Bone Grafting…Whaaaaaat?

 

Everyday, we have patients that question the need for bone grafting.  So what is bone grafting and why is it necessary?  The main goal of bone grafting an extraction site, its to converse the architecture of the jaw bone and the soft-tissue aka “gums or gingiva” that covers it.  There are numerous studies that show, when a tooth is extracted without bone grafting there is an natural loss of the bone, leading to what we surgeons refers to as a “bony defect”.  As expected, when “the bone goes, so does the soft-tissue”, meaning that when the bone is lost, so is the soft-tissue that is supported by the underlying bone.  The bone loss and the subsequent change in the soft tissue can lead to a bony defect that can prevent a patient from replacing the missing tooth with an implant.  We typically see bony defects when the tooth is extracted without bone grafting, which is the reason why it is highly recommended to have bone grafting at the time of extraction in order to conserve as much bone as possible.  (DO NOT let anyone extract your toothin the esthetic zone without bone grafting).  Bone grafting will only help to support the over-lying soft-tissue and reduce the chance of have a bony defect.  The following case demonstrates this phenomenon.

This is a 32 years old gentleman that was referred to us for an emergency extraction of an infected tooth #7.

He had previously had facial trauma as a teenager, when lead to the “tooth dying”, meaning that the root canal or the internal portion of the tooth died – forcing the patient to have a root canal as a teenager.  Fast forward…two decades later, the root canal failed leading to a major infection in his jaw bone – See X-ray.

The endodontist attempted to retreat the root canal but in the process discovered that the root portion of the tooth was fractured and that it could not be saved.  Extraction was recommended.  We obtained a CBCT to see if there was any possibility of placing an “immediate implant”, which means extraction and a placement of an implant in the same visit.  Unfortunately, as you can see below, even with the longest 18mm implant there was not enough bone at the depth of the extraction site to obtain primary stability of the implant.

Hence we had to do this case in two separate surgeries / stages: Stage I. Extraction + bone grafting.  Stage II. Return 4-6 month later for guided implant placement using a surgical guide with a prefabricated temporary crown.

Prior to the extraction of the tooth we have the patient’s general dentist fabricate an “Essix” retainer, which is one of two types of retainer to replace missing teeth.  This retainer in particular is best since it is off the soft tissue and extraction site and does not apply pressure on the soft tissue.  This retainer is best for the immediate postop period as the soft tissue is healing which is about 6-8 weeks.  After the soft tissue is healed the patient can wear a traditional “Stay-plate”, which rests on the soft-tissue underneath.

Essix Retainer

Stay-plate:

Hence, we extracted the tooth atraumatically with periotomes, then performed a bone grafting procedure to prepare the site for eventual implant placement.  See the photos below

4 weeks later :

10 weeks later:

Now the site is ready for guided implant placement with a prefabricated temporary crown using the Anatomage surgical guide.  More to come on this case….stay tuned!