Dental implant therapy has revolutionized the replacement of missing teeth, providing patients with functional and esthetic outcomes that closely mimic natural dentition. The anterior maxilla represents arguably the most challenging area for restoration due to multiple compounding factors: a thin facial/buccal plate, predictable ridge resorption patterns, and heightened esthetic demands. The scientific literature has well established that tooth loss inevitably leads to the loss of periodontal ligament (PDL) attachments, which subsequently results in bone resorption. The implantology field has responded with various preservation and compensatory techniques, including guided bone regeneration, block grafting, ridge splitting, tunnel procedures, and the application of xenografts, allografts, and soft tissue grafts. Despite these advancements, many approaches significantly alter alveolar ridge dimensions—particularly in the facial aspect—potentially compromising esthetic outcomes in the anterior region.

In response to these challenges, Hürzeler introduced the socket shield technique in 2010 as an innovative alternative. This approach intentionally preserves a fragment of the tooth root—specifically the facial portion—while simultaneously placing an immediate implant. By maintaining the PDL attachment to the buccal bone plate, the technique aims to preserve the bundle bone and prevent the dimensional changes typically associated with extraction procedures. The socket shield technique has gained considerable attention in recent years due to its potential to preserve the natural contours of the alveolar ridge, particularly in aesthetically demanding areas. This article provides a comprehensive review of the socket shield technique, including its historical development and evidence, indications and contraindications, surgical protocol, considerations, limitations, and a summary.

The term “ socket shield ” was introduced by Hürzeler and colleagues in 2010. They noted that their technique was inspired by earlier work in dental traumatology, specifically Malmgren’s 1984 decoronation technique for ankylosed and infrapositioned incisors. This earlier approach retained the roots of compromised teeth to preserve alveolar bone for subsequent prosthetic therapy. The decoronation technique itself evolved from evidence published throughout the 1970s through both case reports and animal studies. Notably, in 1978, O’Neal and colleagues conducted an animal study on dogs examining the root submergence technique , finding histologic evidence of new bone, cementum, and connective tissue formation over the coronal dentin surface of submerged roots.

As endosseous dental implants gained popularity for tooth replacement in the 1980s, researchers began exploring the relationship between implants and retained root structures. In 1990, Buser and colleagues published an animal study on monkeys to examine wound healing events around titanium endosseous implants placed proximal to retained root tips. Using cylinder implants with plasma-sprayed surfaces, they discovered histologic evidence of new PDL and a distinct layer of cementum forming on implant surfaces when placed in direct contact or proximity to retained root tips—demonstrating that cementum and PDL could form around implant surfaces.

Building on this promising evidence that retained/ankylosed roots could safely preserve the alveolar ridge, ^,,,,, Davarpanah and colleagues published what appears to be the first human case report series in 2008, where implants were intentionally placed in direct contact with root fragments. They termed this approach “ unconventional implant treatment ,” as the osteotomy was performed through retained ankylosed roots with implants placed in contact with existing roots, ensuring at least half of each implant surface maintained contact with bone. Five implants were monitored for 12 to 42 months under loading, with clinical and radiographic evaluations revealing no abnormal characteristics at the root–implant interface and all implants healing uneventfully.

The socket shield technique itself was formally published in 2010, with animal studies demonstrating histologic evidence that the internal aspect of the root became covered with new cementum and PDL. Additionally, when implants were placed in direct contact with root fragments, cementum could be detected on the implant surface. Following Hürzeler’s initial publication, numerous researchers and clinicians—including Bäumer, Kan, Siormpas, Gluckman, and others—contributed to refining the technique and expanding its evidence base. Long-term clinical studies began emerging in the mid-2010s, with Mitsias and colleagues publishing the first human histologic evidence in 2017. This evidence came from a 63 years old patient who had undergone the socket shield technique (also known as the root membrane technique) with immediate implant placement in 2012, before experiencing a traumatic car accident in 2017, resulting in premaxilla loss. Since only the palatal and coronal aspects showed evidence of trauma, the root–implant interface remained preserved for histologic evaluation. The specimen retrieved after 5 years under loading demonstrated maintenance of the buccal bone plate with intact PDL, successful implant osseointegration with 76.2% bone-to-implant contact, compact mature bone filling the space between the root–implant interface, and new cementum migration from the residual root to the implant surface where direct contact occurred.

Thanks to periodontology and prosthodontic colleagues, as well as international implant clinicians, the socket shield technique has continued to evolve, with various modifications proposed to enhance its predictability and expand its clinical applications. It would be beneficial for oral and maxillofacial surgery practitioners to gain exposure to this innovative technique and incorporate it into their armamentarium, thereby enabling them to provide more comprehensive treatment options for patients requiring anterior maxillary rehabilitation.

The socket shield technique requires meticulous execution and attention to detail. The following steps outline the standard protocol, though variations exist depending on specific clinical situations and operator preferences.

Preoperative assessment

A thorough diagnostic assessment is essential and should encompass both clinical and radiographic evaluations. Clinically, this includes the assessment of tooth vitality, soft tissue biotype, periodontal health, and tooth mobility. Radiographic analysis, utilizing periapical imaging and cone-beam computed tomography, is necessary to evaluate root morphology, bone quality and quantity, proximity to vital anatomic structures, presence of pathologic conditions, and the integrity of the buccal cortical plate ( Fig. 1 ).

( A–N ) 36F with history of dental trauma to teeth #8 and #9 resulting in pulpal necrosis subsequently underwent RCT on both teeth #8 and #9. She presented with apical periodontitis with associated chronic parulis on tooth #9. She opted to have tooth #9 removed and the placement of an immediate dental implant. ( A–E ) Facial photos showing an animated smile with a high smile line. ( E–I ) Intraoral photos showing chronically inflamed parulis apex of tooth #9, otherwise overall healthy gingival tissue. ( J ) Preoperative panoramic radiograph. ( K–N ) Preoperative CBCT confirming periapical radiolucency with labial sinus tract, thin buccal cortical plate, and planned implant positioning.

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