Original Article

Socket shield technique: Stress

distribution analysis
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Ricardo Guimarães Neves, Priscilla Cardoso Lazari-Carvalho,1

Marco Aurélio Carvalho,1 Alexandre Leite Carvalho, João Batista de Souza,2
Érica Miranda Torres3
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Private Practice,
Goiânia, GO, Brazil,
Abstract:
1
Department of
Oral Rehabilitation, Background: To analyze through finite element analysis the stress distribution in peri‑implant bone tissues,
implants, and prosthetic components induced by the socket shield (SS) technique in comparison to other
School of Dentistry,
techniques used to treat tooth loss. Materials and Methods: A three‑dimensional model of a superior central
Evangelical University incisor crown supported by implant was modeled and three different placement conditions were simulated:
of Goias, Anápolis, SS – 2.0‑mm‑thick root dentin fragment positioned between the alveolar buccal wall and implant; heterologous
GO, 2Department of bone graft (HBG) – bovine bone graft positioned the alveolar buccal wall and implant; and control (C) – implant
Restorative Dentistry, fully placed in bone tissue of a healed alveolus. The model was restricted at the lateral surfaces of the bone
School of Dentistry, tissue and the following loads were simulated: Both oblique (45°) loads of 100 N on the lingual surface of the
Federal University of crown (maximal habitual intercuspation) and 25.5 N on the incisal edge of the crown (tooth contact during
Goiás, Goiânia, GO, mandibular protrusion) were simultaneously applied. Tensile stress, shear stress, compression, and displacement
were analyzed in the cortical bone, trabecular bone, dentin root fragment, and bone graft; while equivalent von
3
Department of Oral
Mises stresses were quantified in the implant and prosthetic components. Results: Stress values of SS and
Rehabilitation, School HBG in the bone tissues were higher than C, while slight differences within models were observed for dentin
of Dentistry, Federal root fragment, bone graft, implant, and prosthetic components. Conclusions: The SS technique presented the
University of Goiás, highest stress concentration in the peri‑implant tissues.
Goiânia, GO, Brazil Key words:
The work belongs to Alveolar ridge, finite element analysis, implant placement
the Department of Oral
Rehabilitation, School
of Dentistry, Federal INTRODUCTION root, extraction of the lingual root fragment,
University of Goiás, maintenance of the residual buccal root portion
Goiânia, GO, Brazil

Access this article online

E xperimental studies in humans have shown
the physiological alveolar bone resorption
after single or multiple tooth extractions and the
in contact with the buccal bone plate and
immediate implant placement. The beneficial
effect of the root fragment maintenance has been
Website: consequent reduction in horizontal and vertical histologically demonstrated by the apposition of
www.jisponline.com dimensions of alveolar ridges,[1‑4] which may cementum on the implant surfaces. Following the
DOI: impair implant placement in terms of moderate same concept of partial root extraction, Gluckman
10.4103/jisp.jisp_356_22 esthetic results or the necessity of further tissue et al.[16,17] also suggested filling the space between
Quick Response Code: reconstructions.[5‑7] Ridge alterations following the buccal root fragment and the implant with
tooth extractions seem related to periodontal a particulate bone graft. Mitsias et  al.[18] and
ligament loss and trauma in the buccal bone Siormpas et  al. [19] renamed the technique to
plate that presents more pronounced resorption Root Membrane and claimed that the bone graft
than the lingual/palatal portion of the alveolus.[8] would not be necessary since the preservation

In particular for anterior teeth, different techniques

This is an open access journal, and articles are
have been proposed to stabilize alveolar hard and
distributed under the terms of the Creative Commons
soft tissues and to obtain satisfactory esthetic Attribution‑NonCommercial‑ShareAlike 4.0 License, which
Address for
correspondence: results. [9] Several regenerative biomaterials, allows others to remix, tweak, and build upon the work
such as tissue grafts (autogenous, heterologous, non‑commercially, as long as appropriate credit is given and
Dr. Ricardo Guimarães the new creations are licensed under the identical terms.
Neves, or allograft) and growth‑promoting factors,
Private Practice, have been tested with the aim of preserving the For reprints contact: WKHLRPMedknow_reprints@
Goiânia , GO, Brazil. wolterskluwer.com
alveolar ridge volume after tooth extractions.[10‑14]
E‑mail: ricardogneves@
hotmail.com How to cite this article: Neves RG,
In 2010, Hürzeler et  al. [15] proposed a novel
approach to maintain the buccal bone plate and Lazari‑Carvalho PC, Carvalho MA, Carvalho AL,
Submitted: 01‑Aug‑2022 Souza JB, Torres ÉM. Socket shield technique:
Revised: 25‑Mar‑2023 to improve esthetic predictability. The so‑called
Stress distribution analysis. J Indian Soc Periodontol
Accepted: 22‑Apr‑2023 socket shield (SS) technique consists in removing
2023;27:392-8.
Published: 01-Jul-2023 the dental crown, mesiodistal sectioning of the

392 © 2023 Indian Society of Periodontology | Published by Wolters Kluwer - Medknow

 Neves, et al.: Stress distribution analysis

of the buccal bone plate is based on the maintenance of the computer‑aided design software (SolidWorks Premium
periodontal ligament and part of the root. 2011, 3Dtech‑Solidworks, Concord, MA, USA); next, 3D
models with 15‑mm‑high trabecular bone surrounded by a
Another positive factor associated with the SS technique is the uniform 2‑mm‑thick layer of cortical bone (corresponding to
maintenance of the interdental papillae, which is influenced type III bone tissue typically found in the anterior maxilla)
by the condition of the peri‑implant tissues. Cherel and were generated. [32] In addition, a Ø4.0 mm × 13.0 mm
Etienne,[7] Kan and Rungcharassaeng[20] and Tan et al.[21] have cylindrical body implant with conical apex and Morse
shown that a small root fragment kept in the coronal portion
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taper connection (CM Titamax EX, Neodent, Curitiba, PR,

of the alveolus can protect the buccal, mesial, and distal bone Brazil), a Ø3.3 x 6.0 mm prosthetic abutment with 2.5 mm
plates after immediate implant placement; however, a recent collar height (CM Universal Abutment, Neodent, Curitiba,
animal study demonstrated bone loss between 3.1 and 6 mm PR, Brazil), a feldspathic porcelain veneered‑zirconia
after 4 months.[5] Therefore, more scientific pieces of evidence crown (0.5‑mm‑thick zirconia and 1.5‑mm‑thick feldspathic
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regarding the safe use of the SS technique are still lacking.[22] porcelain) and a 50‑μm‑thick resin cement layer (Panavia
F, Kuraray, Okayama, Japan) were also modeled. Different
Buccal bone losses due to vertical fractures or periodontitis implant placement conditions were simulated [Figure 1]:
and root caries are contraindications for the SS technique.[22,23] SS: 2‑mm‑thick root dentin fragment with 0.25‑mm‑thick
Late migration and internal or external exposure of the root periodontal ligament positioned between the alveolar buccal
fragment figure as among the adverse reactions that cause wall and implant; heterologous bone graft (HBG): filling of
inflammation of epithelial tissue.[24] A current systematic review the gap between alveolar buccal wall and implant with a
on the SS technique reported histologic evidence of rapid bone bovine bone graft (Bio‑Oss, Geistlich, Wolhusen, Switzerland);
loss, failure of osseointegration, the formation of cementum,
Control (C): implant fully placed in bone tissue of a healed
periodontal ligament, or fibrous tissue on implant surfaces in
alveolus.
proximity to the root fragmented.[25]
The files (.iges) were exported to FEA software developed for
To prevent loss and achieve the long‑term clinical success of
stress analysis (Ansys Workbench 13.0, Swanson Analysis
dental implants, it is essential to understand the biomechanical
Inc., Houston, PA, USA), in which meshes were refined and
behavior between bone tissue and implant and the influence of
submitted to a convergence analysis of 5% to confirm the
stress distribution around implants.[26] Three‑dimensional (3D)
accuracy and to ensure the comparability of results.[33,34] The
finite element analysis (FEA) is an efficient technique to
mesh consisted of 0.6 mm tetrahedral solid elements and
evaluate the extent of micromotions and peri‑implant bone
strain distribution.[27] As an appropriate numerical method respective nodes [Table 1], while the contact surfaces between
for analyzing complex biological structures, FEA has been the structures were set as bonded. The model was restricted
widely used to evaluate the effect of several parameters in the at the lateral surfaces of the bone tissue (x‑, y‑and z‑axis) and
peri‑implant region (e.g., implant geometry, prosthesis design, the following loads were simulated: a constant force of 100 N
stress, and strain distribution).[28] obliquely (45°) applied on the lingual surface of the crown
(1.5 mm² area) to simulate maximal habitual intercuspation and
The quality of adjacent bone tissue influences both stress 25.5 N applied on the incisal edge of the crown (perpendicular
distribution and biomechanical behavior of implants; hence, to the implant long axis) with the aim to simulate the tooth
the success or failure of dental implants is dependent on how contact during mandibular protrusion. [35] The software
stresses are transferred to the surrounding bone tissues.[26,29] performed a joint analysis of the two loads simultaneously
The stress distribution induced by the SS technique should be applied [Figure 2].
investigated by considering critical parameters such as bone
anatomy and density, implant positioning, and different loads. Table 1: The number of structures, nodes, and elements
To date, there are no studies in the literature regarding stress in each model
patterns on both implant‑prosthesis complex and peri‑implant Models Structures Nodes Elements
bone to support the use and to predict the long‑term
SS 12 242,172 136,386
performance of SS technique.[22,30,31] Therefore, this study HBG 10 227,795 129,427
analyzed through FEA the stress distribution in peri‑implant Control 9 210,159 119,853
bone tissues, implants, and prosthetic components induced SS – Socket shield; HBG – Heterologous bone graft
by the SS technique in comparison to other techniques used
to treat tooth loss.

MATERIALS AND METHODS

Computed tomographic images (KODAK 9000 3D Extra Oral

Imaging System, Carestream Dental LLC, Atlanta, GA, USA)
acquired from the anterior region of partially edentulous
maxilla were reconstructed and exported to stereolithographic
files  (.stl) with the aid of specific software  (InVesalius 3.0,
Center for Information Technology Renato Archer, Campinas,
São Paulo, Brazil). After soft tissue segmentation, files of Figure 1: Scheme of the different implant placement conditions and experimental
cortical and trabecular bone tissues were imported into a models. SS: Socket shield; HBG: Heterologous bone graft; C: Control

Journal of Indian Society of Periodontology - Volume 27, Issue 4, July-August 2023 393
 Neves, et al.: Stress distribution analysis

Both cortical and trabecular bone tissues were assumed as bone tissues, dentin, and bone graft; while the equivalent von
homogeneous and anisotropic with linear elasticity; while Mises stresses were quantified in the implant and prosthetic
implant, bone graft, root dentine, prosthetic abutment, zirconia, components) and qualitatively analyzed (visual comparison of
feldspathic porcelain, and resin cement were considered images with color gradients and standardized scales).
homogeneous and isotropic with linear elasticity. The x‑,
y‑and z‑axis of the materials correspond to the coordinates of RESULTS
the system. The Young’s Modulus and Poisson’s ratio of each
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material are described in Tables 2 and 3. Quantitative results observed in the different structures
are described in Table 4. The tensile stress values of SS and
The results were both quantitatively (tensile stress, shear, HBG in the cortical bone were higher (approximately 170%)
compression, and displacement were assessed in the peri‑implant than C. Similarly, SS and HBG presented shear stress values
around 80% higher than the C; however, compression and
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Table 2: Mechanical properties of cortical and trabecular displacement values in the cortical bone were similar among
bone tissues in accordance with Huang et al.[33] and Lan the models.
et al.[36]
Considering the trabecular bone, tensile, shear, and
Young’s Shear Poisson’s
compression stress values observed in SS and HBG were
modulus (MPa) modulus (MPa) ratio
higher (approximately 200%) than C, while displacement
Cortical
remained similar among the models.
Ex 12.600 Gxy 4.850 Vxy 0.30
Ey 12.600 Gyz 5.700 Vyz 0.39
Ez 19.400 Gxz 5.700 Vxz 0.39 The root dentin simulated in SS induced tensile stress values (32
Trabecular MPa) slightly higher than the biomaterial simulated in the HBG
Ex 1.150 Gxy 6.800 Vxy 0.001 (28 MPa), while shear stress values were very similar (12.5 and
Ey 2.100 Gyz 4.340 Vyz 0.32 11.2 MPa, respectively). Compression stress values in dentin were
Ez 1.150 Gxz 6.800 Vxz 0.05
higher in comparison to the simulated bone graft (50 and 30 MPa,
MPa – Megapascal respectively). Regardless of the experimental model, the values
of equivalent von Mises stress in implant, screw, and prosthetic
Table 3: Young’s modulus and Poisson’s ratio of all abutment showed slight variation (<10%).
materials modeled
Materials Young’s Poisson’s Reference The qualitative evaluations of the models are shown in
modulus (GPa) ratio Figures 3‑6. In SS and HBG, the maximum principal stress
Feldspathic porcelain 70 0.19 Coelho et al.[37] points were observed at the interface between lingual cortical
Zirconia 205 0.22 Coelho et al.[37] bone and implant coronal area, while the maximum stress in
Resin cement 18.3 0.33 Li et al.[38] the C was found at the interface between the buccal alveolar
Titanium (implants 110 0.33 Cruz et al.[39] ridge and implant platform/coronal threads. Regarding the
and components) screws in all models, the stresses were concentrated on the
Dentin 20 0.31 Dejak and
buccal face and at the level of the implant platform. Similarly,
Mlotkowski[40]
Periodontal ligament 0.05 0.45 Rees and the prosthetic abutments of all models presented maximum
Jacobsen[41] principal stresses in the region in contact with the implant
Bovine bone graft 11 0.30 Fanuscu et al.[42] platform; therefore, the internal aspect of the Morse taper
GPa – Gigapascal connection showed the maximum stresses concentrated in
the implants.

DISCUSSION

A key factor for the success of dental implants is the masticatory

tension to which bone tissue is submitted.[43] According to

Figure 3: Cross‑sectional view of the stress distribution in cortical bone for each
Figure 2: Side view of A: bone tissue as fixed support, B: oblique 100 N and C: model (red arrows indicate maximum principal stress points). Max: Maximum, SS:
25.5 N loads perpendicularly applied to the implant long axis. N: Newton Socket shield; HBG: Heterologous bone graft; C: Control

394 Journal of Indian Society of Periodontology - Volume 27, Issue 4, July-August 2023
 Neves, et al.: Stress distribution analysis

Table 4: Values of tension, shear, compression,

displacement and von Mises stresses in different
structures and models
SS HBG Control
Tension (MPa)
Cortical bone 156 137 52
Trabecular bone 21.6 16 5
Dentin/graft 32 28 ‑
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Shear (MPa)
Cortical bone 42 37 21
Figure 4: Tensile stress distribution in SS and HBG models (red arrows indicate Trabecular bone 6.5 4.4 1.6
maximum principal stress points). MPa: Megapascal; Min: Minimum; Max: Dentin/graft 11.6 11.2 ‑
Maximum, SS: Socket shield, HBG: Heterologous bone graft Compression (MPa)
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Cortical bone 68 69 57
Trabecular bone 17 17 9.2
Dentin/graft 50 30 ‑
Displacement (µm)
Cortical bone 18 16 13
Trabecular bone 15 13 12
Dentin/graft 24 21 ‑
von Mises (MPa)
Implant 413 428 409
Screw 380 389 358
Abutment 1006 985 997
SS – Socket shield; HBG – Heterologous bone graft; Mpa – Megapascal;
µm – Micrometer

Figure 5: Shear stress distribution in SS and HBG models (red arrows indicate

maximum principal stress points). MPa: Megapascal; Min: Minimum; Max: incisors is especially relevant due to the greater biomechanical
Maximum, SS: Socket shield, HBG: Heterologous bone graft risk of failure. So far, only short‑term clinical trials reported the
success of the SS technique; therefore, we performed an FEA
on the biomechanical behavior of the bone tissue adjacent to
an implant placed in the region of central incisors. In both SS
and HBG, tensile, shear, and compression stress values in the
cortical and trabecular bones in both SS and HBG were higher
than the C. In contrast, displacement values and equivalent
von Mises stress in the implant‑prosthesis complex were only
slightly different among models.

The tensile stress values in the cortical bone were higher in

the SS and HBG in comparison to C, which may be explained
by the smaller contact area between bone tissue and implant
in addition to differences in the mechanical properties
of bone tissue, bone graft and, dentin; the latter with the
lower modulus of elasticity.[45] The approximate mechanical
properties of the bone graft and dentin may explain the similar
results. In comparison to trabecular bone, the cortical bone
presents a higher modulus of elasticity, is more resistant to
deformation and can bear more load.[46] The maximum tensile
stress values in trabecular bone followed the same trend
among models; the low elastic modulus of trabecular bone acts
as a stress breaker that better dissipates the chewing forces.[47]
Tension, shear, compression and, displacement criteria were
analyzed to evaluate the biomechanical behavior of fragile
structures such as dentin, bone graft, cortical and, trabecular
Figure 6: Equivalent von Mises stress distribution in screws, prosthetic abutments bone.[48] The von Mises criterion was used for implant, screw,
and implants was similar among the models (red arrows indicate the points of and prosthetic abutment since it is an adequate stress criterion
maximum stress). Min: Minimum; Max: Maximum, SS: Socket shield; to evaluate the tensional behavior of ductile materials such
HBG: Heterologous bone graft; C: Control as titanium. The equivalent von Mises stress represents the
set of principal stresses that act on a solid element; thus,
Newton’s third law, chewing forces transmitted to prosthetic both compressive and tensile stresses are expressed in a
restoration are transformed into energy that is distributed in single value and the stress distribution is easily visualized.[49]
certain amounts through the implant‑prosthesis complex and Differently from C, in which the maximum tensile and shear
peri‑implant bone tissue.[44] The stress transfer to the interface stresses were observed at the interface between the implant
between bone tissue and implants placed in the region of central and buccal bone tissue (implant platform/coronal threads),

Journal of Indian Society of Periodontology - Volume 27, Issue 4, July-August 2023 395
 Neves, et al.: Stress distribution analysis

both SS and HBG were characterized by maximum stresses the shield and bone would be in between the implant and the
concentrated at the interface between lingual cortical bone dentin shield.[54] In order to avoid unreal stress accumulation
and implant coronal area; this result is expected since the in a thin bone layer in this FEA analysis, the authors preferred
oblique load tends to compress the buccal aspect of the to simulate the condition of contact between the implant
implant‑supported crown and to induce tension on the palatal and dentin shield. Considering the limitations related to
aspect of the implant. these constraints of a computer simulation, it is possible to
conclude that the implant placement technique influences the
Despite the satisfactory results of the SS technique, a recent
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peri‑implant bone stress distribution and the SS technique

systematic review based on histological studies in animals presented the highest stress values.
reported complications in 58 (82.86%) out of 70 implants;
54.55% of the cases presented partial buccal bone plate Financial support and sponsorship
loss and 27.27% were associated with failure in implant Nil.
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osseointegration. Thirty‑three (24.26%) among 136 implants

reported in 21 clinical cases presented complications; 78.78% Conflicts of interest
of the cases were found with partial buccal bone plate There are no conflicts of interest.
loss and 12.12% presented root fragment exposure. Even
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