Soft vs. Hard Tissue Grafting for Maxillary Incisor Defects: A Comparative Case Series on Implant Site Management

not-yet-known not-yet-known not-yet-known unknown Background Managing severe labial bone defects in the anterior maxilla poses significant challenges in implant dentistry. Both soft and hard tissue grafting techniques have been employed to enhance peri-implant tissue stability, but their comparative outcomes remain underexplored. Purpose This case series aims to evaluate the clinical outcomes of soft tissue grafting Soft vs. Hard Tissue Grafting for Maxillary Incisor Defects: A Comparative Case Series on Implant Site Management

Managing severe labial bone defects in the anterior maxilla poses significant challenges in implant dentistry. Both soft and hard tissue grafting techniques have been employed to enhance peri-implant tissue stability, but their comparative outcomes remain underexplored. not-yet-known not-yet-known not-yet-known unknown Purpose This case series aims to evaluate the clinical outcomes of soft tissue grafting and hard tissue grafting for managing severe labial bone defects in the maxillary central incisor region and to assess their implications for implant success and aesthetic rehabilitation. not-yet-known not-yet-known not-yet-known unknown Material and Methods Two patients with extensive labial bone defects in the anterior maxilla were treated using different augmentation approaches. In the first case, a 33-year-old female with a fractured maxillary left central incisor (#21) and significant labial bone loss was managed using a soft tissue graft from the palate and guided bone regeneration (GBR) with deproteinized bovine bone material. The second case involved a 27-year-old male with missing #21 and #22 and severe labial bone deficiency, which was treated with a mandibular symphysis block graft. Both cases underwent delayed implant placement following site augmentation, with final prosthetic rehabilitation using screw-retained prostheses.

The soft tissue grafting approach resulted in predictable soft tissue volume enhancement and successful implant osseointegration with favourable aesthetic outcomes. The hard tissue grafting case experienced graft exposure and partial resorption, necessitating additional healing time before implant placement. Despite this complication, CBCT analysis confirmed sufficient ridge dimensions, and implants were successfully placed with ridge expansion using osseodensification.

Both soft and hard tissue grafting techniques can be effective for managing severe labial bone defects; however, each approach presents unique benefits and challenges. Soft tissue grafting offers enhanced aesthetics and lower surgical morbidity, while hard tissue grafting remains essential for cases with significant bone deficiency. Proper case selection, meticulous surgical technique, and patient compliance play critical roles in optimizing clinical outcomes for anterior maxillary implant rehabilitation. Key Clinical Message: This case series highlights the importance of individualized treatment planning in managing anterior maxillary defects. Soft tissue grafting offers a minimally invasive, esthetic solution in cases with adequate bone, while autogenous block grafting remains essential for severe bone loss, despite a higher risk of complications. not-yet-known not-yet-known not-yet-known unknown Introduction The anterior maxilla presents unique challenges in dental implantology due to its high aesthetic expectations and frequent occurrence of compromised hard and soft tissues. Long-term research has demonstrated that implant success largely depends on the quality of peri-implant soft and hard tissues.1 Therefore, ensuring adequate soft tissue and bone volume is critical for successful implant placement.2 Achieving an optimal aesthetic outcome requires restoring the natural volume, colour, and shape of healthy supra-implant gingiva. The contour of the soft tissue overlying an implant is significantly influenced by the surrounding bone, soft tissue characteristics, and the design of the implant restorations.3 Labial bone defects, often resulting from trauma or infection, can further complicate implant placement and may require advanced grafting techniques to restore proper ridge dimensions. Severe defects typically necessitate either soft tissue grafting to enhance mucosal thickness and aesthetics or hard tissue grafting to augment bone volume.4 The extent of the bone defect determines whether bone augmentation procedures can be performed concurrently with implant placement or require a separate procedure.5 Autologous bone offers a unique combination of osteoconductive, osteoinductive, and osteogenic properties, making it superior to other bone substitutes.6 Due to its biological properties and the lack of immunological reactions, autologous bone grafts are regarded as the ”gold standard” for bone regeneration procedures.7 Membranous bone grafts, such as those from the mandibular symphysis and ramus, exhibit lower resorption rates and faster, more effective revascularization compared to endochondral bone grafts, like those from the iliac crest and tibial.8,9 A facial bone thickness of at least 2 mm has been recommended to preserve marginal bone levels around implants over time. Crestal bone loss and primary implant stability are considered critical factors for implant success, while the role of peri-implant soft tissues has often been overlooked.10-12 Recent evidence indicates that peri-implant soft tissues play a crucial role in maintaining peri-implant health.13 Recent long-term clinical studies have demonstrated stable and healthy peri-implant soft tissues after 7 and 12 years, even in cases where buccal bone was absent at implant sites.14,15 In this case series, two patients with severe labial bone defects underwent different treatment approaches. The first case involved a female patient with a fractured tooth #21 and significant labial bone loss, who was treated with soft tissue grafting from the palate. The second case featured a male patient missing teeth #21 and #22, with exposed root tips extending to the apex, who received hard tissue grafting using chin bone. The soft tissue graft case showed predictable healing and successful implant placement, whereas the hard tissue graft case experienced graft exposure and failure, necessitating removal and subsequent healing before final implant placement. These cases highlight the complexities of treating large labial defects and underscore the importance of clinical decision-making and surgical techniques in achieving successful outcomes. Case Report 1: A 33 year old female patient visited our department seeking replacement for her dislodged artificial crown. On clinical examination, her maxillary left central incisor was fractured vertically with a severe soft and hard tissue defect extending up to the root apex (Figure 1A). The clinical crown parts were carious. CBCT report revealed through and through vertical fracture with root fragments drifted about 2 to 4 mm apart and a radiolucency of around 1x1cm was seen extending between the drifted root fragments in apical third region (Figure 1B). Patient gave history of endodontic treatment of the tooth followed by root post and crown which was dislodged few times. CBCT showed about complete loss of labial bone with only 1-2 mm palatal plate shell remaining till the apex of the root and about 6x7 mm alveolar bone apical to the root apex. After discussing possible treatment options, bone augmentation from chin site followed by delayed implant placement. But the patient rejected it citing the added surgical procedure and possible chin aesthetic impairment associated with chin bone harvesting. Then it was decided that the incisor to be extracted followed bone augmentation procedure by artificial bone graft, soft tissue augmentation from palate and delayed implant placement. A signed informed consent was obtained from the patient. All surgical and prosthetic procedures were performed with strict aseptic conditions by the same team. The first surgical phase was performed under local anaesthesia after prophylactic dose of 1gm of amoxycillin 1 hour before. The root fragments were extracted, and the sockets and periapical lesion was debrided thoroughly (Figure 2A). The soft tissue apical and lateral to socket was released and advanced by scoring the periosteum so that tension free closure could be achieved. The socket was filled with deproteinized bovine bone material (DBBM) (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland). The graft was covered with a resorbable barrier membrane (Bio-Guide; Geistlich Pharma AG, Wolhusen, Switzerland) to maintain the volume of the extraction socket well and facilitate implant placement (Figure 2B). 16,17 At the 45-day follow-up, the implant site was evaluated, revealing a soft tissue defect. The defect was measured using a periodontal probe to determine the dimensions required for harvesting a soft tissue graft from the palate (Figure 3A). The second surgical phase was performed under local anaesthesia, involving the elevation of a full thickness mucoperiosteal flap to expose the future implant site. A connective tissue graft (CTG) measuring approximately 9 × 6 mm was harvested from the right posterolateral palate (Figures 3B & 3C). The CTG was tunnelled into a pouch created with a microblade between the keratinized mucosa and the labial bone. Interrupted sutures were placed at the mesial and distal aspects of the sockets to stabilize the CTG in position (Figure 3D). A new CBCT was taken after 45 days of CTG soft tissue volume build-up (Figure 4A). Clinical examination at this time revealed excellent soft tissue volume (Figure 4B). CBCT revealed alveolar bone dimensions of 3.7x12mm. At this third surgical phase, a conservative mucoperiosteal flap was raised and osteotomy was performed using the osseodensification protocol with Densah ® burs (Versah ® LLC, MI, USA) to achieve ridge expansion. Osstem TS III SA 3.0 (Osstem Implant Co., Seoul, Korea) implant of 3x10mm was inserted with a torque of 35Ncm and cover screw was placed (Figure 4C). The flap was approximated and interrupted sutures were given. Stage II surgery was done after 3 months, and healing abutment was placed. Prosthetic phase was performed by using a closed tray impression technique and a cement retained PFM prosthesis was fabricated and cemented using implant luting cement (Premier Implant Cement, Premier Dental Products, PA, USA) (Figure 4D). Case Report 2: A 27 year old male patient visited the dept of Prosthodontics and Implantology with a chief complaint of missing tooth due to trauma few months back. On clinical examination, left central incisor was missing with a healed socket and lateral incisor was drifted distally with entire root exposed (Figure 5A). CBCT report showed about 5x15mm alveolar bone with labial concavity with 21 and very thin shell of only palatal plate remaining with a large periapical radiolucency with 22 (Figure 5B). After discussing possible treatment options, it was decided to proceed with a bone augmentation procedure by means of intraoral autogenous bone harvested from the mandibular symphysis and delayed implant insertion. All surgical and prosthetic procedures were performed by the same team. A signed informed consent was obtained from the patient. The first surgical phase was performed under local anaesthesia after prophylactic dose of 1gm of amoxycillin 1 hour before. The lateral incisor was extracted as atraumatically as possible, and the socket and periapical lesion was debrided thoroughly. full thickness mucoperiosteal flap was reflected on either sides of the socket creating a Y shaped flap as there was no soft or hard tissue over the entire length of 22. The soft tissue apical and lateral to socket was released and advanced by scoring the periosteum so that tension free closure could be achieved (Figure 6A). The defect site of 22 was measured with periodontal probes for harvesting the chin block graft. A full thickness mucoperiosteal flap was elevated to expose the chin bone labial to mandibular central and lateral incisors after administering local anaesthesia. A monocortical chin block of approximately 7x5 was harvested from the donor site (Figure 6B) and secured vertically over the defect of 22 by the help of stainless-steel screws (Figure 6C). The recipient site was decorticated before securing the chin block graft. A deproteinized bovine bone material (DBBM) (Bio-Oss; Geistlich Pharma AG, Wolhusen, Switzerland) and a resorbable barrier membrane (Bio-Guide; Geistlich Pharma AG, Wolhusen, Switzerland) was used to cover the gaps around the graft. The flap was grooved apically and laterally to cover the recipient site with close approximation without tension using 2 vertical interrupted sutures to close the vertical flaps and horizontal flaps (Figure 6D). Donor site was sutured layer wise, and haemostasis was achieved. Patient was recalled after 1 month when one of the screw and inferior part of chin block graft appeared as exposed (Figure 7A). Patient was recalled for graft removal after 2 days, but the patient didn’t show till 5 months. After 6 months of phase 1 surgery came back. A CBCT was advised which showed that the chin block graft was integrated with the labial bone and only 1 screw was left. Site 21 showed bone dimensions of 4.5x11mm and 22 showed 2.71x13mm (Figure 7B). So it was decided to place the implants with ridge expansion. A conservative mucoperiosteal flap was raised and osteotomy was performed using the osseodensification protocol with Densah ® burs (Versah ® LLC, MI, USA) to achieve ridge expansion and 2 3.5x10mm Touareg-S (Adin Dental Implants Systems Ltd., Afula, Israel) were placed with about 35Ncm torque (Figure 7C). The flap was closed with interrupted sutures. Stage II surgery was performed to replace the cover screws with healing abutments. A closed tray impression was made to fabricated splinted screw retained PFM crowns. The crowns were secured with 10Ncm torque, access holes were sealed with PTFE and composite resin (Figure 7D).

The rehabilitation of severely defective labial bone in the maxillary central incisor region presents significant surgical and prosthetic challenges. Both soft and hard tissue grafting techniques play a crucial role in restoring aesthetics, function, and long-term implant stability. The present case series highlights the clinical decision-making involved in selecting the appropriate grafting approach and underscores the importance of meticulous surgical execution to optimize outcomes. Soft tissue augmentation has gained prominence in implantology due to its ability to enhance mucosal thickness, improve aesthetic outcomes, and reduce peri-implant bone loss. In the first case, a connective tissue graft (CTG) from the palate was utilized to improve the peri-implant soft tissue architecture. Studies have shown that soft tissue grafting contributes to enhanced peri-implant aesthetics, reducing the likelihood of recession and exposure of metal components, thereby improving patient satisfaction. 18 Additionally, a thick peri-implant mucosa acts as a protective barrier, reducing crestal bone loss and peri-implant inflammation. 19 In a systematic review, Linkevicius et al. (2015) concluded that implants placed in thick soft tissues exhibited less marginal bone loss compared to those with thinner biotypes. 20 The success of the soft tissue grafting in this case aligns with these findings, demonstrating excellent soft tissue volume and implant stability over time. In cases where significant hard tissue loss is present, as seen in the second case, bone augmentation becomes essential to provide adequate support for implant placement. Autogenous bone grafts, particularly those harvested from the mandibular symphysis, are considered the gold standard due to their osteogenic properties and high success rates. 21 However, donor site morbidity, graft resorption, and potential exposure remain concerns. In this case, graft exposure was observed after one month, which aligns with findings by Chiapasco et al. (2006), who reported that block graft exposure occurs in approximately 10-15% of cases, potentially leading to partial resorption and compromised outcomes. 22 Despite these challenges, CBCT analysis after six months revealed adequate bone volume for implant placement, demonstrating the effectiveness of ridge augmentation when properly managed. The choice between soft and hard tissue grafting should be tailored to each patient’s specific clinical condition and expectations. While soft tissue grafting offers a minimally invasive approach with favourable aesthetic results, it may not be sufficient in cases with severe bone loss. Conversely, hard tissue grafting provides the necessary volume for implant support but carries a higher risk of complications and increased surgical morbidity. 23 From a patient perspective, treatment acceptance often hinges on the invasiveness and recovery period associated with the procedures. In the first case, the patient declined additional chin bone harvesting due to concerns about aesthetics and postoperative discomfort. This highlights the importance of patient-centred decision-making, balancing optimal clinical outcomes with individual preferences. 24 not-yet-known not-yet-known not-yet-known unknown Conclusion Both soft and hard tissue grafting techniques have their respective indications, benefits, and limitations. Advances in biomaterials, such as growth factors (e.g., platelet-rich fibrin) and xenografts, may provide alternative solutions to minimize the need for autogenous bone harvesting while enhancing tissue regeneration. Future research should focus on refining surgical protocols, improving biomaterial properties, and assessing long-term clinical outcomes of different grafting techniques. Clinicians must continue to adopt an evidence-based approach, integrating patient preferences with sound surgical principles to achieve predictable implant success.

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Figure Legends: Figure 1A: Pre-treatment intraoral view showing a fractured and carious central incisor with a significant labial soft and hard tissue defectsFigure 1B: Preoperative CBCT scans showing the severity of labial plate defect in the maxillary central incisor regionFigure 2A: Full-thickness flap elevation revealing bone defect and granulation tissueFigure 2B: Post-suturing view after debridement, bone graft placement, and barrier membrane applicationFigure 3A: Future implant site assessment showing the measurement of the soft tissue defectFigure 3B: Connective tissue graft (CTG) of approximately 9x6 mm harvested from the right posterolateral palateFigure 3C: Prepared de-epithelialized connective tissue graft (CTG) ready for placementFigure 3D: Connective tissue graft stabilized with suturesFigure 4A: Measurement overlay on CBCT scans displaying bone gain following augmentationFigure 4B: Clinical view of enhanced soft tissue volume post-augmentationFigure 4C: Post-implant placement IOPA X rayFigure 4D: Post-prosthesis intraoral viewFigure 5A: Pre-treatment view of drifted maxillary lateral incisor with root exposure up to the apexFigure 5B: Pre-treatment CBCT showing a thin remaining palatal plate and a large periapical radiolucency associated with maxillary lateral incisorFigure 6A: Full thickness mucoperiosteal flap reflection showing large labial plate defectFigure 6B: Monocortical chin block harvested from the mandibular symphysis regionFigure 6C: Chin block secured with stainless steel screwsFigure 6D: Mucoperiosteal flap closure with tension free suturesFigure 7A: Exposed screw and inferior portion of the chin block graftFigure 7B: CBCT showing integration of the chin block graft with the labial plate and presence of a single remaining screwFigure 7C: Post-implant IOPA X rayFigure 7D: Post-prosthesis intraoral view Information & Authors Information Version history Copyright This work is licensed under a Non Exclusive No Reuse License. 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Authors Metrics & Citations Metrics Article Usage 358views 244downloads Citations Download citation Bipin Muley, Virvardhan Alias Shubham Rajveer Patil, Pratik Hande, et al. Soft vs. Hard Tissue Grafting for Maxillary Incisor Defects: A Comparative Case Series on Implant Site Management. Authorea. 23 May 2025. DOI: https://doi.org/10.22541/au.174798575.53927326/v1 DOI: https://doi.org/10.22541/au.174798575.53927326/v1 If you have the appropriate software installed, you can download article citation data to the citation manager of your choice. Simply select your manager software from the list below and click Download. For more information or tips please see 'Downloading to a citation manager' in the Help menu.