Alveolar ridge preservation: Particulate dentin of

extracted teeth are optimal for immediate grafting of

extracted site EDUCAŢIE PROFESIONALĂ

Autor:
Itzhak Binderman1, Gideon Hallel2 and Marius
Leretter3.
1
Dept. of Oral Biology and Biomedical Engineering, Tel Aviv
University, Tel Aviv, Israel.
2
Private Practice.
3
Department of Prosthodontics, Dental School, University
Prof. Itzhak Binderman Prof. Marius Leretter of Medicine and Pharmacy Timișoara.

Prof. Itzhak Binderman, DMD, Professor in Dentistry, Department of Oral Biology and Biomedical Engineering, Tel Aviv University,
Israel. Honorary life member of ICOI and DGZI. Specialization in Prosthetic Dentistry.
Mail: [email protected]
Dr. Gideon Hallel, DMD, Private Practice in Tel Aviv
Prof. Marius Leretter, DMD, Department of Prosthodontics, Dental School, University of Medicine and Pharmacy Timișoara, Romania.
Conflict of interest: IB is co founder of SDG procedure and has interest in Kometabio inc.

Abstract:
The healing process of a tooth extraction site results in significant changes of alveolar ridge contour caused by
alveolar bone loss, most of it, during 3-4 months after extraction. It is therefore strongly indicated to graft the extracted
site with biocompatible or bioactive bone grafts. Most of the synthetic allogeneic and xenografts preserve the alveolar
ridge during the repair phase and then it resorbs during the remodeling phase, thus, achieving only a partial ridge resto-
ration. In recent years, a novel procedure was developed where the extracted tooth is transformed into immediate graft
that preserves best the alveolar ridge for many years. This happens because the autologous dentin undergoes anky-
loses with newly formed bone thatis biologically connected to the host bone this way restoring a functional connectivity
between host bone and dentin particles.

INTRODUCTION: loss at the repair phase of wound healing (Horowitz et al.,

2012; Nevins et al., 2006). Socket preservation techniques
The healing process of a tooth extraction site results for ridge preservation utilizing different biomaterials and/
in significant changes of alveolar ridge contour caused or barrier membranes often result in better maintenance
by alveolar bone loss, significantly greater on the buc- of tissue volumes, although the inevitable biological pro-
cal aspect than on the lingual or palatal (Pietrokovski and cess of post-extraction bone resorption and bone re-
Massler, 1967). It seems therefore, that an accelerated modeling cannot be stopped (Chappuis et al., 2017). We
bone loss takes place during the first three months after have shown that the best results in minimizing resorption
tooth extraction, ensuing in reduction of 50% of the width in such cases can be achieved using autologous dentin
of alveolar ridge within 12 months (Schropp et al., 2003). grafts that interact differently than non-autologous grafts
Moreover, tissues loss due to remodeling continues for (Binderman et al., 2014; Kosinski, 2017).
many years although in a slower pace. The labial bone In fact, tooth dentin and cementum, being similar in
wall thickness has been identified as the most critical fac- their mineral and protein composition to membranous
tor influencing bone resorption, especially it is critical in bone, are instructive to osteogenic cells by directly depos-
the frontal and premolar area of the jaw, in the region of iting new bone matrix on their surfaces resulting in anky-
the thin buccal lamella. It is reasonable to assume that losed dentin-bone interfaces. Such ankylosed interface
the greater resorption of the buccal plates of alveolar happens when avulsed teeth are re-implanted back into
ridge proceeds since most of this bone is formed during their sockets (Andersson et al., 1984; Andersson, 2010;
tooth eruption. Andreasen and Raven, 1972) or when extracted teeth are
The rapid significant changes of the ridge contour processed immediately after being extracted into a par-
including the soft mucosal tissues are key in determin- ticulate dentin graft that is inserted into freshly extracted
ing the esthetic and functional deficiencies. Also, pros- socket, in same patient (Binderman, et al., 2014; Kosinski,
thetic reconstruction using dental implants will often not 2017; Valdec et al., 2017).
be possible, because of deficient alveolar ridge. There is The alveolar bone, during its initial healing phase will
sufficient compelling evidence that immediate grafting of react a lot better to the ankyloses process than it would
the extraction sockets by various ridge preservation tech- to osseointegration only. Recent clinical results show op-
niques including the placement of graft materials and/or timal alveolar ridge contour preservation of over 5 years
the use of occlusive membranes prevents alveolar bone post-surgery when de-coronation of ankylosed teeth is

DENTALIFE / VIAŢA STOMATOLOGICĂ / NR. 04 / 2017 7

performed (Malmgren, 2013; Filippi et al., 2001). In a re- minutes with gentle shaking. The PBS will wash out the
cent study, a case series was reported where a technique remanences of the cleanser and will lower the pH back
in which the extraction socket was augmented with au- to physiological pH of 7.2. Those treatment times were
tologous, particulated mineralized dentin that was placed optimized to achieve complete removal of all organic sub-
immediately after tooth extraction (Valdec et al., 2017; stances from the particulate surfaces. Now, the PBS is
Schwarz et al., 2016; Binderman et al., 2014). In all cases, absorbed into a sterile gauze and the slightly wet particu-
patients exhibited a stable volume of soft and hard tissues late is ready to be grafted. At this point it is possible that
and good osseointegration of titanium implants, having few bacteria can survive the cleansing procedure, how-
been placed in this augmented socket (Valdec et al., 2017; ever, these bacteria are the patient’s bacteria. It is today
Binderman et al., 2014). Here, we describe the efficacy common knowledge that the oral bacterial environment
and safety of the Smart Dentin Grinder (SDG) procedure is normally protective for the patient. The dentist should
for ridge preservation after extraction of teeth. Preserva- be aware about the bacterial biofilm that is concentrated
tion of alveolar ridge effectiveness is not only important in the gingival crevice and produce growth of anaerobic
for implant supported prosthesis, but also to restore or bacterial environment.
augment surgically produced defects, like of impacted
teeth or support dehiscent root surfaces of periodontally (b) Why SDG is an effective procedure?
involved teeth. In fact, since every tooth extraction in- Dentin, cementum and membranous bones (mandi-
duces loss of alveolar bone, it is indicated to process the ble and maxilla) develop from a unique embryonic neural
extracted tooth into a particulate graft whenever possible, crest cell populations. It is therefore inevitable that den-
in order to preserve the alveolar bone. tin and membranous bone consists of similar molecular
cues and structures.
THE CLINICAL PROCEDURE: These tissues consist of hydroxyapatite mineral (HA)
that is deposited on and between type I collagen mole-
(a) Why the SDG is a safe procedure? cules, inside fibers as well as extrafibrillar HA, surround-
The SDG procedure (Smart Dentin GrinderTM) that ing these collagen fibers. In addition, the non collagen
was developed by Kometabio company is indicated only fraction of glycoproteins, although being only a small
for the same patient’s teeth. The extracted tooth is usu- fraction of the matrix volume, are vastly important in reg-
ally covered with a biofilm of bacteria, toxins and soft tis- ulating mineralization, attraction of osteoprogenitor cells
sue such as periodontal ligament on its root surfaces. and instructive molecules like BMP.
In addition, the tooth crown in many instances contains These make this matrix very bioactive and most im-
foreign materials such as cements, filling materials and portant in initiating regeneration of bone or repair of ce-
metal based ceramic crowns. In many treated teeth root mentum and dentin. Interestingly, the mineral of adult
canals are filled with Gutta Percha and cementing mate- dentin and bone matrix is protecting the organic molecu-
rials. In some cases the root canal is infected by bacte- lar structures from being invaded by macromolecules
ria. After extraction, all the foreign materials, polymeric, and bacteria. It is evident that teeth that are extracted by
cements, metallic, ceramic and root canal filling should injury, also called avulsed teeth, when re-implanted into
be thoroughly removed using a bur, drill or piezo knifes. their sockets or transplanted teeth, undergo either partial
This will usually take a minute or two and is performed or total ankyloses and may function for many years.
by the dentist or his auxiliary. At the same time, the ‘shav- The root ankyloses is a biological repair process
ing’ of the organic coat of the root surfaces that includes where the root cementum and dentin surfaces are at-
the periodontal ligament tissue and the bacterial biofilm is tractant to osteogenic cells that attach to root surface
easily removed by a tungsten carbide burr, drill and water. through integrin-RGD covalent biological attachment.
At the end of this phase (2 minutes) we achieve a very Then, the dentin and cementum matrices are instruct-
clean surface of tooth structure that consists of of den- ing local cells to differentiate into active osteoblasts that
tin. At this phase the thin layer of cementum is usually secrete mineralized matrix directly on dentin and cemen-
removed and most of the enamel. Before placing the teeth tum surfaces. This creates an ankyloses interface which
into the sterile grinder chamber they should be thoroughly cements the newly formed bone to dentin surface. At
dried by air flow syringe. The grinding and sorting process the remodeling phase the osteoclasts do not distinguish
into specific particulate usually takes 1minute. The grind- between bone and dentin matrices because dentin and
ing of the tooth takes 3 seconds and vibration for sort- bone have same embryonal origin.
ing of the ground particles takes 20 seconds. More than It is evident that extracted teeth that are processed
90% of the particulate accumulates in special ‘chamber as described above are instructive to the osteogenic en-
drawer’ that contains particulate size of 300-1200 um, vironment in the fresh socket and therefore new bone
the optimal size for achieving an osteogenic interaction at is deposited directly on the dentin particulate surfaces,
the grafted site. It is noted that the particulate volume will leading to ankylosed interfaces between new bone and
be about 2-3 times more than the volume of the tooth. dentin particles. In fact, this process creates hard tissues
In the next step, the particulate is poured into a sterile (bone-dentin) connectivity that restores the alveolar ridge
small glass container. A chemical cleanser that consists and preserves it for many years.
of 0.5M NaOH and 20% ethanol is poured in to cover the
particulate. Some gentle shaking will help the cleanser (C) Clinical cases:
solution to wet the particles and penetrate into the dentin Extraction of teeth is an everyday practice of every
tubules. It is important to note, that the cleanser is very general practitioner dentist. One third of teeth are ex-
effective in dissolving all organic materials, like bacteria, tracted because of advancement of bone loss due to
endotoxins, virues and more even inside the tubules. periodontal diseases. Most of these teeth are without any
After 10 minutes the cleanser is decanted by absorb- prosthetic or endodontic treatments. However, majority
ing the liquid onto a sterile gauze. The PBS solution which of extractions are performed of teeth that are either root
is Phosphate Buffer Saline is poured into the dish for 3 canal treated and have different prosthetic reconstruc-

8
tions. The prosthetic devices in the tooth crown should
be cut out, usually by tungsten carbide. In many cases
roots volume is enough to convert into particulate, since
the particulate dentin recovered from the roots by SDG
procedure will result in 2-3 times the volume of the roots.
When teeth are endodontically treated, the dentist should EDUCAŢIE PROFESIONALĂ
evaluate whether after removing the root canal filling, he
Alveolar ridge preservation
will be left with usefull amount of dentin graft. It should
be noted that 10% of extractions consist of wisdom teeth.
When impacted wisdom teeth or other are extracted it is
a must to graft the large defects in order to restore the tracted tooth into an autologous particulate that grafted
alveolar ridge. The SDG procedure does it best. the extraction site. On follow up, the bone ankylosed to
Here, we present everyday cases in general dental dentin produces a very stable alveolar ridge that other-
practice. Case YM (Figure1) is a young adult that his tooth wise would be resorbed during 3-6 months after extrac-
26 has a local progressive periodontal bone loss. tion. This grafted site preserves the alveolar ridge both
Figure 1 shows that the extracted tooth is a naïve functionally and esthetically. It can be utilized as a site for
tooth with no dental treatment. It shows that during 15-20 implant insertion after 3 month in the maxillary posterior
minutes, the dentist or his assistant is converting the ex- region, changing it from D3 bone into D1 bone.

Figure 1
a b c

d A fter extraction 9 months after dentin graft

Case Y M: Tooth 26 was extracted b ecau se of b one loss du e to

aggressive periodontitis. The tooth was cleaned,dryed,processed b y
SDG and grafted. Total ridge preservation is achieved, 9 month later.

Figure 2 shows a case (ML) where a molar tooth with Here, two implants were inserted 3-4 month after graft-
a root canal filling was extracted. In this case, the crown ing.
was discarded and the root canal filling was removed Also, in this case the dentin particulate was mixed
and the roots underwent the SDG procedure. In this case with PRF before grafting, thus, producing a possibility of
you will find that the extraction site and even some of the ‘sticky bone’ that could be molded into a geometry that
sinus (see Figure 2e, arrow) was filled with dentin graft. fits the restoration of the ridge (Figure2c).

Figure 2
a b c

d e Case ML, 36y old 27 is

extracted, the root canal was
cleaned and filling removed.
Then, SDG treatment graft
prepared and dentin particles
mixed with PRF were grafted.
3months later 2 implants
were inserted and restored.

DENTALIFE / VIAŢA STOMATOLOGICĂ / NR. 04 / 2017 9

 Figure 3 shows a simple case that shows that the ex- build a solid bone-dentine structure that was adequate for
tracted root was capable to preserve the alveolar ridge and implant-prosthetic restoration, after 2-3 months.

Figure 3

In fact, Figure 4 shows an x-ray taken 4 years after shows most viable mineralized bone deposited directly
grafting dentin particulate of a single molar and recon- on the dentine surface, termed as ankyloses.
structing with implants and prosthetic device. The bone This is achieved only by autologous dentin as was
level next to implants was perfectly stable. described before in re-implanting of avulsed teeth and
A bone biopsy taken before placing the implants autotransplantations.

Figure 4

B iopsy tak en 2months after grafting j u st b efore Fou r years after implant insertions and
implant insertion in the lower j aw. D = dentin prosthetic reconstru ction in dentin grafted
particu late. B + newly formed b one ank ylosed sock et au gmentation b y SDG procedu re. N o
to dentin. A rrows show ank yloses interface. vertical resorption at implant interface.

DISCUSSION sorption than low-density grafts. It seems therefore, that

autogenic dentin like membranous bone are optimal for
The use of scaffolds for preserving or reconstructing long standing preservation of augmented alveolar bone
the alveolar bone ridge became a frequent surgical proce- ridge. Autologous dentin and cementum undergo anky-
dure. Bone grafts usually undergo extensive remodeling loses when re-implanted back into the osteogenic socket.
and resorption during the first year after surgery, which Clinical studies of follow-up cases of re-implanted
may affect the feasibility of an effective rehabilitation. avulsed teeth or auto transplanted teeth from one site into
Some authors suggested that graft resorption rate may surgical prepared sockets showed an immediate cellular
be dependent on their embryologic origin, since grafts interaction with dentin or cementum root surfaces that
from membranous bone (i.e. calvarial or mandibular results by cellular biologic attachment to their surfaces,
grafts) do not resorb as extensively as those from endo- differentiation into osteoblasts and deposition of mineral-
chondral bone (as iliac crest bone grafts). Bone graft den- ized matrix directly onto dentin or cementum. This bio-
sity may also be associated with their resorption, as it has logical attachment is termed by clinicians as ankyloses.
been shown that high density grafts undergo a lower re- It is important to note that such biological interface be-

10
 EDUCAŢIE PROFESIONALĂ
Alveolar ridge preservation
tween dentine or cementum mineralized matrices and
the newly deposited mineralized bone matrix is creating a
functional biological connectivity that allows remodeling
of all mineralized tissue in most physiological pattern. Al-
though, root resorption takes place in a very slow pace,
it is replaced by newly formed bone, thus, preserving the
alveolar ridge.
Malmgren and others suggested to decoronate anky-
losed teeth and this way to preserve the alveolar ridge.
This concept of biological ankyloses happens when au-
tologous extracted teeth are undergoing an SDG process
and re-implanted back into extraction sites and/or are
used for grafting alveolar bone defects, deficiency or in
sinus augmentation procedures.
Also, recent clinical findings suggest that dentin grafts Filippi A, Pohl Y, von Arx T.(2001). Decoronation of an
of extraction sockets in the esthetic zone preserves best ankylosed tooth for preservation of alveolar bone prior to
the buccal plate. Recent study from Zurich university (Val- implant placement. Dent Traumatol 17:93–5. 1 Decorona-
dec et al., 2017) that used the same concept of grafting of tion of ankylosed teeth.
particulate mineralized dentin found it safe and effective
in preserving the alveolar ridge in the esthetic zone. Kosinski T.(2017). Innovative Socket Grafting Tech-
In conclusion, the extracted tooth is not anymore a niques in Preparation for Dental Implants. TPD.
medical waste, since in most cases it is the patient tis-
sue that can be transformed immediately into a graft that Malmgren B, Cvek M, Lundberg M, Frykholm A.(1984).
will preserve the alveolar ridge and restore functionctional Surgical treatment of ankylosed and infrapositioned re-
and esthetic reconstructive prosthesis. implanted incisors in adolescents. Scand J Dent Res
1984;92:391–9;

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osseous replacement. Dent Traumatol. 26(5):398–402.
doi:10.1111/j.1600-9657.2010.00912.x. Nevins M, Camelo M, De Paoli S, Friedland B, Schenk
R, Parma-Benfenati S, et al.(2006). A study of the fate of
Andersson L, Blomlof L, Lindskog S, Feiglin B, Ham- the buccal wall of extraction sockets of teeth with promi-
marstrom L.(1984). Tooth ankylosis. Clinical, radio- nent roots. Int J Periodontics Restorative Dent 26:19-29.
graphic and histological assessments. Int J Oral Surg.
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Andreasen JO, Ravn JJ.(1972). Epidemiology of trau-
matic dental injuries to primary and permanent teeth in a Schropp L, Wenzel A, Kostopoulos L, Karring T. (2003).
Danish population sample. Int J Oral Surg 1:235–9. Bone healing and soft tissue contour changes follow-
ing single-tooth extraction: a clinical and radiographic
Binderman, I., Hallel, G.,Casp N., Yaffe A..(2014). “A 12-month prospective study. Int J Periodontics Restora-
Novel Procedure to Process Extracted Teeth for Imme- tive. Dent. 23:313-23.
diate Grafting of Autogenous Dentin.” J. Interdiscipl Med
Dent Sce. 2(6). Schwarz F, Golubovic V, Becker K, Mihatovic I.(2016).
Extracted tooth roots used for lateral alveolar ridge aug-
Chappuis V, Araújo MG, Buser D.(2017), Clinical rel- mentation: a proof-of-concept study. J Clin Periodontol;
evance of dimensional bone and soft tissue alterations 43(4):345–53. doi:10.1111/jcpe.12481.
post-extraction in esthetic sites. Periodontol 2000. 2017
Feb;73(1):73-83. doi: 10.1111/prd.12167.). Valdec S., Pasic P., Soltermann A., Thoma D.,
Stadlinger B. and Rücker M. (2017). Alveolar ridge preser-
Horowitz R, Holtzclaw D, Rosen PS.(2012).A Review vation with autologous particulated dentin—a case series.
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DENTALIFE / VIAŢA STOMATOLOGICĂ / NR. 04 / 2017 11

 SMART DENTIN GRINDER

BENEFICII:
• Reducerea substantiala a timpului de vindecare
• Calitatile unei grefe de os autolog
• Mentine masa osoasa si inaltimea crestei alveolare
• Ofera estetica excelenta
• Elimina efectele adverse ale respingerii si a bolilor de transmitere
• Economie la materialele de reconstructie osoasa

EXTRACT GRAFT 5

GRIND

12