is mostly
very thin due to the palatally oriented im-
plant position. With a small Lindemann bur
(Fig 11), the root is separated in a mesiodistal
direction, creating a buccal and a palatal
root piece. A sulcular incision should be
made on the palatal side (Fig 12) with a mi-
croblade before the palatal piece can be re-
moved carefully with a straight desmotome
(Deppeler) (Fig 13). Care must be taken to
only apply force to the palatal bone, which
functions as the hypomochlion. Levering
against the buccal bone and dentin shield
will quickly lead to fracture and mobilization
of the buccal shield.
4. Preparation of the shield in the
horizontal and vertical dimensions
Preparing the buccal shield to be the correct
length, thickness, and extension to the inter-
proximal area is the most critical part when
performing the socket-shield technique.
Visual magnification, with sufficient illumina-
tion of the surgical field, as well as a direct
line of sight are mandatory to performing this
step. The preparation of the shield is initially
carried out with a 2.8-mm diameter round

294 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020

reinforced bur, following the root canal pre-
cisely until the former apex (Fig 14). As a tac-
tile support, the index finger of the non-dom-
inant hand should be pressed against the
alveolar bone so that possible perforations to
the vestibule can be felt in advance. The apex
needs to be cut roughly 2 to 3 mm coronal
to the tip of the root with a small, long-shaft-
ed Lindemann bur. The access and removal
of the apical delta is carried out through the
implant bed. The removal of the apical delta
will counteract possible inflammatory com-
plications originating from bacterially colo-
nized root canal branching.13 The radio-
graphic image provides additional orientation.
Any remaining root canal filling material is
removed from the buccal shield under direct
vision. The exact dimensional outline of the
shield in an apicocoronal direction and inter-
proximally follows the principles described
above. Depending on whether a biologic or
mechanical ‘locking’ approach is adopted,
the horizontal thickness can vary from coro-
nal to apical. In our opinion, a thickness of 1
to 2 mm in general provides enough stability
for the shield itself. If the shield can be locked
mechanically, the apical thickness is greater
than with the biologic approach. The inter-
proximal dimension (how far the shield
should extend in the interproximal area) and
the design of the shield at the interface to the
bone (ie, a feather edge or an edge) also play
a role. Preparing the margins of the shield in
a feather-edge design facilitates the ingrowth
of bone between the shield and the implant
surface. However, overly reducing the thick-
ness can render the shield prone to fracture
(ie, from 1 to 2 mm moving to 0.5 mm)
(Fig 3).
How far the shield is left interproximally
also depends on two factors. The first is the
presence of natural teeth adjacent to the im-
plant, which allows for a strictly buccally pre-
pared shield. In this case, the preparation from
line angle to line angle is sufficient to maintain
the natural soft tissue contour. In a case where
STAEHLER ET AL
two implants need to be placed side by side in
the esthetic zone, one of the shields should
extend further into the interproximal area, giv-
ing support to the interimplant papilla.12
The second factor is the potential need
for a mechanical ‘locking’ of the shield. The
shield needs to be extended to the interprox-
imal area when a mechanical ‘locking’ ap-
proach cannot successfully be achieved, by
‘locking’ the screws to the apicobuccal side.
In this case, a direct contact between shield
and implant can still be accomplished on ei-
ther side of the implant interproximally (Fig 2).
This interproximal contact should always be
below bone level, never in the coronal part.
5. Coronal shield preparation
There are various aspects to consider when
preparing the coronal part of the shield. In
the presented protocol, we recommend re-
ducing the shield to 0.5 mm above the buc-
cal bone height. The amount of reduction is
determined following bone sounding on the
buccal side. The first step comprises the
preparation of the shield in a concave shape,
leaving as much space as possible between
the emergence profile of the future crown
and the dentin shield.9,14 A carbide bur is uti-
lized for this part of the preparation (Fig 14).
The reduction in height is realized with a
round diamond bur with the same diameter
as the carbide bur (Fig 15). By thinning out the
concave shape from the inside out until di-
rect contact with the periodontal soft tissue
is achieved, the dentin shield is brought down
to the desired amount of 0.5 mm above the
buccal bone crest. The tissue-friendly dia-
mond bur will create a slightly bleeding sur-
face, without thinning out the tissue as the
carbide bur would do (Fig 16). A minor bleed-
ing surface is supportive to create a stable
blood coagulum between the shield and the
healing abutment or the provisional crown.
This increases the chances of a maximal soft
tissue infill, thus avoiding shield exposure.
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CLINICAL RESEARCH
Fig 14 The shield is initially prepared with a 2.8-mm diameter,
round, reinforced bur, following the root until the former apex.
Fig 16 The finalized shield preparation 0.5 mm above the
buccal bone crest.
6. Control of the shield integrity and
stability
The shield needs to be checked for the ab-
sence of cracks. Most teeth suitable for a
socket-shield implant exhibit failed endo-
dontic treatments. These teeth are at higher
risk of developing a vertical root fracture.15
To avoid complications due to a microbial
colonized crack, methylene blue, a blue in
vivo staining agent, is applied to the shield
from the inside. If a crack exists, capillary
296 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
Fig 15 The shield is reduced in height with a round diamond bur.
Fig 17 Methylene blue is used to visualize possible cracks
in the shield.
forces draw the staining agent into the crack
and enable visual confirmation (Fig 17).
When a crack becomes visible, it needs to
be opened with the same small Lindemann
bur as described above. The opening allows
blood vessels to grow into the space, elimi-
nates microorganisms, and enables the in-
growth of bone.14 As a next step, the ab-
sence of mobility of the shield needs to be
checked gently with forceps. If instability of
the shield is present, the removal of the
shield is recommended.

Fig 18 The implant is placed into the implant bed.
7. Implant placement
In the next step, the implant is inserted
(Fig 18), anchored in the bone apical to the
former apex. If a mechanical ‘locking’ ap-
proach is chosen, the implant design can
negatively impact the integrity of the shield.
An implant with an aggressive thread design
or a tapered body design may create exces-
sive pressure on the shield in the apical area.
In this case, the clinician should consider
using a parallel-walled implant, which does
not administer buccal force to the shield.
The position of the implant shoulder also
depends on the implant design. The implant
shoulder is positioned at the level of the buc-
cal bone crest, ie, 0.5 mm below the shield, if
a butt-joint connection implant is used (Fig 19).
8. Management of the gap
Grafting materials are not used to fill the gap
(Fig 19). Various studies have demonstrated
the healing potential of the body, showing
the ingrowth of the bone and the ankylosis
of the shield and implant.9,16 Placing any
type of grafting material seems unnecessary
and might impede the healing process.
STAEHLER ET AL
Fig 19 The implant shoulder is positioned on the level of the
buccal bone crest. The gap is left without filling material.
9. Soft tissue management
As demonstrated in the first socket-shield
technique publication,9 there is no need
for adding a soft tissue graft. However, it
is mandatory that an individualized heal-
ing cap or a provisional anatomical crown
with the original soft tissue profile be con-
structed and installed on the implant. The
individualized healing cap is fabricated
using a sandblasted provisional abutment
and flowable, light-curing, bulk-fill com-
posite. The exposed bone and tissue apical
to the sandblasted individual abutment is
protected by a small piece of rubber dam
(Fig 20). Afterwards, the concave emer-
gence profile of the individualized abut-
ment is finalized, polished, and screwed
on the implant (Fig 21). When the initial
stabilization of the implant allows for an
immediate provisionalization, a provisional
crown using the same emergence profile
as the individualized abutment may be in-
stalled. Another option could be a provi-
sional that is screwed on a palatally placed
implant (Fig 22), ending up as a pontic
over the individualized healing abutment
(Fig 23).
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CLINICAL RESEARCH
Fig 20 Before applying the composite to the provisional abutment
for creating an individualized abutment, the exposed bone is
protected by a small piece of rubber dam.
Fig 22 Palatal view of the provisional screw-retained crown.
10. Postoperative maintenance
After rinsing for 1 week postsurgery with
chlorhexidine mouth rinse, the patient is in-
structed to start a regular oral hygiene rou-
tine again, using a toothbrush and interden-
tal brushes. Depending on the final insertion
torque and the specific implant system, the
impression for the final crown is taken 6 to
12 weeks later. The final crown can then be
placed.
298 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
Fig 21 Finalized provisional abutment in place.
Fig 23 Provisional screw-retained crown placed on a palatally
placed implant, ending as a pontic over the individualized abutment.
Discussion
The socket-shield technique, first described
by Hürzeler et al,9 is a relatively novel ap-
proach in esthetic implant dentistry (Figs 24
to 27). After worldwide clinical application
of this technique and numerous published
studies, it can no longer be called experi-
mental. Over the past decade, we have de-
veloped a detailed knowledge of this pro-
cedure and its corresponding difficulties.

Fig 24 Preoperative view of the first documented socket-shield
case from 2008.
Fig 26 12-year follow-up radiograph.
With this step-by-step protocol incorporat-
ing the underlying understanding of post-
extractional tissue alterations and skeletal
growth, an attempt is made to address the
avoidable complications and possible pit-
falls when applying the technique.
Currently, two systematic literature re-
views have been published on the socket-
shield technique.10,17 The first, by Gharpure
and Bhatavadekar,17 reported complications
occurring in 24% of all included implants in
STAEHLER ET AL
Fig 25 Shield preparation before implant placement. Notice the
coronal placement of the shoulder of the shield.
Fig 27 12-year postoperative view.
human trails. Various approaches were in-
cluded, ranging from the T-Belt technique18
to transdental fixations in animal studies, pri-
marily not intended as a socket-shield pro-
cedure.19 The heterogeneity of the different
approaches complicates the comparison of
the treatment results and might be a reason
for the high number of failures. A more re-
cent literature review by Mourya et al10 com-
pared clinical studies from 2017 onwards
and reported a failure rate of 7%.
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CLINICAL RESEARCH
A 5-year clinical, radiographic, and volu-
metric analysis confirmed the value of the
socket-shield technique in preventing loss
of volume on the buccal side when placing
immediate implants.20 Gluckman et al21
demonstrated over 4 years that the survival
rate of implants placed with the socket-
shield technique is comparable to that of
conventional immediate and early/delayed
implant placement. The first randomized
clinical trial over 2 years reported improved
functional and esthetic outcomes with the
socket-shield technique by maintaining al-
veolar bone volume and peri-implant tissue
when compared with conventional flapless
immediate implantation.22
There are minor differences between
the most frequently described protocols
for the socket-shield technique23,24 and our
protocol.
The ‘partial extraction therapy’ by
Gluckman et al23 comprises decoronation
of the tooth and sectioning of the root me-
siodistally in a longitudinal axis, with the
root canal as a reference. The resected
palatal half is removed with the help of a
micro-periotome. The labial root shield is
reduced to the level of the alveolar labial
bone crest, and the most coronal 2 mm of
the shield is reduced with a large round
bur, creating a beveled chamfer. This al-
lows for additional prosthetic space be-
cause, later on, the implant shoulder is
placed 1.5 mm below the shield. The
oro-vestibular thickness of the labial shield
is somewhat reduced. The exact implant
position in relation to the shield in the hori-
zontal dimension is not reported on, al-
though the contact of implant and shield
does not seem to be encouraged. If a gap
between implant and shield is present, we
recommended that it be filled with particu-
late bone-grafting material. An individual-
ized healing abutment or an immediate
provisional then needs to be fabricated to
support the soft tissue situation.
300 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
The ‘root membrane technique’ by
Siormpas et al25 and Mitsias et al26 is another
adaptation of the socket-shield approach.
After grinding down the tooth to 0.5 to
1.0 mm above the bone crest, the implant
bed is prepared through the long axis of the
tooth in a more palatal position to preserve
the labial socket shield. Two longitudinal
cuts are created through the dentin along
the long axis of the tooth to lever out the
approximal and palatal remnants of the
tooth. According to these authors, the
oro-vestibular thickness of the shield should
be 1.0 to 1.5 mm. The tapered implant
seems to be placed at the level of the labial
bone. No further information is given as to
the shape of preparation of the coronal
shield. The provisional is cemented on top
of a provisional abutment.
What the above two methods have in
common with each other and with our pro-
tocol is the initial step of grinding down the
tooth to the level of the gingiva. In a similar
way to Gluckman et al,23 we use a navigated
surgical template for implant bed prepar-
ation. Like Mitsias et al,26 we leave the root
of the tooth in place during implant bed
preparation, which provides more mechan-
ical stability for the implant bur during prep-
aration compared with the postextraction
empty alveolar socket.27. Contrary to Mitias
et al,26 we do not prepare the implant bed
along the axis of the tooth, but follow the
navigated surgical template. This leads to a
more palatally positioned implant com-
pared with the tooth.
The coronal part of the shield is prepared
differently to how it is described in the initial
publication by Hürzeler et al,9 where it was
suggested to prepare the root 1 mm coro-
nal to the buccal bone plate. Gluckman et
al23 concluded that the supracrestal prepar-
ation frequently results in exposure of the
shield. Therefore, they proposed to reduce
the shield until it is level with the buccal
bone. In 1983, Carnevale et al28 prepared

tooth structure up to the alveolar crest and
demonstrated a 1 mm loss of buccal bone
height after preparing the tooth to the level
of the bone. These findings were attributed
to the need for a reestablishment of the su-
pracrestal connective tissue barrier. With re-
gard to this study, we hypothesize that pre-
paring the shield on the level of the bone
will lead to a resorption of 1 mm of the buc-
cal bone. However, the clinical results ana-
lyzed by the pink esthetic score (PES)29 will
still demonstrate a high level of success and
will be as good as the conventional ap-
proach of implant placement in the esthetic
zone.30
The thickness of the shield is afterwards
prepared to about 1.0 to 2.0 mm and can
vary in the corono-apical direction. There
are many recommendations in the literature
about this issue. In their study, Guirado et
al31 recommend a thickness of 2 mm. Tan et
al32 suggested an ideal thickness of 0.5 to
1.5 mm. In 2019, Calvo-Guirade et al33 ad-
vised a short piece of root in the coronal
part of the alveolus. In our protocol, the cor-
onal part of the shield is positioned about
0.5 mm above the buccal bone. This is a
compromise between limiting the risk of
shield exposure and preserving as much fa-
cial tissue as possible. The coronal part of
the shield is prepared in a concave shape, as
was demonstrated in 2013.14 In contrast to
Mitsias et al,26 a parallel implant is preferred
so as to avoid uncontrollable pressure on
the labial shield, if contact is expected. Also,
a screw-retained suprastructure is used
where there is no need for cementation.
In our opinion, the necessity for a bio-
logic or mechanical ‘locking’ of the shield
needs to be understood. Björk34 and Björk
and Skieller35 demonstrated the lifelong
growth of the maxilla in an antero-caudal
direction. This phenomenon could cause a
long-term complication of the socket-shield
technique.11 Zuhr et al11 demonstrated how
this antero-caudal growth vector provoked
STAEHLER ET AL
a complication with the socket-shield tech-
nique. The dentin shield, designed to be
very short and not be in direct contact with
the implant, moved like a natural tooth in
the antero-caudal direction within 6 years of
function. After coming into contact with the
implant crown placed on the ankylosed im-
plant, oral microorganisms gained access
through the disrupted soft tissue barrier
around the shield. This caused an infection
that necessitated the surgical removal of the
shield. Hence, the movement of the shield
in the antero-caudal direction needs to be
prevented by ‘locking’ the shield to the im-
plant. Due to the short preparation of the
shield, which became infected later on, an
ankylosis between the shield and the bone
had not occurred. This ankylosis would
have prevented further movement of the
shield and would have kept its relation to
the implant. Already in 2010, Hürzeler et al9
found newly formed bone on the implant
surface toward the shield, and showed new
cementum on the shield. It was hypothe-
sized that the application of Emdogain
(Straumann) may have caused the newly
formed cementum. In 2013, Bäumer et al14
did not administer Emdogain in the same
animal model in the maxilla. These authors
could demonstrate new bone formation
between the implant and the shield. Also, in
2018, Schwimer et al16 reported on a human
histology with evidence of bone fill between
the root dentin and an osseointegrated im-
plant surface. Therefore, in our understand-
ing, a noninflammatory ankylosis of the
shield to the bone will most likely ensue if a
sufficient amount of shield is exposed to the
bone. This biologic ‘locking’ approach is fa-
cilitated if the shield is left as long as possi-
ble in an apicocoronal direction, and if the
interproximal areas of the shield are thinned
out to allow the best possible vasculariza-
tion for osteogenesis between implant and
shield. Contrary to Gluckman et al,23 we rec-
ommend (if allowed by the implant position)
The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020 | 301
CLINICAL RESEARCH
the creation of a direct contact between the
implant and shield in the apical area or inter-
proximally achieving a mechanical ‘locking’
of the shield. A small area of contact seems
to be sufficient, and no intimate contact be-
tween the implant and shield over the length
of the entire root is necessary. In our opin-
ion, whenever a parallel wall implant is used,
the advocated danger of fracturing the root
with the pressure of implant insertion seems
to be low. This mechanical ‘locking’ pro-
vides the clinician with the direct certainty
that the shield will remain in position, com-
pared with the biologic approach where an-
kylosis has to occur. Nevertheless, if the
mechanical ‘locking’ cannot be realized, the
ingrowth of bone between the implant and
shield needs to be motivated.9,16 Biologic
‘locking’ or functionally ankylosing the
shield is achieved by the ingrowth of bone
between the implant and shield, without
there being direct contact between them.
The implant position in the present pro-
tocol differs from the position described by
Gluckmann et al,23 who placed the implant
shoulder below the buccal bone using a
platform-switched implant. These authors
reduced the shield to the level of the bone.
This means that with a parallel-wall implant
connected with a butt joint, the implant
shoulder would be placed on the level of
the buccal bone; meanwhile, with a plat-
form-switched implant, the implant shoul-
der would be placed below the buccal
bone. In total, a platform-switched implant
would be placed 1 to 1.5 mm deeper. This
situation can create additional problems
with the contour of the clinical crown on
the buccal side.
Although there are many improvements
and better understandings available, much
remains unknown such as the ideal thick-
ness of the shield, the ideal length, and the
ideal extension in the interproximal area.
302 | The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020
Also, grafting the gap between the shield
and the implant, and the height of the shield
in relation to the buccal bone, are still is-
sues. The present tendency to reduce the
shield to the level of the buccal bone may
end up with some loss of the buccal bone,
but could be safer in terms of shield expo-
sure. In addition, it is still not clear whether
the ingrowth of bone between the shield
and implant surface can be influenced by
any parameters. Nonetheless, it is evident
that the socket-shield technique is techni-
cally demanding and sensitive, and requires
a high level of skill, experience, and biologic
understanding on the part of the clinician.
With the knowledge we have gained in
the 12 years of using this technique as well
as our understanding of relevant mechani-
cal and biologic factors, we believe that very
positive and predictable outcomes can be
achieved if the procedure is executed cor-
rectly, even in very challenging clinical situ-
ations like the replacement of adjacent
teeth in the esthetic zone (Figs 28 to 30).
Conclusion
A considerable amount of data about the
socket-shield technique have been pub-
lished in recent years. The latest systematic
literature review,10 as well as our findings
over the past decade, suggest that the tech-
nique works predictably and delivers satisfy-
ing short- and long-term success. To miti-
gate the known possible risks of applying
the technique in a wider field, standardiza-
tion of this procedure is necessary. For this
reason, this article offers a comprehensive
review of the protocol, and introduces the
concept of ‘locking’ the shield to prevent its
coronal displacement. Given the right indi-
cation in high esthetic cases in the maxillary
anterior area, this technique can provide a
new treatment option for the patient.
 STAEHLER ET AL

Fig 28 Preoperative view of a socket-shield case with two adjacent Fig 29 Clinical situation before placement of the crowns. Notice
implants in the maxillary central incisors. the col of the interimplant papilla.

Fig 30 7-year
follow-up of the
case. Complete
preservation of the
soft tissue can be
observed.

The International Journal of Esthetic Dentistry | Volume 15 | Number 3 | Autumn 2020 | 303
CLINICAL RESEARCH
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