Bioscience Biotechnology Research Communications Vol 14 No (4) Oct-Nov-Dec (2021)

Biomedical Communication

On the Ten-Year Success in the Application of Partial

Extraction Therapy: A Systematic Review

Mohammed M Al Moaleem,1,4* Ali Mohammed M. Abdulrab,2 Hamza K. Khan,3

Arwa H. Khawaji,3 Lujain K. Mawkili,3 Shreefah M. Faris,3 Shada M. Alsam,3
Nada Ibrahim Alalmaie3 and Hind Ibrahim A. Eshwi3
1
Department of Prosthetic Dental Science, College of Dentistry, Jazan University, Jazan, Saudi Arabia
2
Department of Oral and Maxillofacial Surgery, College of Dentistry, Aden University, Yemen
3
College of Dentistry, Jazan University, Jazan, Saudi Arabia
4
College of Dentistry, Ibn al-Nafis University, Sanaa, Yemen

ABSTRACT
Hürzeler presented the socket-shield technique (SST) more than 10 years ago. The partial extraction therapy (PET), a collective
concept of utilizing the patient’s own tooth root to preserve the periodontium and peri-implant tissue, has been remarkably developed.
PET comprises a group of novel techniques for post-extraction implant placement. Several modifications of PET and simultaneous
implant placement have been presented since its inception. Since its origin, several alterations have been employed in the methodology
of partial extraction of the root and the simultaneous implant placement. A repeatable, predictable protocol is needed to provide
tooth replacement in esthetic dentistry. Moreover, a standardized procedure provides a good framework for clinicians to report data
relating to the technique with procedural consistency. This review aims to illustrate a reproducible and systematic protocol for the
PET techniques with immediate implant placement at the aesthetic zone. The most used technique is the socket-shield technique,
which is potentially offers promising results, minimizing the necessity for invasive bone grafts round implants in the aesthetic area,
clinical data to support this is very inadequate. The limited research data existing is cooperated by a deficiency of well-designed
prospective randomized controlled investigations. The present case studies and techniques are of actual incomplete technical value.
Retrospective studies published in limited records but are of inconsistent plan. At this point, it is indistinct whether the socket-shield
technique will offer a stable long-time outcome or not.

KEY WORDS: Partial extraction therapy, Pontic shield, Proximal-

socket shield, Root submergence, Socket shield technique.

INTRODUCTION placed with an out of occlusion provisional crown. Many

cases followed the concept and became published (Han et
Qualitative and quantitative variations, which arise in al. 2018; Gluckman et al. 2018; Schwimer et al. 2019).
the alveolar ridge next tooth removal, can complicate the
implant-prosthetic restoration. Several socket and alveolar The concept of PET is composed of four different techniques
ridge preservation systems have been developed to minimize that aim to preserve slice of the tooth in the bone, thereby
the alveolar ridge atrophy. The tooth root can be conserved minimizing the loss of the bone vasculature and periodontal
to limit bone resorption under a fixed or removable denture ligament attachment, thus eliminating the remodeling and
(Pagni et al. 2012). PET, as a socket shield technique, was resorption of both hard and soft tissues associated with tooth
first introduced by Hürzeler in (2010) and this process removal. Gluckman et al. (2016a), and Shaheen (2021)
was first carried out on dogs, followed by a single implant found that partial extraction therapy (PET) includes root
placement in a human as a proof of concept (Hürzeler et al. submergence (RST), socket shield (SST), proximal socket
2010). Finally, a fabricated screw retained abutment was shield (PSST), and pontic-shield (PST) (BUSER et al. 2000;
Abadzhiev et al. 2014; Troiano et al. 2014; Al-Dary and Al
Hadidi 2015; Durrani et al. 2017; Mitsias et al. 2017; Al-
Article Information:*Corresponding Author: drmoaleem2014@gmail.com Dary and Alsayed 2017; (Durrani et al. 2017; Esteve-Pardo
Received 19/10/2021 Accepted after revision 22/12/2021 and Polis-Yanes et al. 2020; Abd-Elrahman et al. 2020).
Published: 31st December 2021 Pp- 1435-1443
This is an open access article under Creative Commons License,
Published by Society for Science & Nature, Bhopal India.
Available at: https://bbrc.in/ DOI: http://dx.doi.org/10.21786/bbrc/14.4.10 1435
Al Moaleem et al.,
These systems have provided excellent mechanical, Material and Methods
biological, and esthetic outcomes in the hands of
experienced operators with meticulous treatment planning An electronic exploration was achieved to identify related
and case selection. In addition, a modified SST was research. The search was restricted to May (2010) to October
presented by (Glocker et al. 2014). Han et al. 2018 used a (2021), at the time of gathering of the information with the
1.5-mm thick shield with the most coronal portion, while resulting databases from Medline/PubMed, Cochrane,
Guo et al. 2018 modified the SST by placing platelet-rich Scopus, EBSCO host, Google website, Web of Science, and
fibrin (PRF) in the gap between the root fragment and the Wiley Library. The search terms included “Partial extraction
implant and found that that peri-implant tissue was well therapy”, “socket shield technique,” “modified SST”, “root
preserved by the SST without significant peri-implant tissue membrane technique”, “Pontic-shield technique”, “type of
resorption (Aslan 2018). The most commonly used indices the final restoration”, and “immediate implant placement”,
for the evaluation of the aesthetic dimension of anterior and case report, series, and clinical studies. The study was
single-tooth implants are the pink and white aesthetic score finalized manually by evaluating the particular reference
(PES/WES) indices, and they have been used in several tilts of similar articles. Studies published from (2010 to
studies (Belser et al. 2009; Buser et al. 2013; Mangano et al. 2021) were included if they met the following measures:
2014a; Zhao et al. 2016). Pink esthetic score evaluates the case report, case series, prospective and retrospective
anterior esthetic of the implant-supported single crown on studies, clinical trial study, and involves the use of PET
seven points, including mesial and distal papilla, soft-tissue and procedures with IIP after tooth extraction.
color, contour, level, texture, and deficiency of alveolar
(Fonseca 2018 and Mourya et al. 2019). The exclusion criteria were clinical studies on human and
follow-up not less than 3 months after implant assignment.
It comprises 10 variables such as mesial papilla, distal Two review authors (Al MM and A.M.A) evaluated the title,
papilla, curvature of the facial mucosa, level of the facial abstract, and available text of articles documented in the
mucosa, the root convexity, soft tissue color, and texture electronic search and the inclusion and exclusion criteria.
at the facial aspect of the implant site, tooth form, volume, All published papers related to PET reports were evaluated
color, surface texture, and translucency. A score of 2, 1 or 0 for relevance, eligibility, and data extraction. For all type
is assigned to all parameters. All parameters are assessed by of studies, the implant osseointegration, shield exposure,
direct comparison with the natural, contralateral reference shield infection, shield migration, soft tissue contour, and
tooth, estimating the degree of match or mismatch (Belser type of prostheses were recorded. Radiologic result for
et al. 2009). Based on the Kaplan–Meier survival estimator, buccal and/or crestal bone loss were assessed. The selected
the cumulative implant survival rate (implant-based) was studies were analyzed for complications and adverse effects
high. The complications were the infection of the root stated by corresponding author(s).
portion, with suppuration and fistula formation, which
occurred in four cases at 83, 51, 59, and 12 months after All data were extracted, and the contents were screened
implant insertion) and the infection of the root associated by the author. Full texts of the associated studies were
with peri implant mucositis in 1 case (at 113 months from reviewed for further assessment. This systematic review
the insertion of the fixture (Mangano et al. 2019). was designed in accordance with the Preferred Reporting
Items for Systematic reviews (Moher et al. 2009) with
Infection of the root membrane with fistula was determined some modifications specified by recent systematic
in 50% of cases the occurrence of periimplantitis that reviews published in the previous studies (Siormpas et al.
caused the loss of two implants (at 12 and 59 months after 2018; Blaschke and Schwass 2020; Ogawaa et al. 2021;
insertion). In the remaining 50% of cases, however, the Magadmi 2021). The extracted data from the nominated
implant was not affected by the infection (Gluckman et al. studies were as follows: author(s) name, publication year,
2016; Siormpas. et al. 2018). The prosthetic complications type of technique used, arch, region, tooth type, causes
were divided into minor complications, such as no treatment of extractions, implant placement, loading protocol, final
needed or 60 min chair time and additional laboratory restoration type, complications, survival rate, and follow-up
costs, repositioning of a loosened abutment, and removal period (Table 1). The quality of each involved study was
of a fractured abutment or fabrication of new restorations. evaluated by the authors (Al MM and A.M). The included
Static and dynamic occlusions were evaluated using articles were evaluated using the Checklist for Systematic
standard occluding papers. All prosthetic complications Review, Case Reports and/or Series. Data were organized
were carefully registered and managed if possible, during and summarized in designed tables. The mentioned variables
the follow-up visits. Mangano et al. (2016) and Han et in all collected studies in any form were summarized and
al. (2018) have shown a prosthetic complication such analyzed (Blaschke and Schwass 2020; Ogawaa et al. 2021;
as abutment screw loosening, abutment fracture, and/or Magadmi 2021).
chipping/fracture of the ceramic restorations. Al-Dary
and Alsayed (2017) replaced missing maxillary 2 central Results and Discussion
incisors with zircon cantilever bridge (Abd-Elrahman et
al. 2020). This review aims to illustrate a reproducible and The flowchart for the selection of articles based on their
systematic protocol for the PET techniques with IIP at the eligibility for the current systematic review is presented in
aesthetic zone and summarize the clinical outcome of this Figure 1. The database search across literature resulted in
technique during the last 10 years. 561 articles related to questions raised, and these articles
were gathered and analyzed. The author further separated

1436 Partial Extraction Therapy BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

 Al Moaleem et al.,
the publications and removed similar studies and other and eight case series were conducted between 2014 and
papers articles not correlated to the question elevated. A total 2021. Majority of the case reports were about SST and
of 496 studies were removed, because they are duplicates or immediate implant placement. All cases were followed up
not related to the study. By screening 65 articles, 21 studies with minimum of 3 months and extended up to 10 years. All
were omitted, because they were not related to the review, the parameters’ data are represented and arranged. Graph
leaving 44 studies (Figure 1: Flowchart). Eight studies were 1 represents the outcome of screened studies in relation to
included for each of clinical studies and case series, while PET with immediate implant.
the remaining articles were case reports (28).
The highest percentage of the type of technique used. The
Variables related to PER among clinical studies or both case proportion of implant loading technique (immediate vs.
series and reports were presented in Table 1. The extracted delayed), arch involved maxillary or mandibular arch, the
items were included the author(s) name, publication year, place of studies applied, and the ratio of each tooth type are
type of technique used, arch, region, tooth type, causes shown. Parameters such as causes of extraction, follow-up
of extractions, implant placement, loading protocol, final period, and survival rate for each study are presented in
prostheses type, complications, survival rate, and follow- Graph 2. The details of the materials used for final prosthesis
up period. A total of 44 articles were included in the and the number of screws retained or cemented prosthesis
present review, as shown in Table 1. Eight clinical studies are shown in Graph 3.

Table 1. Qualitative analysis of studies included in this review and arranged ascending

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS Partial Extraction Therapy 1437

Al Moaleem et al.,
Continue Table 1

1438 Partial Extraction Therapy BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

 Al Moaleem et al.,
Continue Table 1

Figure 1: Flowchart of the study selection process (Moher et Graph 2: Causes of tooth extraction, follow-up period, and
al. 2009; Siormpas et al. 2018; Blaschke and Schwass 2020; survival rate of studies included in this review.
Ogawaa et al. 2021; Magadmi. 2021).

Graph 3: Numbers of different types of prostheses (final

restoration) used in studies and cementation technique.

Graph 1: Extracted data in relation to type of PET. Study

type, arch type, position, and restored tooth type.

In addition to that the studies by Arora and Ivanovski (2018),

Han et al. (2018); Hana et al. (2020); Mathew et al. (2020)
recorded 102,33,25,13,7, and 3 maxillaries central, lateral,
canine, 1st and 2nd premolar, and mandibular canines were
recorded, respectively. Abadzhiev et al. (2014) (80%), Arora
and Ivanovski (2017) (88%), Schwimer et al. (2018) (100

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS Partial Extraction Therapy 1439

Al Moaleem et al.,
%); Zuhr et al. (2020) (100.00%), Hana et al. (2020) (95%) Ideally, a method for the prevention of alveolar ridge
found high percentage of success with different period of resorption should be cost-effective and minimally invasive.
follow-up as recorded after each one. Canti-lever of 6 unites Various methods of guided bone regeneration (GBR) have
from maxillary canine in the left side into canine on other been described to retain the original dimension of the bone
side with two abutments. Lateral’s incisors were used by after extraction. All these procedures are cost-intensive and
Polis-Yan et ai. (2020). technique-sensitive. The presented method is cost-effective
but is a technique-sensitive SST that avoids the resorption
Cemented retained cantilever all ceramic with abutment of the bundle bone by leaving a buccal root segment (socket
was lateral incisor and the pontic was the adjacent central shield) in place (Mourya et al. 2019; Ogawa et al. 2021).
incisors, while Abadzhiev et al. (2014) used mixed ceramic The SST seems to be beneficial for ridge preservation
and PFM crowns for their final restoration after SST with despite its insufficient documentation. In this case report
or without IIP. Other authors used mixed PFM and CC as series, implants were placed immediately after extracting a
Arora and Ivanovski (2017) used Screw R PFM, cemented hopeless tooth by using this technique, and the patient was
PFM. Pour et al. 2017 used SR CC, while Hinze et al. (2018) followed up for 1 year to document functional and esthetic
used PFM and ceramic crowns (Esteve-pardo and Colombia outcomes (Mourya et al. 2019; Ogawa et al. 2021).
2018). Various PET techniques have provided outstanding
biological, mechanical, and aesthetic consequences in PES was between 8–10 and 6–10 after 6 and 12 months,
hands of knowledgeable clinicians with careful treatment while previous studies recorded 12.2 PES with complete
arrangement and case collection. A uniform assessment of score for central incisors, recorded 13.5 mm, and recorded
PET outcomes needs to be established to provide objective a mean PES of 12. Only a single article recorded PES
findings, in addition to a consistent protocol for root and MBL for CIIP of 10.8 and 0. 88 mm by, respectively.
portions preparation and to place dental implants in the The MBL for SST was 0.1 ± 0.2 mm as determined in the
ideal place and achieve long term success of treatment. This previous studies and 0.17-0.22 mm as determined in the
review aims to determine the advantages of different PET previous studies (Baumer et al. 2017; Zhu et al. 2018; Germi
techniques aesthetic outcome IIP in the aesthetic zone and et al. 2020; Mathew et al. 2020; Sun et al. 2020; Mathew et
the different types of final prostheses used (Esteve-pardo al. 2020; Mathew et al. 2020). Other information in relation
and Colombia 2018; Oliveira et al. 2021). to case series are available in Table 1 and Graph 1.

Among the PET techniques, SST is the most used technique The advantage of RST is inexpensive preservation of
because of its many advantages in cases of post extraction alveolar bone dimensions to provide a good retentive
immediate implant with IIP, such as high stability and well- surface area for RDP or to preserve alveolar bone for a future
preserved hard and soft tissue; it preserves the buccal bone dental implant, or to preserve the tissues’ dimensions in the
marginal and inter-implant papilla with minimum marginal pontic’s area under a tooth supported FDP, with a chance of
bone loss, maintains alveolar bone level, and does not developing bone and new cementum and connective tissue
change soft tissue dimensions (Nguyen et al. 2020; Alone coronal to submerged segment. It also preserves the tissues
and Niswade 2021; Srivastava et al. 2021; Oliveira et al. next to a dental implant and improves the predictability of
2021). This method is good alternative to preserve BCP interdental papillae height in DIT (Roe et al. 2017; Petsch
in aesthetic area and healthy per-implant tissue, improved et al. 2017; Baumer et al. 2017; Pour et al. 2017; Kumar
buccal contour stability and or better esthetic outcomes can and Kher 2018; Verma et al. 2018; Guo et al. 2018; Mattar
achieved (Dayakar et al. 2018; Patel et al. 2019; Arabbi et 2018; Patel et al. 2018; Schwimer et al. 2019).
al. 2019; Schwimer et al. 2019; Dash et al. 2020).
In the aesthetic area, the preservation of the interdental
In a case series by Habashneh et al. (2019) and Alshammari papilla among two implants is one of the major challenges
et al. (2020) they show minimally invasive approach that of implant rehabilitation, and the PSST was first proposed
can preserve hard and soft tissue and contour of ridge, and and described by involving the similar values of the SST,
this method was implemented in areas of high aesthetic but the distal root piece was used instead of the buccal
demands to achieve good esthetic outcomes. SST with IIRP one. Consequently, studies about this technique are lacking
preserved hard and soft tissue and kept it stable without any (Chen et al. 2018). The complications observed during
changes in dimension, resulting in optimum aesthetic results follow-up of case series include a shield failure caused by
and improving and preserving the buccal contour of ridge infection, a case of deficiency of alveolar ridge, a patient
areas of high aesthetic demands (maxillary anterior up to who had complications with the three other socket shields
premolars) to achieve good esthetic outcomes (Glocker et exposed caused by failure of soft tissue closure (Lagas et al.
al. 2014; Mitsias et al. 2017; Habashneh et al. 2019; Mathew 2015; Gluckman et al. 2016b; Schwimer et al. 2019).
et al. 2020; Nguyen et al. 2020; Germi et al. 2020). Tissue
volumes remain unchanged, and good osteointegration The pontic ST was recognized as the modified SST, and
was achieved (Troiano et al. 2014; Gluckman et al. 2016b; it was introduced to preserve both hard and soft tissues
Baumer et al. 2017). In addition to the above characteristics, in the pontic extents following the same technique as the
a group of clinical studies showed excellent scores for PES SST. However, instead of inserting an IIP in the socket, a
and was in clinical studies (Sun et al. 2020; Hana et al. 2020; bone grafting material was used to seal the socket, and the
Abd-Elrahman et al. 2020). socket was closed by a repositioned flap, gingival graft,
or membrane. Moreover, under the presence of an apical

1440 Partial Extraction Therapy BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

 Al Moaleem et al.,
pathology, the buccal pieces can be conserved, while all Dentistry; 30(4): 338-345. doi: 10.1111/jerd.12385.
the other tooth structures and apical lesions are detached, Aslan S (2018). Improved volume and contour stability
which overcomes a matter that was identified with the use with thin socket-shield preparation in immediate implant
of RST (Nisar et al. 2020).
placement and provisionalization in the esthetic zone. The
Conclusion International Journal Of Esthetic Dentistry; 172- 70L6M&
13 t /6MB&3 2t.
The findings of the present study suggests that although Baumer D, Zuhr O, Rebele S et al. (2018). Socket Shield
PET can be used for dental implant treatment, it remains Technique for immediate implant placement – clinical,
difficult to predict long-term success of this technique until radiographic and volumetric data after 5 years. Clin. Oral
high-quality evidence becomes available. Studies published
Impl. Res; 28: 1450–1458
from 2010 to 202 were included. A total of 40 studies were
included, as randomized controlled trial, cohort studies, Belser UC, Grutter L, Vailati F, et al. (2009). Outcome
clinical case reports, and case series. 123 patients were evaluation of early placed maxillary anterior single-
treated with PET, most of them underwent SST with IIP. tooth implants using objective esthetic criteria: a cross-
The follow-up was conducted between 3–120 months after sectional, retrospective study in 45 patients with a 2- to
placement. Several complications were recorded, but it was
4-year follow-up using pink and white esthetic scores. J
manipulated. Most studies reported implant survival without
complications (91%). Most of cases that were followed up Periodontol; 80(1): 140-51.
for more than 12 months after implant placement achieved a Blaschke C and Schwass DR (2020). The socket-shield
good aesthetic appearance. The failure rate was low without technique: A critical literature review. Int. J. Implant Dent;
the complications, although some failures occurred because 6: 52. doi: 10.1186/s40729-020-00246-2.
of failed implant osseointegration, socket shield mobility Buser D, Chappuis V, Belser UC et al. (2017). Implant
and infection, socket shield exposure or migration, and
placement post extraction in aesthetic single tooth sites:
apical root resorption.
when immediate, when early, when late? Periodontology
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