Grafting or Graftless - different treatment approaches for single teeth

In the first part of our 3-part series “To graft or not to graft”, FOR Experts Dr. Edith Groenendijk, Dr. Ana Ferro and Dr. Jay Malmquist discuss the treatment options for missing teeth with and without grafting procedures.

Dr. Edith Groenendijk, who runs a practice in The Hague, Netherlands, opens the session focusing the discussion on single tooth treatments in the aesthetic area. Preferring a minimally invasive approach, She observes that single tooth replacements can be very challenging, especially when the three-dimensional biology is not fully understood. Even the slightest mistake during diagnosis of the indication can lead to undesirable aesthetic outcomes. Furthermore, suboptimal decisions on the surgical and prosthetic approach can dramatically impact the aesthetic results. The resulting poor aesthetic outcomes are often difficult to repair and restore. Dr. Groenendijk asks the audience to think about what happens when a tooth is extracted without treatment of the alveolar socket. Scientific data shows a dramatic alveolar bone loss of up to 63% can be expected within the first month. This is a significant amount and these missing tissues need to be repaired.

In a case presentation, the site is opened following an early implant placement protocol and a V-shaped defect is observed. An implant is placed into the one-wall defect with bone grafting material in front of the implant. Dr. Groenendijk asks the audience, “Is this a predictable?”.  The audience agrees with her that this a predictable as the results can be predicted. But, it will not be an optimal result as the implant is placed exactly in the place where the bone growth is expected – bone grows from bone and not from implant. She shares her experience with the application of early implant placement, as introduced by Daniel Buser in 2004 and how buccal concavity was a common outcome. Dr. Groenendijk credits Dr. Ueli Grunder in her subsequent treatment approach  to build a hard tissue graft of minimum 2mm in front of the implant to stabilize the soft tissue for the long term. Dr. Groenendijk recommends an implant therapy in the aesthetic zone should either be immediate or delayed.

Dr. Groenendijk presents a 45 years old female, who presented herself to the office with the request to get a new crown on a central incisor. After reviewing the CBCT, Dr. Groenendijk informed the patient that the tooth had a horizontal fracture, a massive bone loss and an inflammation was present. There was already some soft tissue recession present and the distal papilla was also compromised. After presenting the initial situation, she asks the audience to select from the following three treatment options:

1. Option: follow a delayed protocol and graft
2. Option: follow a delayed protocol and preserve
3. Option: follow an immediate protocol and preserve

The audience is indecisive between the first and third option. This aligns with the literature as there is no consensus on how to treat this situation. Dr. Groenendijk shares her treatment approach: immediate implant placement. Her rationale: as long as bony ingrowth from the interdental septa and the cranial can be expected based on the pre- operative CBCT scans, she places an immediate implant followed by a ridge preservation procedure in front of the implant. And, as long as the interdental septa are intact, papilla ingrowth is very predictable because when the distance between the bone crest and the contact point does not exceed 5 millimeters. She explains the implant position, being maximal to the palate, and the socket itself is used for a bone graft, i.e. bone preservation. Showing a 1-year follow up of the case, she mentioned the patient’s focus of was not on the distal papilla, which was already  compromised at initial presentation and could not be restored 100%. It is important to discuss this with the patient before the treatment is started. Dr. Groenendijk summarized her procedure so that after tooth extraction, a preparation is made maximal to the palatal, if possible, into the palatal wall. About 5mms of bone height is needed in the palato-apical area to reach primary stability, and the implant is restored directly thereafter. Firstly, the socket is filled with bone substitute, which is considered to be the ridge preservation procedure and then the implant is installed. The socket is simply closed by the creation of a composite crown on top. No membrane is used, no connective tissue graft, and no flap is raised. The experienced results are supported by the scientific literature showing immediate implant placement often is associated with soft tissue recessions. When explaining why, she looked at the three-dimensional biology, were thick buccal crests are rare, with only 3% of patients presenting with a buccal crest of more than 2mms. A thick buccal crest is not expected to resorb significantly post-extraction. The majority of patients show a thin buccal crest with less than 1mm of thickness. This bony aspect consists of bundle bone and is vascularized by the periodontal ligamentum.  With the extraction of a tooth, this blood supply is taken away which leads to its destruction. The literature confirms a vertical crestal bone loss of 7.5mm within eight weeks post-extraction can be expected. And when such a case is opened up, a V-shaped defect is present. So intact sockets are bone defects after eight weeks. Fresh extracted sockets also form an ideal situation for preservation of the alveolar volume because bone ingrowth from the buccal side is not expected. A nice four wall defect is present which is predictable to graft and directly after extraction growth factors and regenerative cells are present, which is very favorable for wound healing. By placing the implants maximal to the palatal, sufficient space is present for new bone ingrowth in front of the implants. To validate this method, a prospective clinical case series including 100 patients with both intact socket as buccal bone defects was started. The investigators found a tremendous improvement of the soft tissues from a PES score of 9.9 towards 12 after one year post surgery.  Stable after three years, ist was also found was that bone defect didn't influence the soft tissue aesthetic outcome. This could be achieved because in those situations it is possible to overcontour the alveolar process. This leads to the assumption that is an advantage when the buccal crest is not present because that dimension is lost anyways. Dr. Groenendijk continues by displaying several cases showing the development of the soft tissue over several years. She concludes with a statement about her treatment approach: prevention is better than healing and that preservation is preferred over grafting, before introducing the next speaker.

Dr. Ana Ferro opens her presentation by thanking Dr. Groenendijk for her research in the matter and that it is important to develop protocols. Protocols help to develop a routine process which helps to compare cases and draw conclusions. Although the treatment of full arch cases is Dr. Ferro’s specialty, she also treats other indications. When planning and treating a case, she reminds us to keep the patient in mind and include them in the conversation to ensure their needs are addressed. She illustrates her treatment approach with a pie graph showing equal sections for the patient, the surgeon and materials. The patient comes with a diagnosis, desires and needs. The surgeon brings his/her knowledge, skills and experience and the materials represent the tools and products available. Presenting her first case, a 32-year-old female was in need of a treatment of the first upper molar. The patient, who was also a friend, had high aesthetic demands. During the anamnesis, Dr. Ferro noticed that the tooth already had furcation involvement in terms of sinus symptoms and gum recession. The patient complained about food impaction and a slight mobility was noticeable. The CBCT showed the need to extract the tooth. After the extraction, there would not be enough bone to place an implant, so Dr. Ferro was aware that a sinus lift procedure was necessary. She intensely discussed and defined several treatment options with the patient. Presenting these options, Dr. Ferro asks the audience to select their preferred treatment:

1. Option: extraction of the tooth, after 4 months perform a sinus lift, after 6 months place implant, after 6 months place final crown
2. Option: extraction of the tooth, after 4 months perform a sinus lift, after 6 months place implant with immediate crown
3. Option: extraction of tooth and perform sinus lift, after 6 months place implant with immediate crown
4. Option: perform sinus lift, after 6 months extraction of tooth, implant placement and immediate crown

The audience showed a clear preference for options 1 and 4. Dr. Ferro considers the patient demand to never be without tooth during the treatment – even for the molar. She also highlights that the treatment decision should be a shared responsibility between the surgeon and the patient. After considering other critical aspects, such as any medical history regarding the sinus, does the tooth need periodontal treatment, is it stable despite the furcation? Moving on to the treatment, Dr. Ferro explained that she performed the sinus lift using xenograft material with a lateral window approach. When moving on to extracting the tooth, she ensured that it was gently removed, ensuring that the bone between the tooth roots was kept intact. She concludes the case presentation with a photo her friend sent her some weeks ago, which shows a 11-year follow-up for this treatment.