Latest / Straumann® ProTalk / Why preserve the ridge at extraction? Dr. Larissa Steigmann on alveolar ridge preservation (video version)

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Why preserve the ridge at extraction? Dr. Larissa Steigmann on alveolar ridge preservation (video version) · Straumann® ProTalk

• 0:00
  Let's face it, it's often a financial decision.
• 0:02
  A lot of the times I say it's not very sexy.
• 0:05
  It's not the big augmentation.
• 0:07
  It doesn't require advanced grafting from you.
• 0:10
  It's not what we think, it's what we know.
• 0:12
  Now, what happens in an extraction socket?
• 0:15
  Bone.
• 0:16
  And as I told you before, 90% of the cases in the anterior
• 0:19
  maxilla have less than one.
• 0:21
  So basically it means most of the time we need to do it, no questions asked.
• 0:25
  And they came back and I had to re-graft at the time of implant placement.
• 0:43
  The moment we extract the tooth, biology starts to remodel that ridge.
• 0:47
  So the real question is, how much of that change can we actually control?
• 0:52
  In this episode of Straumann ProTalk Clinical, Dr. Larissa Steigmann
• 0:55
  joins me to discuss alveolar ridge preservation, when it matters, what
• 1:00
  are we trying to preserve, and how our decision at the time of extraction can
• 1:04
  influence any implant treatment that
• 1:06
  follows.
• 1:07
  Don't miss this episode.
• 1:09
  Larissa, thank you very much for accepting our invitation, for
• 1:12
  participating in Straumann ProTalk Clinical directly from International
• 1:17
  Aesthetic Days in Copenhagen.
• 1:18
  What an honor to have you with us.
• 1:20
  Thank you so much for the invitation.
• 1:22
  It's a pleasure to be here.
• 1:23
  It's a pleasure to be here with you.
• 1:24
  Pleasure to be in Copenhagen, Aesthetic Days.
• 1:27
  Not a bad place to be.
• 1:28
  Not a bad place to be.
• 1:29
  The weather could be better, That's what's expected here.
• 1:33
  Your, luggage could have arrived as well.
• 1:34
  If my luggage could have arrived, that would've been, probably the one
• 1:39
  thing that would've solved a lot of problems these days- but it's okay.
• 1:44
  That is a complex one to solve.
• 1:46
  That's a- The topic today is not as complex, right?
• 1:48
  Exactly.
• 1:48
  Or-
• 1:49
  We're in control … or it- This one we're in control of.
• 1:51
  The rest- It's manageable
• 1:52
  … it's manageable.
• 1:53
  All right.
• 1:54
  Exactly.
• 1:54
  So for everybody listening to us, we're talking today pretty much even though
• 1:59
  Larissa has a wealth of knowledge that we can pick your brain with, but
• 2:04
  we're gonna focus a little bit on, something that I know is very close
• 2:07
  to your heart, you're educating people about, the alveolar ridge preservation.
• 2:12
  And in the podcast we cover a few building blocks that what is it, why
• 2:17
  does it matter, and how should we do it?
• 2:19
  I know this is a conversation, not a lecture or that we have resources.
• 2:24
  It's more to grasp what ticks your heart, how things are done.
• 2:27
  And in the context of alveolar ridge preservation, first things first,
• 2:31
  what exactly are we talking about?
• 2:33
  Okay.
• 2:34
  I think, it's one of the topics that is very underrated.
• 2:40
  I do… I would say that I've seen that in the last years it
• 2:44
  have gotten a bit more attention.
• 2:46
  It has emerged more and more in the block, I would say, of
• 2:50
  regeneration, this hot topic status.
• 2:54
  Okay?
• 2:55
  So I'm very glad about that.
• 2:57
  Why?
• 2:59
  when we're extracting a tooth, let's think about it.
• 3:02
  We're talking about implant therapy at the end of the day, right?
• 3:05
  So any implant therapy starts with a lost tooth, right?
• 3:11
  Most of the time, we're the one needing to extract this tooth, and we're
• 3:16
  known or we know that we eventually will need to place an implant.
• 3:21
  Now, in between, there is a lot of changes happening within our tissue,
• 3:26
  within our hard tissue and soft tissues that we underestimate, okay?
• 3:33
  With alveolar ridge preservation, we have a chance to limit the
• 3:38
  resorptive processes that we know that are occurring, especially when
• 3:42
  we talk about hard tissues, okay?
• 3:44
  Meaning bone resorption is occurring after tooth extraction, and it can
• 3:50
  lead to a lot of problems, meaning a lot of surgical interventions that
• 3:55
  will need to occur in the future if we're not preserving these tissues.
• 4:00
  So alveolar ridge preservation, long story short, right?
• 4:03
  Alveolar ridge preservation is the surgical intervention that is limiting
• 4:08
  our bone resorptive processes exactly occurring after tooth extraction, and
• 4:14
  this is the best time to intervene and the best time for us to preserve
• 4:19
  because we took out the tooth, right?
• 4:22
  Yeah.
• 4:23
  So that's why I'm always saying it's such a underrated surgical
• 4:27
  process, b- s- surgical process because it's more conceptual.
• 4:33
  It's not a very technical, difficult surgery, okay?
• 4:38
  I lo- a lot of the times I say it's not very sexy.
• 4:40
  It's not the big augmentation.
• 4:43
  It's not the big surgery that makes us feel like we're, doing, being this
• 4:48
  big surgeon, but the effect of it is so crucial and so big when it comes to
• 4:56
  the long-term success of our implants.
• 4:59
  So yeah, that's alveolar ridge preservation.
• 5:03
  That's the definition, and I like you, you hit the nail on the head.
• 5:06
  That's pretty much how it defines.
• 5:08
  And when- When, except in very rare occasion, let's assume a trauma, but
• 5:15
  normally we don't extract a, or ortho maybe, we don't extract a healthy tooth.
• 5:20
  Yes.
• 5:20
  There are, pathological and many factors that could be on the table that can alter
• 5:27
  the site itself after extracted, right?
• 5:30
  Yes.
• 5:30
  And that will dictate probably one route or another.
• 5:34
  What is your decision-making there to assess a defect site if there's
• 5:38
  adhesance, if there's one defect, or h- how do we move in that direction?
• 5:44
  So that actually is the exact point that has been so difficult when it
• 5:51
  comes to alveolar ridge preservation, because people usually want to have
• 5:55
  a technique or one combination of our materials that should be used when it
• 6:00
  comes to alveolar ridge preservation.
• 6:02
  But-
• 6:02
  You mean one size fits all or-
• 6:03
  One size fits all.
• 6:04
  Oh.
• 6:05
  Exactly.
• 6:05
  Once it's we're doing this combination of this bone grafting with this
• 6:10
  membrane, this is alveolar ridge preservation, but that's not how it works.
• 6:14
  Exactly how you mentioned, what we need to do is that we
• 6:18
  need to start with a diagnosis.
• 6:20
  Like in any aspect of the medical field, before you do any sort of
• 6:25
  treatment or intervention, you first need to have a diagnosis.
• 6:28
  So we haven't really done that so far.
• 6:30
  We haven't really started to diagnose our sockets, and we need
• 6:35
  to start to diagnose our sockets.
• 6:37
  How do we do that?
• 6:38
  We look at the buccal bone.
• 6:40
  We need to start to look at the buccal bone, especially the
• 6:45
  thickness of our buccal bone.
• 6:47
  I
• 6:48
  don't wanna cut you.
• 6:48
  You're saying before we even touch the patient, we can assess it, or after
• 6:53
  extraction, then you make that assessment?
• 6:56
  You can also do it beforehand.
• 6:58
  So the a- the ways that you can diagnose your socket is
• 7:01
  through a CBCT analysis, okay?
• 7:04
  And additionally, at the time of extraction, additionally,
• 7:07
  you need to confirm it, right?
• 7:09
  I see.
• 7:09
  Because we cannot 100% rely on our CBCT, but exactly, a diagnosis that
• 7:14
  should be performed through our CBCTs and additionally clinically-
• 7:19
  confirmed.
• 7:20
  Now it's clear.
• 7:21
  Okay.
• 7:21
  With our periodontal probe.
• 7:23
  So what do you want to actually look at?
• 7:25
  Okay.
• 7:25
  The buccal
• 7:26
  bone.
• 7:26
  The
• 7:26
  buccal bone.
• 7:27
  So the buccal bone can be, I always say the bone morphology can be two aspects.
• 7:33
  One is the buccal bone thickness, and the other aspect is the
• 7:37
  presence or, on the other hand, the absence of our buccal plate, okay?
• 7:43
  So 90% of our sockets in the anterior maxilla, okay, are or do have less
• 7:51
  than, one millimeter of buccal bone thickness The biggest predictor
• 7:57
  that we have for bone volume changes after tooth extraction is what?
• 8:02
  Buccal bone thickness.
• 8:03
  Buccal bone.
• 8:05
  Okay?
• 8:05
  The thickness.
• 8:07
  So the thickness is actually dictating what type of combination
• 8:12
  or the, that we actually first of all need or are in need of the support
• 8:18
  of alveolar ridge preservation.
• 8:20
  In the classification that we published, okay, that is exactly describing this
• 8:25
  type of techniques, there is this differentiation between diagnosing your
• 8:30
  socket, checking if it has a thickness of more or less or more than one millimeter,
• 8:36
  and then next, if it has a dehiscence, and then the extent of the dehiscence
• 8:42
  or the presence of a fenestration.
• 8:45
  And then you can start one by one to see, do I need a bone
• 8:50
  grafting with a sealing agent?
• 8:52
  Do I need a collagen membrane?
• 8:54
  Do I need a non-resorbable membrane?
• 8:57
  And then we start to speak more about specifics on how we can
• 9:00
  actually treat the sockets.
• 9:02
  Can we, in a nutshell, do a small elaboration how you…
• 9:05
  Let, let's assume- Yes … I walk into your office.
• 9:08
  Yes.
• 9:09
  I don't know if we're gonna be able to picture all three pillars
• 9:11
  as you… Three pillars you said?
• 9:14
  Yes.
• 9:14
  Okay.
• 9:15
  All three pillars, but let, I walk into your office.
• 9:17
  I have an indication for extraction.
• 9:18
  First we
• 9:18
  have a coffee.
• 9:19
  First you walk into my office, where we have a coffee.
• 9:22
  Then, okay.
• 9:24
  then you come with the bad news.
• 9:26
  Then I come with the bad news.
• 9:27
  First I'm gonna make you feel comfortable, Exactly.
• 9:32
  Let's assume you make a diagnosis, and I have this, you say, like one
• 9:41
  millimeter, you assess one millimeter of buccal plate with certain recession
• 9:49
  Change of phenotype, let's assume.
• 9:53
  walk me through your-
• 9:55
  Sure
• 9:55
  … process there.
• 9:56
  So basically, we have these three pillars, and I will make it long
• 10:00
  story short a bit, as much as I can.
• 10:02
  Yeah.
• 10:03
  If we have a thick buccal bone, if we only place a collagen that is actually
• 10:08
  helping us in our homeostasis, we do have a four-wall defect that has a
• 10:13
  very strong osteogenic potential, where we know that it's not as necessary to
• 10:19
  actually have alveolar ridge preservation.
• 10:21
  It's always better, but it's not so crucial.
• 10:24
  The moment-
• 10:24
  How thick is a thick?
• 10:25
  Thick, one millimeter.
• 10:26
  One?
• 10:26
  Yes.
• 10:27
  One plus?
• 10:27
  Yes, one plus, exactly.
• 10:29
  That's our cutoff point.
• 10:30
  That's the borderline.
• 10:32
  The moment it is less than one millimeter, we know that there's huge benefits,
• 10:36
  and actually it is almost necessary.
• 10:38
  It is indicated, and as I told you before, 90% of the cases in the
• 10:43
  anterior maxilla have less than one.
• 10:46
  Yeah.
• 10:46
  Okay?
• 10:46
  So in 50%, less than 0.5.
• 10:50
  So basically it means most of the time we need to do it, okay?
• 10:55
  No questions asked.
• 10:57
  Then if we just have a thin buccal bone without any dehiscence, we place a bone
• 11:04
  substitute material with a sealing agent.
• 11:07
  That can be a collagen or it can be a socket seal, which
• 11:10
  can be soft tissue, okay?
• 11:12
  To avoid any sort of soft tissue collapse.
• 11:15
  Then in the next pillar, it can be a fenestration on the apical aspect,
• 11:19
  which we most see in endodontic lesions.
• 11:22
  Or we have an initial dehiscence, so a third of our buccal plate is missing.
• 11:28
  There we can use a combination of a bone substitute with a collagen membrane, so
• 11:33
  the called, ice cream cone technique.
• 11:35
  Cross-linked membrane ideally, that is covering our defect and
• 11:39
  is placed inside our socket.
• 11:41
  Then if we start to have less presence, so more than one-third
• 11:47
  are missing of our buccal bone, we switch to non-resorbable membranes.
• 11:52
  And I want to emphasize here that we never have to perform any sort of primary
• 11:59
  closure Which is really confusing.
• 12:02
  And the moment I start to talk about non-resorbable membranes,
• 12:05
  everybody starts to panic.
• 12:07
  I don't like to use non-resorbable membranes.
• 12:09
  The risk of infection is higher.
• 12:12
  You have to remove
• 12:12
  it.
• 12:12
  I don't know, you have to remove it, you have to all this.
• 12:14
  And I always say, "This is a different regenerative process."
• 12:18
  Okay?
• 12:19
  Here we can use a non-resorbable membrane, okay?
• 12:22
  Because we actually don't, we're not performing guided bone regeneration.
• 12:27
  So with this non-resorbable membrane in this type of defects, we're actually
• 12:31
  tunneling this membrane on the buccal and the lingual aspect in combination
• 12:35
  with the bone grafting material.
• 12:36
  And only if we have more than two-thirds of our buccal bone
• 12:41
  missing, we actually elevate the flap-
• 12:44
  again, use a non-resorbable membrane to specifically locate it around our
• 12:49
  defect on an apical extent, making sure it's covering our bone in a combination
• 12:54
  with a bone grafting material, and close the site without any primary closure,
• 13:01
  even though we have performed a flap.
• 13:03
  All right.
• 13:06
  Okay.
• 13:07
  Why not closing that?
• 13:09
  So the biggest misunderstanding when it comes to biology of alveolar ridge
• 13:15
  preservation is that we're not dealing with a guided bone regeneration or
• 13:19
  a regeneration of an atrophic ridge.
• 13:24
  If I now go into my office or you come into my office, right?
• 13:29
  And you have a defect.
• 13:31
  You tell me, "Listen, I lost this tooth three years ago, and I have
• 13:35
  now a resorption of my ridge, and I want to regenerate this bone." I
• 13:40
  know as a clinician that I need to respect certain principles, okay?
• 13:44
  Principles of primary closure-
• 13:46
  angiogenesis- the stability of my bone graft, space maintenance, because if
• 13:52
  I just place bone graft there and I do absolutely nothing, I don't close it, I
• 13:55
  don't stabilize it, I will not find bone.
• 13:59
  Now, what happens in an extraction socket?
• 14:01
  I take out a tooth, and I would do absolutely nothing.
• 14:04
  What would I find?
• 14:05
  Bone.
• 14:06
  Bone.
• 14:08
  Why?
• 14:08
  Because it's, a physiological, genetical different, process that
• 14:15
  we're having after tooth extraction.
• 14:18
  This is triggered through the loss of our bundle bone and so on and so
• 14:22
  forth, so our body is not having this reaction because it's not that w-
• 14:29
  it doesn't want to regenerate- Yeah
• 14:30
  like we're doing in guided bone regeneration.
• 14:32
  Your body wants to bring that back, that bone, because genetically
• 14:37
  it's triggered that way.
• 14:38
  So actually, the non-resorbable membrane is not treated the same way.
• 14:43
  It's not actually being pushed away from our body.
• 14:47
  The only thing that we need to do when we're using non-resorbable
• 14:50
  membranes, like you said, we need to remove it after six weeks.
• 14:53
  Yeah.
• 14:54
  But the space maintaining,
• 14:57
  value that we have from it, you still have it.
• 15:00
  You just don't need to close it with primary closure.
• 15:03
  And this is why I always say this is the best time of intervention,
• 15:07
  and we're not moving our tissues.
• 15:09
  We're not actually manipulating our tissues back and forth and back and forth.
• 15:14
  Yeah.
• 15:14
  it's a dream.
• 15:16
  So there will be sites that as much as you would like to try, even you
• 15:21
  make some releasing incisions or horizontal s- s- releasing- approach,
• 15:27
  it will be, even if you want, very hard to, get primary- Yes … closure.
• 15:31
  A few others, however, c- can be quite easier.
• 15:35
  What you're saying about n-
• 15:39
  It's not necessary or it plays against you?
• 15:42
  So- Plays against you.
• 15:43
  Oh.
• 15:43
  Oh, it does play against you.
• 15:45
  No, it does, not play against you in terms of the regenerative process.
• 15:48
  Okay.
• 15:49
  It plays against you in the, with the goal of having an
• 15:54
  aesthetic outcome in the future.
• 15:57
  Because it is not necessary, so if you're performing it, it means that you're
• 16:03
  moving your tissues, you're damaging your tissues, you're compromising
• 16:07
  your blood supply, where you never in the first place had to do it.
• 16:11
  Yeah.
• 16:12
  So I'm always saying that, I always make this joke.
• 16:17
  In residency, you, can do a primary closure of your socket.
• 16:20
  Why?
• 16:22
  Because you want to do a lot of surgeries.
• 16:23
  So at the time of recovery, you tell, "I need to have, do a free gingival graft
• 16:27
  because I moved my tissues." Yeah, So you gained, and it is, it's a bad joke.
• 16:33
  It's a bad joke.
• 16:34
  It's a very bad joke.
• 16:35
  You create the problem, sorry.
• 16:35
  You create the problem.
• 16:36
  That's exactly what I'm say- You got it.
• 16:38
  You're creating a problem because you as a student say, "I gain a
• 16:42
  surgery that I can practice." Yeah.
• 16:44
  It's awful to say- Yeah … but this is how I put it.
• 16:45
  Got the voucher.
• 16:46
  But if I see this, somebody doing this, not knowing that it was not
• 16:52
  necessary, I say, "What are you doing?"
• 16:55
  Because putting here in the front on a high smile line case now a free
• 17:00
  gingival graft where it was not needed-
• 17:04
  Yeah
• 17:04
  … yeah.
• 17:06
  Yeah, it, it- Then I say, "I think you created here a problem-
• 17:08
  Yeah
• 17:09
  … that can be s- very severe-
• 17:11
  Yeah
• 17:11
  … aesthetically speaking." So it is not working for you
• 17:16
  because it is not necessary.
• 17:18
  That's-
• 17:19
  I like how you, you describe, and thank you for that.
• 17:22
  One thing that is still, for me is that we live a golden age in bone
• 17:27
  substitutes and biomaterial, right?
• 17:29
  We have sources of vast.
• 17:33
  And when we talk about long-term resorbing or, when we are approaching the alveolar
• 17:39
  ridge preservation, or even at some point, if we manage to get to that
• 17:44
  gap management with immediate implant placement, we're talking about what kind
• 17:48
  of bone substitute ideally can we combine?
• 17:52
  There will be countries where certain sources are not necessarily
• 17:56
  quite seen as ideal for whatever reason, religious sometimes.
• 18:00
  How do we bridge that keeping the standard of care?
• 18:04
  I was very, lucky in this sense because I lived in so many different
• 18:10
  continents, and I did realize always one thing, that you have the a bit
• 18:16
  of like a, a availability bias, okay?
• 18:19
  Meaning what?
• 18:20
  Meaning I know what to do with w- with what I have available.
• 18:25
  Or I will give you an answer with what I know that is available around
• 18:30
  me So it's always an answer of what is the ideal and what can I do?
• 18:38
  So usually when I give courses, people come to me exactly like you said, and they
• 18:41
  say, "But I don't have this available."
• 18:44
  Now, the answer that I will give you is the ideal answer, okay?
• 18:47
  Ideally, if you have everything available It should always be a combination.
• 18:55
  Okay?
• 18:55
  A combination of your bone grafting material.
• 18:57
  Why?
• 18:59
  Because you want to use the best characteristic of each of these
• 19:04
  type of bone grafting materials for your regenerative processes, okay?
• 19:09
  What I mean is that you should ideally use an allograft in
• 19:12
  combination with a xenograft, okay?
• 19:14
  Because you want to combine the osteoinductive properties that help you
• 19:18
  with the cell differentiation and the osteoconductive properties that help
• 19:23
  you with the volume stability over time.
• 19:26
  Because on the one hand, you want to have good mineralized bone, but on the other
• 19:31
  hand, you don't want it to get resorbed.
• 19:32
  Yeah.
• 19:33
  And you want it not to get resorbed one year after implant placement or two years.
• 19:37
  You want it to stay 10 years-
• 19:39
  Going every-
• 19:40
  … 15 years.
• 19:41
  Yeah.
• 19:41
  You,
• 19:41
  go against- You want it to stay … 12 year.
• 19:43
  Yeah, exactly.
• 19:45
  so I think that ideally, always there should be a combination when talking
• 19:51
  specifically about socket management.
• 19:54
  Now, obviously, we can go into a lot of discussions.
• 19:57
  What happens if I do… This is why people, misunderstand sometimes, "Oh, this
• 20:03
  clinician said I'm using 50/50." Okay?
• 20:06
  No, I'm using 50/50 in this clinical scenario.
• 20:10
  Okay?
• 20:10
  So when talking about socket preservation-
• 20:13
  Yep
• 20:14
  … you can go, if you have a four-wall defect with a thin buccal bone,
• 20:18
  you can even increase the amount a bit of an allograft, okay?
• 20:24
  But you should always have the addition of a xenograft.
• 20:27
  The more you go outside the envelope of bone, the more you should increase the
• 20:32
  amount of a xenograft, so of the volume stable material, because it is necessary.
• 20:37
  So that's is very important.
• 20:39
  The thing that's very important is we're in ridge preservation, we're not in
• 20:43
  guided bone reser- regeneration, we're not talking about vertical bone augmentation,
• 20:47
  we're not talking about horizontal.
• 20:49
  We're, specifically in one branch of alveolar ridge preservation, and
• 20:54
  there the ideal is a combination of an allograft and a xenograft.
• 20:58
  I like how you describe because for every choice comes with a compromise, right?
• 21:03
  And then if you're saying ideally a little bit of this, a little bit of that,
• 21:07
  now the bit of that could potentially come with a faster resorption, right?
• 21:11
  And you mitigate-
• 21:13
  Exactly
• 21:13
  … you jiggle that ball in a way that you will…
• 21:16
  Exactly.
• 21:17
  It's funny because it, it's, you always want a bit of everything, right?
• 21:22
  Yeah.
• 21:22
  Yeah, In life- yeah … in generally, So when people ask me, I say, "A
• 21:26
  bit of everything," and they were like, "Yeah, no, Larissa, you cannot
• 21:29
  always have a bit of everything."
• 21:30
  And I said, "No, but ideally speaking-" Okay?
• 21:34
  If you want to provide the best treatment outcome- … this is
• 21:38
  what I would recommend to do.
• 21:40
  a bit of everything is not too much to ask.
• 21:42
  Too, too-
• 21:43
  Too
• 21:43
  much of everything … too much of everything
• 21:45
  it's… Too much of a bit of everything is too much to ask.
• 21:48
  Exactly.
• 21:48
  That's true.
• 21:50
  Larissa, I would like to shift gears a bit.
• 21:51
  We discussed this at the beginning.
• 21:53
  We have this section called it's not what we think, it's what we know.
• 21:59
  And evidence matters more than anything.
• 22:01
  That's how implantology was shaped, because we had pioneers trying and doing
• 22:05
  many things before us, and now we can use as a basal source to maybe also disagree
• 22:12
  with that and go in a different direction.
• 22:14
  But for you, was there any piece of evidence that it was a a- aha moment
• 22:19
  for you that you said, "Wow, I, thank you for whoever did that, that opened my
• 22:25
  eyes to something I never thought about, or literally made me change or reca-
• 22:29
  repath my journey to what I do now"?
• 22:32
  Can you think of one off the top of your head, or…?
• 22:36
  So specifically when talking about socket management, I think for me, a one
• 22:40
  eye-opening, piece of research, I would say, was when I was reading about, the
• 22:48
  publication of Chapuis that showed that in thin phenotype or patients that have
• 22:54
  a thin buccal bone, we have almost a seven times increase of our soft tissues.
• 23:02
  Okay?
• 23:02
  So every time we face a patient that has this type of thin
• 23:06
  pheno- a thin buccal bone-
• 23:08
  Yep
• 23:09
  … this is being replaced, right?
• 23:12
  By a amount that is se- seven times greater of soft tissue.
• 23:18
  Now, I'm a periodontist, okay?
• 23:21
  So I do a lot of soft tissue management, a lot of soft tissue
• 23:25
  grafting, and we always talk about adding a soft tissue graft, right?
• 23:30
  Yeah.
• 23:30
  And we talk about adding soft tissue grafts because we want to gain thickness.
• 23:36
  So this piece of evidence is that evidence that really showed me
• 23:40
  or made me understand, first, how significant the thickness of the buccal
• 23:45
  bone is, and secondary, that if we just understanding in our heads the
• 23:53
  biological changes, we can play with them and we can work with them, okay?
• 23:59
  Because like I told you, not always doing more means you're doing
• 24:03
  better, but understanding more, learning more will make you better.
• 24:09
  So that's what research should be doing in the first place.
• 24:12
  So it showed me, Larissa, you don't need to graft.
• 24:16
  You know that if there is a seven times increase, and I place my implant in the
• 24:21
  correct prosthetic position, cingulum position, and I start with a thin
• 24:25
  phenotype patient, I'm, I may end up with a thick phenotype without any grafting
• 24:31
  or nothing just by having understood I need to preserve, then I need to mold my
• 24:36
  tissues, I need to work with my prosthetic design, I need to place it in the correct
• 24:40
  position, and I will have my thickness.
• 24:43
  So that changed completely my thinking, and it had a very
• 24:45
  big influence in my approach.
• 24:48
  Oh, a- and how did you do before?
• 24:50
  And how did I do before?
• 24:53
  I did… Before I believed, let's put it this way, it's not that
• 24:57
  I changed necessarily something.
• 24:59
  I believed that I need to do much, much more intervention in order to
• 25:04
  have the peri-implant phenotype.
• 25:07
  Peri-implant phenotype meaning I want two millimeter of buccal bone thickness,
• 25:10
  two millimeter of mucosal thickness, two millimeter of keratinized tissue, right?
• 25:16
  I, was thinking me as a surgeon- Yeah … as a clinician, I need to create it.
• 25:21
  And then I started to understand, no, it will be there.
• 25:24
  You just need to mold it into the direction of getting there.
• 25:28
  It's win-win.
• 25:29
  It's win-win, and so that was a- Mind changer
• 25:34
  Aha
• 25:35
  Mind-blowing.
• 25:36
  Aha moment.
• 25:36
  Aha moment.
• 25:37
  Not always more is better.
• 25:39
  Again.
• 25:41
  Thickness matter, but not- Yeah.
• 25:45
  Let me say, now this one point, you come, it's notorious, you come with this amazing
• 25:52
  backpack of, knowledge and experience behind through our education, your work.
• 25:57
  You mentioned you work with your father at some point.
• 25:59
  This is great, and I'm sure, like everybody else, we have some case
• 26:05
  in our heads that we think, I wish I knew then what I know now," or
• 26:09
  I had the tools or the, all the elements that I have at hand now-
• 26:13
  that I didn't have then.
• 26:14
  And I remember that one case that I would have approached
• 26:17
  from a complete different angle.
• 26:19
  Do you remember what that was, and was, what was the lesson behind
• 26:23
  and now you take it forward?
• 26:27
  talking about this topic, I would definitely say it's not
• 26:30
  comboi- combining my bone grafting material, and I explain to you why.
• 26:35
  In my residency, I did my residency in the United States, and, it is
• 26:42
  funny because in the United States, everything is about using allografts.
• 26:46
  Yeah.
• 26:47
  Allografts, allografts- Very allograft … allografts, okay?
• 26:49
  Every time you mention the use of a xenograft, they're like-
• 26:53
  They get
• 26:53
  itchy … "I'm not, ah, no, it's not good.
• 26:55
  We should not use it." Then you come to Europe, where I'm from Europe, okay?
• 27:00
  And here we didn't have allografts for a long period of time.
• 27:04
  So obviously it was always, xenograft, xenograft, So I went to the US, and
• 27:12
  I started with ridge preservation.
• 27:15
  And ridge preservation is such a procedure that in the beginning, as a resident,
• 27:20
  you start to do ridge preservation.
• 27:22
  So your early procedures are a lot extract the tooth, get to know the
• 27:25
  bone grafting materials, you pl- place the bone grafting materials.
• 27:28
  So some of these patients, I, they were maybe not compliant.
• 27:33
  They didn't show up exactly four months after.
• 27:36
  they came back one year later.
• 27:38
  And so I performed, alveolar ridge preservation, and they came
• 27:42
  back, and I had to regraft at the time of implant placement.
• 27:46
  Basically, it really resorbed in some of these cases.
• 27:51
  And then I started to read, I started to learn more, and by the end of my
• 27:56
  residency, I started to incorporate, also because I'm European, but also because of
• 28:03
  what I learned along the way, to y- really incorporate that xenograft, component.
• 28:09
  And the patients came back, and I had a beautiful- Ridge
• 28:15
  And obviously if I would go back, that's what I would not do, right?
• 28:20
  And I did a lot of cases where I knew basically I did grafting and actually
• 28:26
  I didn't get the outcome that I wanted.
• 28:30
  lessons learned, use your biomaterials wisely.
• 28:34
  Okay.
• 28:35
  I like that very much I'm with you 100%.
• 28:39
  I feel really sorry for clinicians that they know at some point this patient
• 28:46
  will have to receive a, a, a tooth replacement for a site, and an extraction
• 28:52
  is randomly done without thinking of the sequence of events that will come after.
• 28:57
  And it's… Alveolar ridge preservation has this amazing and huge social-
• 29:04
  impact on a population.
• 29:06
  I wish public services will always have that as default route when
• 29:11
  something's extracted, even if they don't any, don't do any matrix of
• 29:15
  the defects, but try to preserve it.
• 29:18
  There's noth- there's nothing to lose, Valerie.
• 29:20
  Yes.
• 29:21
  And then this patient, when it comes to the time of implantation,
• 29:26
  it will be in a much more favored position, much m- less invasive, less
• 29:32
  costly, either for whoever is, is government sponsored or out of pocket.
• 29:39
  I don't see any downside.
• 29:40
  Yeah.
• 29:42
  the, the problem is, from a practical mindset.
• 29:47
  working a lot in private practice, let's face it, it's a, it's often
• 29:52
  a financial decision, right?
• 29:54
  We're always trying to maximize our finances, okay?
• 29:57
  Yeah.
• 29:58
  And it's, one thing that I always, when I talk to clinicians, I say,
• 30:05
  "Listen, you want the best outcome for your patient, but I also
• 30:08
  understand your reality," right?
• 30:11
  because I'm not… I'm educating a lot of clinicians.
• 30:14
  I'm not only educating my patients, right?
• 30:16
  I'm educating a lot of clinicians.
• 30:18
  So I'm always saying, "I'm with you. I understand that you want to do it,
• 30:22
  but let me explain to you how the, use of a bone grafting material at the
• 30:29
  time of extraction will, first of all, avoid you from possibly needing to
• 30:36
  regraft at a later time point, A," okay?
• 30:38
  So you used it.
• 30:39
  You don't have to use it again.
• 30:41
  Sometimes you need to regraft, okay?
• 30:44
  But the amount will be together with your implant placement, so it will be less.
• 30:50
  It doesn't require advanced grafting from you, okay?
• 30:53
  Yeah.
• 30:53
  That can lead to a sacrifice of the aesthetic outcome- Yeah … or
• 30:57
  even functional outcome.
• 31:00
  Second, I say, I am sure that if you explain to your patient the
• 31:05
  benefits also of using a bone grafting material, obviously it is
• 31:11
  something that is gonna be covered, partially from the patient because
• 31:15
  it's a bone regenerative procedure.
• 31:17
  And if you explain anybody the benefits of it, right?
• 31:21
  Of you want to have an implant, you need bone.
• 31:24
  Yeah.
• 31:25
  The best time for me to do it is right now.
• 31:27
  I think that most people would agree.
• 31:30
  Yeah.
• 31:30
  They just don't know, and you think to yourself, "You know what?
• 31:34
  It will heal anyways." And that's the biggest mistake because the moment that
• 31:39
  you have this conversation, it should be from the beginning a conversation
• 31:42
  with our patients that we tell them, "Listen, we have this chance to do it.
• 31:46
  Do you want to do it?" And I guarantee you that most of the
• 31:50
  patients will answer, "Yes, doctor.
• 31:52
  Yes, of course."
• 31:53
  Yeah.
• 31:53
  " If that's what I need, if I need bone and we can place bone, of
• 31:56
  course let's do it now." So the cost-effectiveness is not really
• 32:00
  something that should play such a role.
• 32:02
  And I, in my opinion, that's the only reason that I'm seeing why we
• 32:06
  should not be performing it- Yeah
• 32:07
  at time of extraction, right?
• 32:09
  So yeah.
• 32:12
  Larissa, this was a delightful conversation.
• 32:16
  I would encourage everybody who is watching us today that has an opportunity
• 32:21
  to be somewhere where your courses are taking place, where they can find you?
• 32:26
  they can find me… Nowadays it's not difficult to find people.
• 32:30
  That's the good thing.
• 32:31
  If you know my name, you, on, on one platform, on one
• 32:36
  metaverse- … you will find me.
• 32:39
  Okay?
• 32:40
  they can find me online on our website of the Steigmann Institute where I'm,
• 32:45
  lecturing together with my father, and we're educating all around the world.
• 32:50
  We're having different modules on periodontology and implantology,
• 32:54
  everything about regeneration from beginning till the end.
• 32:59
  we're really around the world, giving these modules, giving these courses.
• 33:03
  and then obviously any sort of speaking engagement, social media,
• 33:10
  website.
• 33:12
  just, I think at this point, you know at this point, if you just
• 33:16
  leave your phone close by, right?
• 33:19
  And you just mention the name-
• 33:21
  somehow it will end up in your feed.
• 33:23
  That's where we're at.
• 33:25
  So to find people nowadays, I don't think it's really the problem.
• 33:29
  It w- it will come to you if you have the interest to learn, to get better, to
• 33:33
  have more clinical, understanding- Yeah … as well as experience and training.
• 33:40
  it's my passion.
• 33:40
  So- Educating
• 33:42
  is my passion … D41 Steigmann Institute.
• 33:44
  Yes.
• 33:45
  Social media, we're gonna leave then the link in the description of the video, and
• 33:49
  then everywhere else where you can find
• 33:51
  Larissa.
• 33:51
  Everywhere else where you can find me.
• 33:53
  Just come up with the question and I will guide you in what to do and
• 33:57
  where to find me and how I can help.
• 33:59
  Larissa, thank you very much.
• 34:00
  Thank you
• 34:02
  so much.
• 34:03
  It was a delightful talk.
• 34:03
  Thank you so much.
• 34:03
  And to all of you that watched this episode and think this content is going to
• 34:06
  be beneficial to a friend that had not had the opportunity to watch it, send it over.
• 34:11
  Sharing is caring.
• 34:13
  And until the next episode, stay tuned.
• 34:16
  Ciao.