Received: 23 April 2021 Revised: 19 June 2021 Accepted: 2 August 2021

DOI: 10.1111/jerd.12812

REVIEW ARTICLE

The socket shield technique for immediate implant placement:

A systematic review and meta-analysis

Momen A. Atieh BDS, MSc, DClinDent, PhD1,2 | Maanas Shah BDS, MSD, CAGS3 |
4 5
Mohammed Abdulkareem BDS | Haif A. AlQahtani BDS |
Nabeel H. M. Alsabeeha DMD, MSc, MFDS RCPS (Glasg), PhD6

1
Chair and Associate Professor of
Periodontology, Mohammed Bin Rashid
University of Medicine and Health Sciences,
Hamdan Bin Mohammed College of Dental
Medicine, Dubai, United Arab Emirates
2
Honorary Associate Professor, Faculty of
Dentistry, Sir John Walsh Research Institute,
University of Otago, Dunedin, New Zealand
3
Department of Periodontology, Mohammed
Bin Rashid University of Medicine and Health
Sciences, Hamdan Bin Mohammed College of
Dental Medicine, Dubai, United Arab Emirates
4
Dental Intern, Mohammed Bin Rashid
University of Medicine and Health Sciences,
Hamdan Bin Mohammed College of Dental
Medicine, Dubai, United Arab Emirates
5
Dental Intern, Imam Abdulrahman Bin Faisal
University, Dammam, Saudi Arabia
6
Consultant Prosthodontist, Department of
Prosthodontics, Ras Al-Khaimah Dental
Center, Ministry of Health and Prevention,
United Arab Emirates
Correspondence
Momen A. Atieh, Mohammed Bin Rashid
University of Medicine and Health Sciences,
Hamdan Bin Mohammed College of Dental
Medicine, Dubai, United Arab Emirates.
Email: maatieh@gmail.com
Abstract
Background: Immediate implant placement with socket shield technique (SST) may
maintain the buccal bone plate and soft tissue levels, however, the potential clinical
benefits of SST lack strong scientific evidence. The aim of this systematic review and
meta-analysis was to evaluate the effects of SST on dimensional changes of hard tis-
sues, esthetic outcomes, implant stability, complication, and implant failure rates.
Methods: Electronic databases were searched to identify randomized controlled trials
(RCTs) that compared immediate implant placement with and without SST. The risk
of bias was assessed using the Cochrane Collaboration's Risk of Bias tool. Data were
analyzed using a statistical software program.
Results: A total of 982 studies were identified, of which, seven RCTs with 206 imme-
diately placed dental implants in 191 participants were included. Overall meta-
analysis showed significant differences in the changes in buccal bone plate width
(mean difference (MD) –0.22; 95% confidence interval (CI) –0.30 to 0.15;
p < 0.0001) and height (MD –0.52; 95% CI -0.85 to 0.18; p = 0.002) in favor of
SST. The use of SST was also associated with significantly less changes in peri-
implant marginal bone levels and better pink esthetic score than immediately placing
implants without SST. The differences in implant stability, complication and implant
failure rates were not statistically significant between immediate implant placement
with or without SST.
Conclusions: The short-term complication and implant failure rates following immedi-
ate implant placement with or without SST were comparable. The SST has short-term
positive effects on the changes in width and height of buccal bone plate, peri-implant
marginal bone levels and esthetic outcomes. Further evidence from long-term RCTs
are still required to substantiate the current findings.
Clinical Significance: SST can reduce changes in buccal plate width and height and
improve the soft tissue profile following immediate implant placement in
esthetic zone.

KEYWORDS
immediate implant placement, meta-analysis, socket shield technique, systematic review

J Esthet Restor Dent. 2021;1–15. wileyonlinelibrary.com/journal/jerd © 2021 Wiley Periodicals LLC. 1

2 ATIEH ET AL.

1 | I N T RO DU CT I O N 2 | M A T E R I A L S A N D M ET H O D S

One of the main challenges in immediate implant therapy is the The Preferred Reporting Items for Systematic Reviews and Meta-
preservation of soft and hard tissue architecture following simulta- Analyses (PRISMA) statement,20 and the Cochrane Collaboration
neous tooth extraction and implant placement. Volumetric tissue guidelines21 were followed in preparing the present systematic
changes following tooth extraction are inevitable as they are part of review. The participant, intervention, comparison, outcome (PICO)
1
the remodeling processes. The loss of periodontal ligament and its framework21,22 was used to structure our research question:
vascular contribution cause marked resorption of the thin and deli-
cate buccal bone.2 This can have negative implications when imme- 1. Participant: Human adults aged ≥18 years that require dental
diate implant placement in the esthetic zone is considered. To implant placement following tooth extraction.
3
reduce adverse bone changes, grafting materials, connective tissue 2. Intervention: Immediate implant placement with SST.
grafts,4 and growth factors5 were used in conjunction with immedi- 3. Comparison: Immediate implant placement without SST.
ate implant placement. Immediate implant placement, however, 4. Outcomes: Changes in width and height of the buccal bone plate,
remains a challenging technique with higher risk of complications changes in peri-implant marginal bone levels, implant stability mea-
and implant failure compared with conventional implant placement surements, pink esthetic score, complications, implant failure rate.
protocols.6–8
Socket shield technique (SST) was first described by Hurzeler
and co-workers back in 2010.9 It was proposed as an alternative 2.1 | Types of studies
minimally invasive procedure to preserve the buccal bone and
improve treatment outcomes with immediate implant placement. 2.1.1 | Inclusion criteria
Over the years, several modifications of the original protocol of
the SST were applied and other terminologies introduced such as This review included RCTs reporting on immediate implant placement
10,11
the partial extraction therapy, the root membrane tech- with and without STT. The included studies had to report on changes
nique 12,13 and the modified SST. 14 In general, the SST involves in buccal bone width and height, peri-implant marginal bone levels,
decoronation of the tooth indicated for extraction and then split- implant stability measurements, pink esthetic score, complications, or
ting the root portion mesio-distally into a buccal and palatal por- implant failure rate. No language restrictions were employed.
tion. The palatal portion is removed leaving only the buccal part
intact with the coronal part of it at the level or 1 mm above the
crest of the buccal bone. The buccal portion is thinned out to a 2.1.2 | Exclusion criteria
concave profile leaving 1.5 mm14 or half of the buccal root por-
tion. 11 The dental implant is then placed engaging the buccal root Non-RCTs, retrospective studies, case series, case reports,
portion or with a gap in between. Depending on the surgical pro- histomorphometric research, and studies that did not provide suffi-
tocol followed, the gap can be grafted or left to heal cient data were excluded.
spontaneously. 11
Treatment outcomes with dental implants immediately
placed using the SST have been reported in several retrospective, 2.1.3 | Type of participants
case series studies and reviews. 13,15–19 Acceptable survival
rates were reported but with considerable risk of complica- Participants that were 18 years of age or older and received dental
13,16,17,19
tions. These studies, however, did not include control implants immediately following tooth extraction.
groups with traditional immediate implant placement protocols
for objective comparison of outcomes. Hence, the true impacts
of the SST on implant survival and esthetic outcomes remain to 2.1.4 | Types of interventions
be objectively assessed. The aim of this systematic review and
meta-analyses, therefore, is to evaluate the outcomes of immedi- Comparing between immediate implant placement with and
ate implant placement with and without SST in terms of hard tis- without SST.
sue changes, peri-implant marginal bone level changes, implant
stability, esthetic outcomes, complications and implant failure
rates based on the available evidence from randomized con- 2.2 | Outcome measures
trolled trials (RCTs).
Our focused research question was: in patients requiring dental 2.2.1 | Primary outcomes
implants following tooth extraction, does immediate implant place-
ment with SST improve clinical outcomes as compared with immedi- • Changes in width of buccal bone plate (as measured by
ate implant placement without SST? radiographs).
ATIEH ET AL. 3

• Changes in height of buccal bone plate (as measured by TABLE 1 Databases and search terms
radiographs). Databases Keywords
Published studies
PubMed (1965 - June (socket shield OR root membrane*
2.2.2 | Secondary outcomes 18, 2021) OR partial extraction OR partial
root retention) AND (immediate
• Changes in peri-implant marginal bone levels (as measured by implant* OR dental implant* OR
oral implant* OR post-extraction
radiographs).
implant*)
• Implant stability (as measured by implant stability quotient).
EMBASE via Ovid (1947 (socket adj shield).mp OR (root adj
• Esthetic outcomes (as evaluated by pink esthetic score).
- June 18, 2021) membrane).mp. OR (partial adj
• Complications (such as exposed shield, mucosal recession, discom- extraction).mp. OR (partial adj
fort, pain and swelling). root adj retention).mp. AND
• Implant failure rate (defined as implant removal). (immediate adj implant$).mp. OR
(dental adj implant$).mp. OR
(oral adj implant$).mp. OR
(postextraction adj implant$).
2.3 | Search strategy mp.
Cochrane Central (socket adj shield).mp OR (root adj
The search protocol followed standard guidelines.23 The following Register of Controlled membrane).mp. OR (partial adj
electronic databases were searched for ongoing and unpublished Trials (CENTRAL) via extraction).mp. OR (partial adj
Ovid (June 18, 2021) root adj retention).mp. AND
trials up to June 182,021: MEDLINE, EMBASE, The Cochrane Cen-
(immediate adj implant$).mp. OR
tral Register of Controlled Trials (CENTRAL), MetaRegister, (dental adj implant$).mp. OR
ClinicalTrials.gov, and the System for Information on Gray Litera- (oral adj implant$).mp. OR
ture in Europe (http://www.opengrey.eu) (Table 1). The search (postextraction adj implant$).
mp.
was performed independently and in duplicate by three authors
Unpublished studies
(M. A. A., M. A. and H.A.). Manual search of the last 5 years of rele-
vant dental journals (Clinical Implant Dentistry and Related MetaRegister of controlled (socket shield technique OR root
trials membrane technique OR partial
Research, Clinical Oral Implants Research, Implant Dentistry, Interna-
OpenGrey (www. root retention) AND (immediate
tional Journal of Oral and Maxillofacial Implants, International Jour- opengrey.eu) implant OR oral implant OR
nal of Periodontics and Restorative Dentistry, International Journal of ClinicalTrials.gov dental implant OR
Prosthodontics, Journal of Cranio-Maxillofacial Surgery, and Journal (June 18, 2021) postextraction implant)

of Periodontology) and bibliographies of all eligible papers was car-

ried out to look for other additional studies.
2.4 | Selection of studies
Three reviewers (M. A. A., M. A., and H. A.) independently and in
duplicate examined the retrieved citations on the basis of the title,
abstract, and keywords. Irrelevant papers were excluded and the
full-texts of the remaining ones were obtained. An eligibility form
was used to examine papers for inclusion in the review. Any dis-
agreements were resolved by discussion to reach a consensus or
by consultation with a fourth reviewer (N. A.). In the event of
duplicate papers, the one with the most relevant and sufficient
information was selected. All the reasons for exclusion were
reported.
2.5 | Data collection
Three authors (M.A.A., M.A., and H.A.) used a data extraction form
and independently collected the following information from the
included studies:
1. Study characteristics: title, authors' names, contact address, study
location, language of publication, year of publication, published or
unpublished data, source of study funding, study design (parallel
group or split mouth), method of randomization, allocation con-
cealment and blinding (participants, investigators, outcome
examiners).
2. Participants: demographic characteristics, inclusion/exclusion
criteria, number of participants in test and control groups, number
of withdrawals and reasons for dropouts.
3. Interventions: number of participants where immediate implant
placement was performed with SST.
4. Comparison: number of participants where immediate implant
placement was performed without SST.
5. Outcomes: changes in buccal bone width and height, peri-implant
marginal bone levels, implant stability measurements, pink esthetic
score, complications, and implant failure rate.
6. Length of the observation period. Any disagreements between
reviewers were resolved by discussion to reach a consensus or by
consultation with a fourth reviewer (N.A.). Corresponding authors
of the included studies were contacted for additional information
if required.
4 ATIEH ET AL.
2.6 | Quality assessment of included studies
Three reviewers (M. A. A., M. A., and H. A.) used the Cochrane Collab-
oration's Risk of Bias (RoB) tool for randomized studies of interven-
tions21 to independently assess the included human studies to
determine the risk of bias. The RoB tool for RCTs consists of seven
domains (sequence generation, allocation concealment, blinding of
participants and investigators, blinding of outcome assessment,
incomplete data outcome, selective outcome reporting, and potential
sources of bias). The first part of the tool describes each domain while
the second part categorizes studies into those having (a) low risk of
bias if all the criteria were met, (b) unclear risk of bias if one or more
criteria were partially met, or (c) high risk of bias if one or more criteria
were not met.
2.7 | Data synthesis
A statistical software program (Review Manager [RevMan] software,
version 5.3, The Nordic Cochrane Center, The Cochrane Collabora-
tion, Copenhagen, Denmark) was used to conduct meta-analyses for
studies of similar comparisons reporting the same outcome measures.
Continuous data, such as changes in width and height of buccal bone
plate, were expressed in mean difference (MD) or standardized mean
difference (SMD) and 95% confidence intervals (CIs). Dichotomous
data, such as implant failure rate, were expressed in risk ratio
(RR) estimates and 95% CIs. Random-effects model was used to pool
the results from more than one study as heterogeneity between
FIGURE 1 Flowchart of the search process
studies was expected. Split-mouth and parallel group studies were
combined using the generic inverse variance option in the statistical
software program.
With fewer than 10 studies, publication bias was not formally
assessed because the power to detect publication bias was lim-
ited.21 The statistical heterogeneity across different studies was
assessed by means of the Cochran's test for heterogeneity and I2
statistic.21 An I2 value of >50 indicated a substantial heterogene-
ity. The unit of analysis was the implant rather than the participant
as the outcomes may have varied between the two surgical
techniques.
3 | RE SU LT S
3.1 | Characteristics of the study settings
A total of 982 studies were retrieved from the databases (Figure 1).
After titles and abstracts were examined independently and in dupli-
cate by two review authors (M. A. A., M. A., and H. A.), nine studies
were eligible for full-text review.24–32 Two studies24,32 were subse-
quently excluded and as a result seven studies25–31 were included in
the present review (Table 2). Of the seven included studies, three
were conducted in the Egypt,25,26,28 one in Italy,27 one in Iraq,29 one
in China,30 and one in India.31 All the included RCTs were parallel-
group studies conducted in university setting. Two studies27,31 were
self-funded, while the remaining five25,26,28–30 did not report on the
source of funding.
TABLE 2 Characteristics of the included studies

Abd-Elrahman
et al. 2020 Barakat et al. 2017 Bramanti et al. 2018 Fattouh 2018 Hana and Omar 2020 Sun et al. 2020 Tiwari et al. 2020
ATIEH ET AL.

Study design RCT (parallel group) RCT (parallel group) RCT (parallel group) RCT (parallel group) RCT (parallel group) RCT (parallel group) RCT (parallel group)
Location Cairo University, Alexandria University, University of Cairo University, University of Dohuk, First Affiliated Saraswati Dental
Giza, Egypt Alexandria, Egypt Messina, Messina, Giza, Egypt Kurdistan Region, Hospital of Xi'an College and
Italy Iraq Jiaotong Hospital,
University, Xi'an, Lucknow, Uttar
China Pradesh, India
Number evaluated 25/40a 20/20 40/40 20/20 40/40 30/30 16/16
(participants/implants)
IIP without SST 16/20 10/10 20/20 10/10 20/20 15/15 8/8
IIP with SST 18/20 10/10 20/20 10/10 20/20 15/15 8/8
Age (years), Range 21 to 39 20 to 50 NR NR 28 to 65 NR 18 to 30
Smoking habits NR NR None NR NR NR NR
Use of GBR with conventional No GBR No GBR Buccal gap was filled Buccal gap was filled No GBR Buccal gap of more No GBR
IIP with xenograftb with xenograftc and than 1 mm was
resorbable collagen filled with
membraned xenograftc
Immediate implant Both groups Delayed implant loading at Both groups Both groups Both groups Both groups Delayed implant
restoration/loading 4 months loading at
4 months
Teeth extracted Maxillary incisors and Maxillary incisors and Maxillary and Maxillary incisors and Maxillary incisors and Maxillary incisors and Maxillary incisors,
canines canines mandibular incisors canines canines canines canines and
and canines premolars
Reason for extraction NR NR Horizontal or vertical NR NR Trauma, caries, NR
fracture, endodontic lesions
destructive caries,
internal resorption
and endodontic
problems not
treatable with root
canal therapy
e f g h
Implant system NR NR NR
Implant diameter (mm) 3.3, 3.7 3.3, 3.8, 4.3 4.5 4.1 3.5 to 5 3.5, 4.0 NR
Implant length (mm) 14, 16 10, 12, 14 NR 13 11 to 14 NR NR
Method(s) of assessment CBCT, resonance CBCT, Standardized Standardized Standardized CBCT, periodontal CBCT, photographs, CBCT
frequency analysisi radiograph, panoramic radiograph, radiograph, probe resonance
radiograph, resonance photographs frequency analysisi
frequency analysisi

(Continues)
5
 6

TABLE 2 (Continued)

Abd-Elrahman
et al. 2020 Barakat et al. 2017 Bramanti et al. 2018 Fattouh 2018 Hana and Omar 2020 Sun et al. 2020 Tiwari et al. 2020
Changes in buccal bone width (mm)
IIP without SST 0.28 ± 0.15 0.34 ± 0.11 NR NR NR 0.53 ± 0.05 0.19 ± 0.09
IIP with SST 0.12 ± 0.07 0.10 ± 0.03 NR NR NR 0.22 ± 0.09 0.03 ± 0.13
Changes in buccal bone height (mm)
IIP without SST 0.77 ± 0.35 1.61 ± 0.78 NR NR NR 0.87 ± 0.12 0.16 ± 0.01
IIP with SST 0.34 ± 0.12 0.44 ± 0.24 NR NR NR 0.28 ± 0.08 0.03 ± 0.01
Peri-implant marginal bone level changes (mm) at 6 months
IIP without SST NR NR 1.02 ± 0.10 0.98 ± 0.17 NR NR NR
IIP with SST NR NR 0.54 ± 0.06 0.64 ± 0.12 NR NR NR
Peri-implant marginal bone level changes (mm) at 12 months
IIP without SST NR NR NR 1.06 ± 0.24 NR NR NR
IIP with SST NR NR NR 0.69 ± 0.11 NR NR NR
Peri-implant marginal bone level changes (mm) at 36 months
Conventional IIP NR NR 1.12 ± 0.13 NR NR NR NR
IIP with SST NR NR 0.61 ± 0.06 NR NR NR NR
Implant stability at placement (ISQ)
IIP without SST 66.40 ± 5.64 57.20 ± 9.15 NR NR NR 75.56 ± 1.07 NR
IIP with SST 68.60 ± 3.81 60.30 ± 6.43 NR NR NR 76.01 ± 1.31 NR
Implant stability at 6 months (ISQ)
IIP without SST 75.50 ± 4.40 65.60 ± 5.66 NR NR NR NR NR
IIP with SST 76.71 ± 3.49 69.80 ± 3.77 NR NR NR NR NR
PES at 3 months
IIP without SST NR NR 11.45 ± 1.60 10.60 ± 0.69 NR NR NR
IIP with SST NR NR 12.50 ± 0.94 11.40 ± 0.84 NR NR NR
PES at 6 months
IIP without SST 8.85 ± 1.81 NR 11.05 ± 1.53 10.30 ± 0.48 NR 11.73 ± 1.67 NR
IIP with SST 12.00 ± 1.12 NR 12.30 ± 0.86 11.20 ± 0.91 NR 12.00 ± 1.77 NR
PES at 12 months
IIP without SST NR NR NR 10.20 ± 0.42 9.63 ± 1.34 11.53 ± 1.73 NR
IIP with SST NR NR NR 11.10 ± 0.73 12.26 ± 1.04 12.20 ± 1.57 NR
PES at 36 months
IIP without SST NR NR 10.30 ± 1.59 NR NR NR NR
IIP with SST NR NR 12.15 ± 0.87 NR NR NR NR
Complications N (%)
IIP without SST 0 (0) NR NR NR 5 (25) NR NR
IIP with SST 1 (5) NR NR NR 2 (10) NR NR
ATIEH ET AL.
 ATIEH ET AL. 7

3.2 | Characteristics of participants at baseline

Abbreviations: CBCT, cone beam computed tomography; GBR, guided bone regeneration; IIP, immediate implant placement; NR, not reported; PES, pink esthetic score; RCT, randomized controlled trial; SST,
Tiwari et al. 2020
3.2.1 | Inclusion criteria

0 (0) 1. Aged ≥18,28 ≥ 25,29 > 25,30 18 to 50,31 20 to 50,26 or 20 to

0 (0)
12
60 years.25
2. Adequate plaque control.25–29
3. Maxillary anterior tooth with intact buccal periodontal tissues and indi-
Hana and Omar 2020 Sun et al. 2020

cated for extraction followed by immediate implant placement.25–31

4. Intact buccal bone plate.29–31
5. Intact socket following extraction.30
0 (0)
0 (0)
24

6. Buccal bone plate of less than 1.526 or 2 mm.31

7. Ability to provide consent and comply with follow-up
appointments.27,28,31

3.2.2 | Exclusion criteria

1 (5)
1 (5)
12

1. Systemic conditions and/or medications that may affect wound

healing.25,26,28–31
2. Uncontrolled diabetes mellitus.25–27
Fattouh 2018

3. Autoimmune disease.26,27
4. History of radiation therapy.25–27,31
0 (0)
0 (0)

5. History of chemotherapy.26,27
12

6. Use of immunosuppressive drugs.27

Bramanti et al. 2018

7. Current or previous use of intravenous bisphosphonates.27

8. Smoking,27,29 ≥ 10 cigarettes per day,30 or heavy smoking.25,28
9. Alcohol or drug abuse.26,27
10. Current pregnancy or lactation.27,30,31
0 (0)
0 (0)

11. Psychiatric problems or unrealistic expectations.27,30,31

36

12. Parafunctional habits.26

13. Periodontally compromised teeth.25,26
14. Untreated carious lesions.30
NobelReplace Conical Connection implant, Nobel Biocare, Gothenburg, Sweden.
Barakat et al. 2017

15. Teeth diagnosed with external or internal root resorption, vertical root
fracture or horizontal fracture at or below the crestal bone level.25
16. Teeth with grade II mobility.27
17. Acute infection at the site intended for implant placement.27,28,30
Nine patients received immediate implants with and without SST.
0 (0)
0 (0)

CopiOs, Zimmer Biomet Dental, Palm Beach Gardens, FL, USA.

18. Active periodontitis.27,28

7

19. Buccal clinical attachment loss of more than 3 mm.27

Bio-Gide, Geistlich Pharma AG, Wolhusen, Switzerland.

Superline implant, Dentium, Gangnam-gu, Seoul, Korea.

Bio-Oss, Geistlich Pharma AG, Wolhusen, Switzerland.

20. Absence of adjacent teeth.28,29

21. Mobility of the remaining root portion used for SST.27
Abd-Elrahman

Dual implant, Titan industries EG, Cairo, Egypt.

22. Implants placed with an insertion torque of less than 30 Ncm28

et al. 2020

EUROTeknika implant, Sallanches, France.

or 35 Ncm.27
0 (0)
0 (0)
6

Reasons for tooth extraction were only reported in two studies27,30

Osstell AB, Gothenburg, Sweden.

and included trauma, extensive carious lesion, root fracture and end-
Follow-up period (months)
(Continued)

Implant failure rate N (%)

odontic problems that cannot be managed with root canal therapy.

socket shield technique.
IIP without SST

3.3 Characteristics of the interventions

IIP with SST

|
TABLE 2

Preoperative assessment included clinical examination and the use of

cone beam computed tomography (CBCT) to assess buccal bone
b

h
e

g
a

i
8 ATIEH ET AL.

thickness and height25,28 or standardized periapical and/or panoramic • Pink esthetic score at 3,27,28 6,25,27,28,30 12,28–30 and 36 months.27
radiographs26,28 to assess the site intended for tooth extraction and • Complications.25,29
implant placement. In the control group, minimally traumatic extrac- • Implant failure rate.25–31
tion was carried out using periotomes and forceps to preserve the
remaining alveolar bone and socket walls.25,26,28 A flapless25–27,29 or
minimally invasive flapped approach28,31 was followed. The socket 3.5 | Risk of bias
was gently debrided with curettes and the osteotomy was performed
to allow the implant to engage the palatal side of the socket at 2– Three studies25,27,30 described the methods of randomization and
25–28
4 mm apical to the crestal bone level. were judged to be at low risk of bias, while six studies25,26,28–31
In the socket-shield group, the tooth was decoronated to the did not adequately describe the allocation concealment and thus
27 31
gingival level, below or up to 1 mm above the gingival level were judged to be at high risk of bias for this domain. Due to the
under copious irrigation.25,26,29 The buccal part of the tooth was nature of the intervention, it is not possible to mask operators or
then separated from the remaining part of the tooth using Lin- participants, but masking the investigators who collect the data
demann or long shank bur25,26,28,29,31 or piezosurgical insert27 in was possible. Nevertheless, none of the studies reported any mas-
mesio-distal sweeping action from gingival margin down to root king and were all judged to be at high risk of bias. For attrition and
apex. The palatal part of the tooth was removed with periotome to reporting biases, all the studies25–31 were rated as low (Figure 2,
avoid damaging the buccal part. The buccal shield was then shaped Table 3).
in a concave fashion and reduced to the level of crestal bone,25,29
1 mm below27 or above the crestal bone.28 Stability of the buccal
shield was checked with gentle probing and the socket was gently
debrided and irrigated with physiologic saline solution.26,28,29 Oste-
otomy was prepared in a way that allowed implants to either be in
contact with the buccal shield31 or leave 2 mm gap from the buccal
shield.27 Implants were also engaging the apical and palatal sides of
the sockets at 2 mm below the crestal bone level.25–27,29 A surgical
guide was used in one study30 and dental implants were immediately
restored in all studies except two.26,31 In three studies27,28,30 bone
grafting material was used to fill the buccal gap between implant
surface and socket wall or root shield at the time of implant
placement.
Postoperative care included the use of cold packs,26 antibiotics,
analgesics25,26,29 and rinsing with 0.2% Chlorhexidine.25,26,29,30 The
changes in hard tissue dimensions were measured using CBCT25,26,29–31
or standardized radiograph,27,28 while the implant stability measure-
ments were recorded using resonance frequency analysis.25,26,30 The
pink esthetic score was recorded at different time points25,27–30
and changes in soft tissue dimensions were assessed using digital
photographs of the casts.30

3.4 | Characteristics of outcome measures

3.4.1 | Primary outcome measures

• Changes in width of buccal bone plate.25,26,30,31

• Changes in height of buccal bone plate.25,26,30,31

3.4.2 | Secondary outcome measures

• Peri-implant marginal bone loss at 6,27,28 12,28 and 36 months.27

F I G U R E 2 Assessment of applicability concerns and risk of bias
• Implant stability measurements at placement 25,26,30 and of the included studies presented with low (green), unclear (yellow),
6 months. 25,26 and high (red) risk of bias
 ATIEH ET AL.

TABLE 3 Assessment of risk of bias of the included studies

Abd-Elrahman
et al. 2020 Barakat et al. 2017 Bramanti et al. 2018 Fattouh 2018 Hana and Omar 2020 Sun et al. 2020 Tiwari et al. 2020
Random sequence Low risk High risk Low risk High risk High risk Low risk High risk
generation (selection Reported in the article No information in the Reported in the article “A No information in the No information in the Reported in the article No information in the
bias) “The allocated sites article randomization table article article “using a computer- article
were randomly divided was created generated random
into two equal groups electronically number table”
using block (randomization.com) in
randomization with blocks of 2 patients”
stratification using a
Microsoft Excel
Formula”
Allocation concealment High risk High risk Low risk High risk High risk High risk High risk
(selection bias) No information in the No information in the Reported in the article No information in the No information in the No information in the No information in the
article article “The treatment article article article article
assignment was
performed by a person
not involved in any
part of the clinical
treatment using sealed
envelopes”
Blinding of outcome High risk High risk High risk High risk High risk High risk High risk
assessment No information in the No information in the No information in the No information in the No information in the No information in the No information in the
(detection bias) article article article article article article article
Incomplete outcome Low risk Low risk Low risk Low risk Low risk Low risk Low risk
data (attrition bias) All data presented All data presented All data presented All data presented All data presented All data presented All data presented
Selective reporting Low risk Low risk Low risk Low risk Low risk Low risk Low risk
(reporting bias) All outcomes appear to be All outcomes appear to be All outcomes appear to be All outcomes appear to All outcomes appear to All outcomes appear to be All outcomes appear to
detected detected detected be detected be detected detected be detected
Other bias None detected None detected None detected None detected None detected None detected None detected
9
10
F I G U R E 3 Comparison: Immediate implant placement with socket shield technique versus immediate implant placement without socket
shield technique. Primary outcomes: (A) Changes in width of buccal bone plate. (B) Changes in height of buccal bone plate
3.5.1 | Sample size calculation
Two studies30,31 reported on the sample size calculation.
3.5.2 | Clinical trial registration
25
Only one RCT was registered before the initiation of the study.
3.6 | Effects of interventions
In total, 191 participants with 206 dental implants were included in
the present review. Of these, 103 implants were placed in conjunction
with SST, while the remaining implants were immediately placed
without SST.
3.6.1 | Changes in width and height of buccal
bone plate
Four studies25,26,30,31 reported on the dimensional changes of buccal
bone plate. With regard to the changes in the width of buccal bone
plate, less changes were observed amongst immediately placed
implants with SST compared to those placed without SST. The differ-
ence was statistically significant (MD -0.22; 95% CI –0.30 to
p < 0.0001; Figure 3(A)). Substantial heterogeneity was detected (Chi
square = 13.58, df = 3 [p = 0.004]; I = 78%). Likewise, the changes
2
in buccal bone height were also in favor of SST with statistically signif-
icant difference (MD -0.52; 95% CI –0.85 to 0.18; p = 0.002;
ATIEH ET AL.
Figure 3(B)) but with considerable heterogeneity (Chi square = 178.24,
df = 3 [p < 0.0001]; I2 = 98%).
3.6.2 | Peri-implant marginal bone level changes
The changes in peri-implant marginal bone levels were documented in
two studies.27,28 The meta-analysis showed statistically significant dif-
ference in favor of SST at 6 months (MD –0.42; 95% CI –0.56 to
0.29; p < 0.0001; Figure 4(A)). Substantial heterogeneity was
detected (Chi square = 3.91, df = 1 [p = 0.05]; I2 = 74%). Only one
study reported changes in peri-implant marginal bone levels at either
1228 or 36 months,27 and therefore any estimate will be imprecise to
determine any significant differences.
3.6.3 | Implant stability
The meta-analysis, which included three studies, 25,26,30 showed
that sites where implants were immediately placed with SST had
higher implant stability measurements compared with sites
receiving immediate implant placement without SST. The differ-
ence, however, was not statistically significant (MD –0.62; 95%
CI –1.44 to 0.20; p = 0.14; Figure 4(B)) and no substantial hetero-
geneity was detected (Chi square = 1.72, df = 2 [p = 0.42];
0.15; I 2 = 0%). Similar changes in implant stability measurements were
recorded at 6 months with no statistically significant difference
(MD -2.20; 95% CI –4.95 to 0.56; p = 0.12; Figure 4(C)). Moder-
ate heterogeneity was detected (Chi square = 1.44, df = 1
[p = 0.23]; I 2 = 31%).
ATIEH ET AL.
F I G U R E 4 Comparison: Immediate implant placement with socket shield technique versus immediate implant placement without socket
shield technique. Secondary outcomes: (A) Changes in peri-implant marginal bone level at 6 months. (B) Changes in implant stability
measurements at placement. (C) Changes in implant stability measurements at 6 months
3.6.4 | Pink esthetic score
25,27–30
Five studies recorded pink esthetic score at different time
points. The pink esthetic score was significantly higher in the socket
shield group compared with the immediate placement control group
at three (MD –0.90; 95% CI –1.42 to 0.38; p < 0.0001; Figure 5(A)),
six (MD –1.41; 95% CI –2.49 to 0.33; p = 0.01; Figure 5(B)), and
12 (MD -1.43; 95% CI –2.67 to 0.18; p = 0.02; Figure 5(C)). No sub-
stantial heterogeneity was detected at 3 months (Chi square = 0.22,
df = 1 [p = 0.64]; I2 = 0%). However, considerable heterogeneity was
detected at six (Chi square = 19.23, df = 3 [p = 0.0002]; I = 84%)
2
and 12 months (Chi square = 15.49, df = 2 [p = 0.0004]; I2 = 87%).
Only one study reported on pink esthetic score at 36 months,27 and
therefore any estimate will be imprecise to determine any significant
differences.
3.6.5 | Complications
Two studies25,29 reported incidents of exposed shield in the test
group, while one study29 reported incidents of gingival recession and
inadequate keratinized tissue in the control group. The overall meta-
analysis showed less complications when SST was followed, but the
difference between the two groups was not statistically significant
(RR 0.68; 95% CI 0.12 to 3.85; p = 0.66; Figure 6(A)). The immediate
11
implant placement and postoperative follow-up period in both groups
were uneventful in the remaining studies.26–28,30,31
3.6.6 | Implant failure rate
In one study,29 two dental implants failed, one in each group
during a follow-up period of 12 months, while the remaining six
studies25–28,30,31 did not report any implant failure during the
observation period. The meta-analysis demonstrated no significant
differences between the two groups (RR 1.00; 95% CI 0.07 to 14.90;
p = 1.00; Figure 6(B)).
4 | DI SCU SSION
4.1 | Summary of main results
The present systematic review included seven RCTs that compared
the outcomes of implants immediately placed with SST to those
placed without SST. The SST seems to have positive effects on the
changes in the width and height of buccal bone plate, peri-implant
marginal bone levels and esthetic outcomes as demonstrated by sig-
nificantly less changes in bone levels and higher pink esthetic score at
different time points. However, implant stability measurements,
12 ATIEH ET AL.

F I G U R E 5 Comparison: Immediate implant placement with socket shield technique versus immediate implant placement without socket
shield technique. Secondary outcomes: (A) Changes in pink esthetic score at 3 months. (B) Changes in pink esthetic score at 6 months.
(C) Changes in pink esthetic score at 12 months

F I G U R E 6 Comparison: Immediate implant placement with socket shield technique versus immediate implant placement without socket
shield technique. Secondary outcomes: (A) Complications. (B) Implant failure rate
ATIEH ET AL.
short-term complications and implant failure rate were not influenced
by immediate implant placement with or without SST.
4.2 | Quality of evidence
In the present systematic review, we have only included RCTs and
followed strict selection criteria in order to minimize the expected
heterogeneity and improve the overall quality of our search. Never-
theless, significant heterogeneity amongst the included studies was
observed. Sources of heterogeneity could be related to the use of dif-
ferent modifications of SST, particularly in relation to either dec-
oronating and shaping the buccal root shield to 1 mm below,27
above28 or at the crestal bone level.25,29 Adding to the heterogeneity
25,26,29,31
in the surgical techniques of SST, four studies did not fill the
gap between the shield and implant surface while three studies27,28,30
grafted the gap using xenograft. As a result, generalizability of findings
can be an issue and the conclusions of the present review cannot be
extrapolated to all surgical modalities used in performing SST. Another
possible source of heterogeneity could be related to the use of differ-
ent methods for the assessment of hard tissue changes. The use of
the pink esthetic score and resonance frequency analysis, on the other
hand, have contributed to the homogeneity in assessing the esthetic
outcomes and implant stability across the included studies.
None of the included studies used blinded assessment of the out-
comes and were judged to be at high risk of bias. All the studies reported
that participants completed the study without any dropouts and were
25,27,30
rated at low attrition risk. In terms of selection bias, three studies
reported on the method of randomization while all but one27 suffered
from high risk of bias due to the lack of information on randomization
concealment. The absence of adequate concealment of allocation is
known to be associated with substantial bias in the findings of RCTs33
and may have influenced the outcomes of the included studies. The small
number of included studies and the heterogeneity amongst the studies
are acknowledged limitations of the present systematic review and there-
fore any conclusion derived should be considered with caution.
4.3 | Applicability of evidence
Despite the many modifications of the SST described in the
literature,9,11–13,16,34 the technique remains a minimally invasive pro-
cedure for immediate implant placement. The sensitive nature of the
technique, however, requires thorough training and experience and
clinicians need to go through a learning curve to perform it with per-
fection. The modifications of the SST are mainly related to the way
the buccal root shield is prepared. This would include the thickness
and height of the root shield, its relationship to the crestal bone level
and whether the root shield is prepared before or at the time of
implant osteotomy preparation. In addition, there is still no consensus
on whether to fill the gap between the shield and the surface of the
implant or not.9,11,12,16 For example, several clinical and histological
studies have shown that leaving a gap will promote new bone
13
formation instead of cementum.9,12,35 Others,11,16,24 on the other
hand, opted to graft the gap with xenograft on the premise of
preventing soft tissue migration into this space.
It remains unclear whether different SSTs could have different
impacts on the long-term treatment outcomes of immediately placed
dental implant. The present systematic review did not include suffi-
cient number of studies with adequate number of participants to com-
pare between the different surgical approaches of the SST.
Nevertheless, the review showed that SST is a successful technique
that can reduce changes in the buccal plate width and height and
improve the esthetic outcome following immediate implant placement
with short-term complication and implant failure rates that are compa-
rable to immediate implant placement without SST.
The limited number of adverse effects, reported in this review,
however, must be considered within a larger context of complications
observed in some long-term retrospective and case report studies.
Incidences such as internal and external root shield exposure or
resorption12,16 or peri-implant bone resorption36 were reported. The
presence of these complications and the possible need for additional
soft or hard tissue augmentation could undermine the proposed bene-
fits of the SST as a minimally invasive approach. It remains to be seen,
for a novel technique such as the SST, whether surgical modifications
can circumvent the reported complications and improve the treatment
outcomes. For example, it has been suggested that decoronating the
buccal shield to the level of the crestal bone and providing a space
between the coronal edge of the shield and the subgingival margins of
the crowns could prevent shield exposure.16 This recommendation,
however, did not translate into improved clinical outcomes where
shield exposure following buccal shield reduction to the crestal bone
level was reported.25,29 In one study,25 one incident of an internal
shield exposure was reported to be minimal and did not require any
corrective therapy, while in another study29 further reduction for two
cases of internal and external shield exposure was required. Interest-
ingly in both studies25,29 no grafting materials were used to fill the
gap between the root shield and the implant surface. It could only be
speculated that coronal reduction of the shield and grafting of the gap
may be required simultaneously to improve the outcomes of the SST.
4.4 | Agreements and disagreements with other
systematic reviews
Treatment outcomes with SST and related clinical and technical
aspects were previously reported in two systematic reviews.15,18 The
most recent review15 included 25 studies, majority of which were clin-
ical case reports. A substantial number of complications were
reported, including 17 events of internal and external shield expo-
sures. In two cases, connective tissue grafts were needed to achieve
closure of exposed shields and removal of three shields was required
due to infection. Incidences of peri-implantitis, resorption of the shield
and failure of osseointegration were also reported. Mourya and co-
workers, on the other hand, presented a review of 21 studies of mixed
designs, including animal and technical reports.18 The review showed
14
positive results with the SST and recommendations on certain aspects
regarding grafting of the gap and modification of the SST were pres-
ented. For example, the need to graft jumping gaps of more than
1 mm and the provisions for a root shield thickness of 0.5–1.0 mm to
reduce adverse bone changes and improve the esthetic outcomes.
Both reviews15,18 however, did not require the inclusion of con-
trol groups with conventional immediate implant placement for objec-
tive comparisons of outcomes. By contrast, the present review
followed a rigorous search strategy and included only RCTs that met
stringent criteria particularly in terms of having a control group in
which implants were immediately placed without SST. Moreover, the
present review reported quantitative analysis of outcomes related to
changes in hard and soft tissues, implant stability measurements, com-
plication and implant failure rates. It remains clear, however, that the
current literature is still in need for a stronger evidence to validate
the SST as an alternative treatment approach to conventional immedi-
ate implant placement protocols for routine clinical application.
5 | C O N CL U S I O N S
Within the limitation of this review, immediate implant placement
with or without SST have comparable short-term outcomes in terms
of complication and implant failure rates. There is an indication that
SST has short-term positive effects on the changes in width and
height of buccal bone plate and esthetic outcomes. Further evidence
from long-term, well-designed RCTs that adhere to CONSORT guide-
lines are needed to substantiate the findings of the present review.
DIS CLOSURE
The authors declare that they do not have any financial interest in the
companies whose materials are included in this article.
AUTHOR CONTRIBUTION
Momen A. Atieh: Concept/design, data collection, data analysis/inter-
pretation, drafting article, critical revision of article, approval of article.
Maanas Shah: Critical revision of article, approval of article.
Mohammed Abdulkareem: Concept/design, data collection, critical
revision of article, approval of article. Haif A. AlQahtani: Data collection,
critical revision of article, approval of article. Nabeel H. M. Alsabeeha:
Critical revision of article, approval of article, statistics.
DATA AVAI LAB ILITY S TATEMENT
N/A
ORCID
Momen A. Atieh https://orcid.org/0000-0003-4019-9491
Mohammed Abdulkareem https://orcid.org/0000-0002-7156-3463
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How to cite this article: Atieh MA, Shah M, Abdulkareem M,
AlQahtani HA, Alsabeeha NHM. The socket shield technique
for immediate implant placement: A systematic review and
meta-analysis. J Esthet Restor Dent. 2021;1-15. https://doi.
org/10.1111/jerd.12812