Human Histologic Evidence of New Bone Formation and

Osseointegration Between Root Dentin

(Unplanned Socket-Shield) and Dental Implant:
Case Report
Charles Schwimer, DMD, BS1/Gregory A. Pette, DMD, MS2/Howard Gluckman, BDS, MChD (OMP)3/
Maurice Salama, DMD4/Jonathan Du Toit, BChD, MSc(Dent)5

The socket-shield technique described 7 years ago has since grown in its reporting in the literature as a
valid method of ridge preservation at immediate implant placement. To date, large clinical cohorts with
up-to-4-year follow-up have been reported. Additionally, evidence of tissue histology at the dental implant
and socket-shield has been demonstrated in the animal model. However, human histologic evidence has
not yet been available, and the clinician’s uncertainty regarding the tissues that may form between the
socket-shield and dental implant may remain unanswered until now. This case report presents the first
human histologic evidence that bone may entirely fill the space between root dentin and an osseointegrated
implant surface. Int J Oral Maxillofac Implants 2018;33:e19–e23. doi: 10.11607/jomi.6215

Keywords: dental implant, implantology, partial extraction therapies, ridge preservation, socket-shield

L iterature reporting on the retention of the tooth

root or part of the tooth root to maintain alveolar
ridge volume and offset postextraction collapse has
Hürzeler and coworkers2 as well as Bäumer and co-
workers3 have provided valuable histologic evidence
of the healed socket-shield and implant sectioned from
been growing in recent years.1 The socket-shield tech- the alveolar ridge. Yet, these have been presented in the
nique has been proposed as such a method, section- canine model. The clinician may still be uncertain as to
ing the facial root portion for it to remain submerged what tissue grows between the socket-shield and den-
in situ with its physiologic attachment to bundle bone tal implant in a human. Is it periodontal ligament, new
intact.2 The hypothesis asserts that this root portion, cementum, or partial or full periodontal regeneration?
when retained, circumvents the destruction of Sharp- Will the identification of this tissue architecture affect
ey’s fibers inserted into bundle bone and “shields” the the decision-making when selecting the socket-shield
facial alveolar ridge from collapsing adjacent to the im- technique to offset resorptive complications at immedi-
plant.2,3 The literature to support this theory is grow- ate implant placement? The objective of this case report
ing.1–14 As yet, the technique requires additional data was to present the first human histologic evidence that
to advocate in everyday practice, especially data rank- demonstrates the healing possibility of new bone and os-
ing higher in the hierarchy of scientific evidence. seointegration between root dentin and dental implant.

CASE REPORT
1Private Practice, Pittsburgh, Pennsylvania, USA.
2Private Practice, Naples, Florida, USA. A woman aged 45 years presented to the offices of
3Director, Implant and Aesthetic Academy, Specialist in
her periodontist for a routine check-up, and provided
Periodontics and Oral Medicine, The Implant Clinic, Cape Town, a history that included among others discomfort and
South Africa.
4Clinical Assistant Professor of Periodontics, University of vague sensation associated with her implant crown
Pennsylvania, Philadelphia, Pennsylvania; Medical College of at the left maxillary first premolar site. The patient’s
Georgia, Augusta, Georgia; Private Practice, Atlanta, Georgia, USA. medical history was noncontributory. The dental his-
5Resident, Department of Periodontics and Oral Medicine,
tory entailed loss of the premolar tooth 2 years prior
University of Pretoria, Faculty of Health Sciences, School of
Dentistry, South Africa. and an immediate implant being placed. A period of
submerged healing followed, with subsequent im-
Correspondence to: Dr Charles Schwimer, 6201 Steubenville plant exposure and definitive restoration with a ce-
Pike, McKees Rocks, PA, 15136, USA. Email: F40chuck@[Link]
ment-retained crown. Intraoral examination noted no
©2018 by Quintessence Publishing Co Inc. overt inflammation, peri-implant mucositis, or tissue

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Fig 1   At first presentation, the peri-implant Fig 2  Periapical radiograph shows coro- Fig 3   Full-thickness flap was elevated to
tissues displayed no signs of disease or nal bone loss at the implant-abutment in- expose the ridge buccal to the implant; the
inflammation. The probe was able to be terface, and a root fragment at its mesial/ coronal bone loss is evident.
inserted to a depth of 6 mm at the mesio- mesiopalatal aspect.
buccal site.
Fig 4   (Left) After preparation of a lateral
window for removal of the implant.

Fig 5  (Right) The cleaned site after im-

plant removal.

Fig 6   (Left) The mesial aspect of the im-

plant and restoration affixed, with the root
fragment adhering to its surface. Bone ad-
hered to the implant apex, with an absence
of fibrous soft tissue on the implant.

Fig 7   (Right) The distal aspect of the im-

plant and restoration affixed, with the root
fragment adhering to its surface.

recession. Circumferential probing at the implant preparation (Figs 4 and 5). At removal, the longitudinal
crown was warranted to investigate further, and in- root section could be noted adherent to the implant
creased probing depths were noted, deepest at the surface (Figs 6 and 7). The implant with any attached
mesiobuccal location: 6 mm (Fig 1). A periapical radio- tissue as is was photographed and then placed into
graph was taken, noting crestal peri-implant bone in 10% buffered formalin to be sent for histologic exami-
a “saucerization” presentation, and what appeared to nation. The site was debrided, rinsed with saline, and
be a foreign object mesial at the implant (Fig 2). The grafted with an allograft particulate bone (Puros, Zim-
clinical features of crestal loss and bleeding on prob- mer Biomet) hydrated in recombinant human plate-
ing supported the diagnosis of peri-implantitis, yet let-derived growth factor-BB (rhPDGF-BB) (Fig 8). The
with a surviving implant. The radiographic diagno- graft was covered by a layer of nonresorbable, titani-
sis of a retained root fragment in proximation to the um-reinforced dense polytetrafluoroethylene (dPTFE)
implant, coupled with the peri-implantitis diagnosis, membrane (Cytoplast, Osteogenics Biomedical) cov-
merited presenting the patient with the option of ered by a resorbable collagen membrane (Bio-Gide,
implant removal and rehabilitation of the site. Alter- Geistlich). The flap was closed (Fig 9) and the site left
native treatment options, including no additional to heal for a period of 3 months, whereafter a second
treatment, were offered to the patient, among which implant was placed and subsequently restored fol-
removal and retreatment with an implant-supported lowing osseointegration (Fig 10).
restoration was selected by the patient.
Following local anesthesia of the site, a
full-thickness mucoperiosteal flap was raised to ex- HISTOLOGIC ANALYSIS
pose the facial alveolar ridge at the implant (Fig 3). A
window was prepared, and the implant with its res- The implant with adherent tissue was fixed in 10%
toration was torqued and removed laterally via the neutral buffered formalin, dehydrated, infiltrated,

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Fig 8  (Left) Site grafted with allograft

particulate bone hydrated in rhPDGF-BB,
covered by dPTFE and collagen membrane
layering.

Fig 9  (Right) Final closure of the GBR

procedure.

Fig 10   (a) Re-entry of the augmented site

at 3 months, with (b) reinsertion of a den-
tal implant.

a b

then slowly embedded in a glycol methacrylate-based occupied the interthread spaces, when viewed by po-
polymer resin block, and cut by microtome into unde- larized microscopy, exhibited mineralization with con-
calcified sections (Exakt Apparatebau). The sections centric lamellae, evident of mature, remodeled bone
were then polished to within 10 microns and stained (Fig 11d). The space between the implant surface and
with Stevenel’s blue and van Gieson picro fuchsin. bone was a separation artifact that likely resulted from
Viewed at low power (25×) under a light microscope, the microtome preparation of the sample.
an adherent root section was observed extending
the vertical extent of the implant approximately 3
mm coronally beyond the first thread and polished DISCUSSION
implant collar (Fig 11a). The fragment was verified as
tooth root, displaying dentinal tubules that span the New treatments not yet supported by strong scientific
dentin layer that interfaces with an outer cementum evidence may be unsound and even controversial. Alas,
layer. At medium power magnification (40×), the den- all health care innovations have their starting point.
tinal tubules were distinct (Fig 11b). A lateral canal was Typically, in vitro precedes in vivo application, with test-
also observed at about the apical third of the implant. ing in the animal model before human subjects.15 The
Tissue was present within the implant apical chamber socket-shield technique has progressed to the current
and between the implant threads (Figs 11a to 11d). stage, where the literature reports on case cohorts as
The tissue contained in the apical chamber and that large as 128 patients in a single study, with follow-up
filled the implant’s interthread spaces was confirmed at 4 years. Additionally, histologic reports in the canine
as bone, displaying a marbled appearance—the rest- model have provided insight into the healing of tissues
ing and creeping reversal lines typical of alveolar at an implant placed adjacent and in contact with a root
bone’s histologic presentation (Fig 11c). This tissue fragment.2,3,16 However, the clinician contemplating this
was intimately apposed to the implant surface with technique may still have unanswered questions; para-
continuation to the root section. The bone that filled mount among these: What tissues grow between the
the thread spaces was confirmed to be vital, display- implant and socket-shield? Since several studies over
ing osteocytes housed in lacunae, with large atypical the last two decades have investigated the probability of
vacuolar spaces, which themselves contained bone tis- forming a periodontal ligament and periodontal tissues
sue in areas (Fig 11c). These circular vacuoles were first onto the implant surface and failed to achieve osseoin-
thought to be vascular lumens of Volkmann canals or tegration, the clinician would be wary to suspect similar
Haversian systems. The current hypothesis explaining of the socket-shield technique. The distinction, though,
this presentation is that fragments of dentin dislodged is to be made regarding the root section configuration,
during implant insertion were contained within these and the origin of the mesenchymal cells that have osteo-
in the interthread bone. There appeared to be an ab- blastic differentiation potential. Buser et al had experi-
sence of fibrovascular tissue at the interfaces between mented with implantation into retained primate teeth.17
bone and dentin, and bone and implant. The bone that This novel study demonstrated that a cementum layer

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Schwimer et al

Fig 11a  Undecalcified section of the implant

with the root fragment closely adherent to its
surface, spanning from apex well beyond the
implant’s polished collar. Tissue is visible filling
each thread space, as well as within the api-
cal chamber. Light microscopy, 25×, Stevenel’s
blue and Van Gieson’s picro fuchsin.

Fig 11b   The dentinal tubules of the root frag-

ment are prominent (asterisks), as the root
fragment interfaces with root cementum (ar-
rows). Note that each thread space is wholly
*
occupied by bone, which intimately interfaces
* with the root dentin. The interthread bone dis-
plays circular, vacuolar structures. Bone tis-
sue obliterates, partly infiltrates, or centrally
occupies these vacuoles. Light microscopy,
40×, Stevenel’s blue and Van Gieson’s picro
fuchsin.

Fig 11c  High-power magnification verified

mature, living bone, organized in concentric la-
mellae, containing osteocytes within lacunae.
Vacuolar structures central to the interthread
bone themselves contain bone tissue. Light mi-
croscopy, 200×, Stevenel’s blue and Van Gie-
son’s picro fuchsin.

Fig 11d  Bone filled each thread space inti-

mately interfacing between the root fragment
and implant surface. Note the Haversian sys-
tems containing vessels. Polarized light micros-
copy, 40×, Stevenel’s blue and Van Gieson’s
picro fuchsin.

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 Schwimer et al

formed on the implant surfaces and that a periodontal ACKNOWLEDGMENTS

ligament consistently was present, inserting fibers from
implant cementum into adjacent bone. Fifteen years The authors wish to acknowledge Hari Prasad for the expert
preparation of the histologic specimens. The authors reported
later, Parlar and coworkers similarly aimed to investigate
no conflicts of interest related to this study.
the potential of periodontal tissues to form around den-
tal implants placed into canine teeth.18 The teeth were
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