Bone Grafting and Implants: Always the Best Treatment?

Figure 1. Patient before treatment, showing 2 missing maxillary anterior teeth with a large bone defect. Figure 2. Periapical radiograph of the bone defect. Figure 3. Facial view of bone and the soft-tissue defect. Figure 4. Occlusal view of the bone and soft-tissue defect.

When reading the most prestigious dental implant publications, it appears that the solution to most of the difficult partial and completely edentulous situations with inadequate bone lies in grafting the defective sites, waiting for healing, placing dental implants, and restoring the defects. In such cases, significant amounts of autogenous bone (the patient’s own bone), allograft (human cadaver bone), alloplast (synthetic graft materials), or xenograft (animal bone) are placed into the defective site.
      There is no question that these procedures are desirable, and sometimes successful. However, the process can be extremely expensive. If the grafting material is autogenous, it is often painful at both the site from which the graft was taken and the site into which it was placed. Grafting large defects can be time consuming, often unpredictable overall, and can sometimes result in a less than perfect aesthetic result. We, as educated dentists, are the most knowledgeable clinicians concerning these situations. Are we providing adequate information to patients to allow them to make an educated and informed decision about their complex therapy? Is informed consent education providing all of the alternatives for such difficult situations being delivered to them? Often, patients see restorative dentists and prosthodontists after the grafting and implant placement has already been accomplished by a surgical specialist. At that late time, there are no alternatives except to proceed with whatever the surgical clinician accomplishing the grafting and implant placement envisioned. The clinical result may range from adequate to disastrous.
      In recent months, we have seen clinical examples that have caused concern about apparent overtreatment or mistreatment. In the following cases, more conservative plans would have been possible and potentially better than those planned:

• Older teenagers with partial anodontia and stable remaining primary teeth treatment planned for removal of all functional and stable primary teeth, extensive iliac crest bone grafting in to all 4 quadrants, placement of many implants into the edentulous jaws, and fixed restorations on both jaws. Each of the jaw restorative rehabilitations had the planned cost of a new automobile. The cost of an entire oral rehabilitation such as this often equals the cost of an average house in the United States.
• Partially edentulous patients with inadequate bone for standard-diameter implants (3 mm or larger in diameter), who were planned for extensive ridge augmentation using chin or ramus grafts; followed by implants, abutments, and crowns; when a simple, predictable fixed or removable prosthesis would satisfy the clinical situation from both a functional and aesthetic standpoint.
• Edentulous senior patients with inadequate bone for standard-diameter implants who were planned for major autogenous bone grafting into the anterior mandible and maxilla, before rehabilitation with removable overdentures; when placement of small, up to 3 mm in diameter, implants would have been ideal in the resorbed, mostly cortical bone that was present.
• Planning for the removal of functional and aesthetically acceptable 3-unit fixed prostheses; grafting of the single tooth edentulous site; and placement of an implant, abutment, and crown; under the guise that an implant in the edentulous single tooth areas would serve the patient better than the currently functional 3-unit fixed prosthesis.
• Planning for an active chemotherapy/radiation therapy patient to remove all remaining teeth, graft defective sites, place 4 implants on each arch; followed by a fixed prosthesis on each arch.
• Planning for placement of single implants between treated, previously periodontally involved mobile teeth. These patients are often in a maintenance stage, but the long-term prognosis for the teeth is questionable. These patients often have several remaining teeth on each arch, several implants between the teeth, and a full-mouth rehabilitation is planned. Removal of the remaining teeth and placing conventional complete dentures or implant supported dentures often satisfies such situations more adequately, less expensively, and with more predictability.
• Planning for 4 or more implants with flattening of the bone on the crest of the ridge, and placing several over 3 mm diameter implants and a fixed prosthesis, when numerous other more conservative treatment plans could be considered.
  The many more examples witnessed over our cumulative years in practice would only add to the anxiety that we have stimulated in you already. The questions related to this article are clear. Should grafting and placement of implants be planned for everybody? Or, should more conventional therapy be accomplished occasionally?

This article is a call for each of us to ensure that our patients are:

• Honestly informed of the numerous alternatives for their complex oral rehabilitation needs;
• Encouraged to consult with other practitioners for their clinical opinions in addition to our own suggestions;
• Convinced that the “best” treatment for their specific situation is eventually chosen in light of their health, aesthetic needs and concerns, financial ability, age, temperament, and psychological well being. They should know that their treatment plan is not based on the highest revenue-producing procedure or whatever may be the most technologically advanced procedure at the time.

It appears that the previously described patients did not have the opportunity to make educated decisions about their therapy, since many of the planned treatments were neither logical nor in the patient’s best interest. For some dentists, the excitement of treating a “big” case and the obvious financial rewards cast a shadow over the patient’s true needs.
      Both of the authors of this article are prosthodontists. And both of us graft defective bone sites and place implants. We agree that in many situations, grafting, healing, implant placement, and restoration constitute the best treatment. However, we also see many cases in which the treatment was excessive; ill-timed; too expensive for the patient or family, causing financial distress; or placed in situations where conventional oral therapy would have actually been better.

Figure 5. Build-ups, tooth extraction of maxillary canine, grafting of canine socket, and tooth preparation ready for healing and provisional restoration. Figure 6. One single-cast unit fixed prosthesis in porcelain-fused-to-noble-metal (John Archibald, CDT). Figure 7. Tissue side of fixed prosthesis. Figure 8. Anterior view with lips retracted. Figure 9. Maximum smile of patient, which does not show any objectionable abnormal gingival architecture.

TREATMENT PLANNING FACTORS: GRAFTING AND/OR IMPLANT PLACEMENT
We will use an actual patient to encourage you to think about treatment planning for difficult cases.
Figures 1 and 2 show the radiographs of a patient who came to us for a “second opinion.” According to the patient, a surgical dentist in our geographic area had removed a single upper anterior tooth, which led to removal of another apparently defective anterior tooth, an autogenous bone graft, and the eventual failure of the bone graft.
      Figures 3 and 4 show the resultant significant bone and soft-tissue defects. A surgical dentist had suggested another extensive bone graft into the defect, some implants and crowns. The patient, an educated and intelligent person, was concerned about more surgery, its expected success, the aesthetic result, and the time involved for the overall procedure. After considerable dentist and staff time expended for “informed consent” (Table), and evaluation of the potential for functional and aesthetic success, the patient decided to have a conventional fixed prosthesis. We agreed with the patient’s decision, feeling that grafting and the other procedures were not in the patient’s best interest, although we could have easily accomplished the other route with more grafting and restoration with implants.
      We agreed to do the therapy. A defective canine was removed and the socket of the extracted canine was grafted with an Alloplast (Bioplant by Kerr) to provide long-term socket and ridge stability for the soon-to-be-made pontic. The other remaining teeth were built up and prepared for the fixed prosthesis (Figure 5). The prosthesis was made in a one-unit casting using high palladium noble metal, with both tooth-colored and gingival-colored ceramic placed on the metal. It was fabricated as shown in Figures 6 and 7.
      The clinical result is shown in a lip-retracted view in Figure 8 and the patient’s highest natural smile is shown in Figure 9. Only the upper teeth including the premolars were included in the fixed prosthesis. The mandibular teeth and the maxillary molars were not restored due to their stability, their lack of aesthetic needs, and to control expense for the patient. Obviously, the gingival-colored ceramic as shown in Figure 8 will never show unless the lips are forcefully retracted, in spite of a relatively good aesthetic result. The patient was highly satisfied with the result.
      The following factors were considered and discussed in detail with the preceding patient before he decided to accept conventional dentistry instead of another large bone graft, a long healing period, significantly more expense, and an unknown clinical outcome.

EXAMPLE INFORMED CONSENT PROCEDURE
Alternatives for treatment:

• Leave his maxillary anterior teeth “as is,” repair the defective crown margins, and make an all-resin or metal-supported removable partial prosthesis;
• Place a fixed prosthesis, including the maxillary premolars and the remaining anterior teeth;
• Extensive grafting, implant placement, abutments, and crowns;
• The ultimate failure—remove all of the maxillary teeth and place a removable complete denture, with or without implants.

Advantages of each treatment: After discussing the advantages of each alternative, the patient rapidly elected to accept the fixed prosthesis. The advantages of the fixed prosthesis were:

• Three appointments only spread throughout a period of several weeks;
• After removal of the defective canine tooth and analysis of the other remaining teeth, the cost of the rehabilitation will be known;
• Significantly lower cost than grafting and implants;
• Known predictability for aesthetics and function;
• Relative lack of discomfort compared to the surgical approach.

Disadvantages and risks related to the fixed prosthesis:

• Higher cost than the removable prostheses options;
• Possibility for endodontic therapy need for some of the remaining vital teeth. However, some restorative dentistry would have also been needed if grafting and implants had been done;
• Unknown longevity of the fixed prosthesis, as with any restorative dentistry.
• Relative cost of the respective therapy: In this case, the grafting, implants, abutments, and crowns would have been at least 3 times the cost of the fixed prosthesis as shown.

IN CLOSING
Numerous treatment plans are present for most extensive, difficult cases, including missing teeth and significant bone loss. In light of the observed frustration of many patients, concerning how to best treat their complex oral conditions, it appears that many patients need more information before agreeing to their treatment plans. The treatment team (consisting of general dentist, dental specialist, and dental laboratory technician) needs to communicate better before committing patients with complex needs to extensive/expensive treatment plans. Although dental implants are highly desirable treatment when indicated, all possible treatments should be considered and explained to patients before proceeding with oral rehabilitation. Usually grafting and implant placement are the most adequate therapy. However, conventional treatment that doesn’t include implant placement and complex bone grafting may often be the best treatment choice.

Dr. Christensen is currently a practicing prosthodontist in Provo, Utah. His degrees include DDS, University of Southern California; MSD, University of Washington; and PhD, University of Denver. He is a Diplomate of the American Board of Prosthodontics, a Fellow and Diplomate in the International Congress of Oral Implantologists, a Fellow in the Academy of Osseointegration, American College of Dentists, International College of Dentists, American College of Prosthodonists, AGD (Hon), Royal College of Surgeons of England, and an Associate Fellow in the American Academy of Implant Dentistry. Drs. Gordon and Rella Christensen are co-founders of the nonprofit CR Foundation (previously CRA) and the Gordon J. Christensen CLINICIANS REPORT. He has presented more than 45,000 hours of continuing education throughout the world and has published many articles and books. He can be reached at (801) 226-6569 or at info@pccdental.com.

Disclosure: Dr. Christensen reports no conflicts of interest.

Dr. Child is the CEO of CR Foundation, a nonprofit educational and research institute (formerly CRA). He conducts extensive research in all areas of dentistry and directs the publication of the Gordon J. Christensen CLINICIANS REPORT, and other publications. Dr. Child graduated from Case Western Reserve University School of Dentistry, completed a prosthodontic residency at Louisiana State University, and maintains a private practice at the CR Dental Health Clinic in Provo, Utah. He is also a certified dental technician through National Board of Certification in Dental Lab Technology. Dr. Child lectures nationally and copresents the “Dentistry Update” course with Drs. Gordon and Rella Christensen. He lectures on all areas of dentistry, with an emphasis on new and emerging technologies. He maintains membership in many professional associations and academies. He can be reached at (801) 226-2121 or via e-mail at toni@cliniciansreport.org.

Disclosure: Dr. Child reports no conflicts of interest.