Bone grafting after tooth removal: Why, when, and what to use (2022)

Tooth extraction is a common practice in the United States, with a prevalence of roughly 50% of adults in the age range of 20–64 having at least one tooth extracted. 1 The normal pattern of bone healing following tooth extraction is resorptive, typically leaving both hard- and soft-tissue defects in the alveolus without site preservation and/or tissue grafting.2 This is problematic for various reasons. Loss of tissue structure in the jaw directly affects the functional and esthetic outcomes of dental implants as well as tooth-borne fixed prosthetics (dental bridges).

Why bone grafting?

Although unpredictable, a greater amount of alveolar ridge loss following extraction usually occurs in the horizontal dimension and affects the buccal bone of the ridge.3 In fact, 50% of alveolar bone dimension can be lost after tooth extraction, with losses reported of up to 6–7 mm (figure 1). Two-thirds of this loss of bone volume can occur within the first three months of tooth extraction.4

Loss of vertical ridge height can also occur and usually takes place along the buccal aspect of the ridge to a lesser degree than horizontal ridge loss.5 Corresponding reductions in vertical ridge height ranging from 2–4 mm have been noted.6 The combination of this resorptive pattern results in a ridge that has moved in a palatal/lingual direction and has atrophied vertically (figure 2).

These alveolar bone changes often compromise implant placement due to thin bone volume (figures 3–6).

Reduction in quantity and quality of bone can also compromise functional and esthetic outcomes of both implants and fixed bridge restorations (figures 7 and 8).

When to use bone grafting?

Because of this alveolar resorptive pattern after tooth extraction, bone grafting the extraction socket after tooth extraction procedures has become a solution that attempts to limit the amount of hard- and soft-tissue loss. There are many systematic reviews in the literature that compare the results of residual ridge dimension following tooth extraction after the use of a bone graft (with or without a membrane) versus extraction alone without grafting.7 Sockets that were preserved with bone grafting and/or membrane on average lost 2 mm less of ridge width, 1 mm less of ridge height, and had 20% more bone volume when compared to sockets that were not grafted.8 Maxillary sites lost more than mandibular sites, and most ridge resorption occurred on the buccal aspect of the ridge.

Indications for bone grafting extraction sites include:

site development to increase hard and soft tissue for pontic sites in fixed bridge prosthetics (figures 9–14);

(Video) LIVE SURGERY DENTAL EXTRACTION AND BONE GRAFT

rebuilding defects around adjacent teeth after extracting teeth due to periodontal disease (figures 15–17);

correcting bone defects impinging upon anatomical structures after tooth extraction, such as oroantral communication (figure 18); and

preserving tissue structure for subsequent dental implant therapy.

Decision matrix

With these indications in mind, does every extraction socket need to be grafted? The answer is no. A good decision matrix is based on “A Simplified Socket Classification and Repair Technique” by Elian et al.9

sfds

Classification when existing tooth is still present

Type 1 socket—Buccal plate present and soft tissue present

•Type 1a socket (figure 19)—Thick biotype, posterior tooth, and buccal plate present: no graft needed

•Type 1b socket (figure 20)—Thick biotype, anterior tooth, and buccal plate present: clot stabilizer

(Video) Post-Operative Guide to Tooth Extractions (With or Without Bone Grafting) | Dr. John W. Thousand IV

•Type 1c socket (figure 21)—Thin biotype, anterior or posterior, and buccal plate present: bone graft

Type 2 socket (figures 22 and 23)—Buccal plate missing, but soft tissue present: bone graft +/- membrane (if graft containment is needed)

Type 3 socket (figure 24)—Buccal plate missing and soft tissue missing: bone graft + membrane +/- biologic agent (consider soft-tissue graft if keratinized tissue is less than 2 mm)

What bone grafting product?

Although there are many types of grafting products commercially available, choosing the right one may be difficult. An ideal bone graft substitute should be biomechanically stable; able to degrade within an appropriate time frame; exhibit osteoconductive, osteogenic, and osteoinductive properties; and provide a favorable environment for invading blood vessels and bone-forming cells.10 The graft material used should facilitate the three tenets of bone regeneration: clot stability, space maintenance, and blood supply/bone-forming cells.11 Unfortunately, many clinicians assume all grafting products are created equal and select the material based on price point alone. If the bone grafting material is not formulated correctly, degradation may not occur, and the graft can become fibrously encapsulated, leading to poor bone turnover and graft failure (figures 25–27).

One particularly good bone graft material that provides scaffolding space maintenance as well as stabilizes the blood clot is Geistlich Bio-Oss Collagen (Geistlich Pharmaceuticals).12 Geistlich Bio-Oss
Collagen is 90% Bio-Oss granules (size range 0.25–1.0 mm) and 10% collagen. The proprietary formulation of the collagen component gives the material its scaffolding and moldability qualities, which makes it an excellent product for site preservation after tooth extraction, especially during flapless site preservation.13 Finally, this graft material has been shown to outperform other graft materials in comparative studies looking at site preservation after tooth extraction.14

Editor’s note: This article originally appeared in Dental Economics’ partner publication Perio-Implant Advisory, a chairside resource for dentists and dental hygienists for issues relating to periodontal and implant medicine. Visit perioimplantadvisory.com to sign up for a newsletter subscription.

Read more about bone grafts in “A review of bone graft material” by Adam Bear, DDS, on the PIA website.

Originally posted in 2019 and updated regularly

(Video) Who Needs Bone Grafts and Why?

References

1.Dye BA, Thornton-Evans G, Li X, Iafolla TJ. Dental caries and tooth loss in adults in the United States, 2011–2012. NCHS data brief, No. 197. Hyattsville, MD: National Center for Health Statistics; 2015. https://www.cdc.gov/nchs/data/databriefs/db197.pdf.

2.Agarwal G, Thomas R, Mehta D. Postextraction maintenance of the alveolar ridge: rationale and review. Compend Cont Educ Dent. 2012;33(5):320-324; quiz 327, 336.

3.Hansson S, Halldin S. Alveolar ridge resorption after tooth extraction: A consequence of a fundamental principle of bone physiology. J Dent Biomech. 2012;3:1758736012456543. doi:10.1177/1758736012456543.

4.Schropp L, Wenzel A, Kostopoulos L, Karring T. Bone healing and soft tissue contour changes following single-tooth extraction: a clinical and radiographic 12-month prospective study. Int J Periodontics Restorative Dent. 2003;23(4):313-323.

5.Lekovic V, Camargo PM, Klokkevold PR, et al. Preservation of alveolar bone in extraction sockets using bioabsorbable membranes. J Periodontol. 1998;69(9):1044-1049. doi: 10.1902/jop.1998.69.9.1044.

6.Lam RV. Contour changes of the alveolar processes following extraction. J Prosthet Dent. 1960;10:25-32.

7.Avila-Ortiz G, Elangovan S, Kramer KW, Blanchette D, Dawson DV. Effect of alveolar ridge preservation after tooth extraction: a systematic review and meta-analysis. J Dent Res. 2014;93(10):950-958. doi:10.1177/0022034514541127.

8.Aimetti M, Manavella V, Corano L, Ercoli E, Bignardi C, Romano F. Three‐dimensional analysis of bone remodeling following ridge augmentation of compromised extraction sockets in periodontitis patients: a randomized controlled study. Clin Oral Implants Res. 2018;29(2):202-214. doi:10.1111/clr.13099. Epub November 17, 2017.

(Video) What is a dental bone graft?

9.Elian N, Cho SC, Froum S, Smith RB, Tarnow DP. A simplified socket classification and repair technique. Pract Proced Aesthet Dent. 2007;(19)2:99-104; quiz 106.

10.Janicki P, Schmidmaier G. What should be the characteristics of the ideal bone graft substitute? Combining scaffolds with growth factors and/or stem cells. Injury. 2011;42(suppl 2):S77-S81.

11.Mellonig JT, Triplett RG. Guided tissue regeneration and endosseous dental implants. Int J Periodontics Restorative Dent. 1993;13(2):108-119.

12.Araújo Mauricio, Linder E, Wennström J, Lindhe J. The influence of Bio-Oss Collagen on healing of an extraction socket: an experimental study in the dog. Int J Periodontics Restorative Dent. 2008;28(2):123-135.

13.Cardaropoli D, Tamagnone L, Roffredo A, De Maria A, Gaveglio L. Alveolar ridge preservation using tridimensional collagen matrix and deproteinized bovine bone mineral in the esthetic area: a CBCT and histologic human pilot study. Int J Periodontics Restorative Dent. 2018;38(suppl):S29-S35. doi:10.11607/prd.3702.

14.Scheyer ET, Heard R, Janakievski J, et al. A randomized, controlled, multicentre clinical trial of post‐extraction alveolar ridge preservation. J Clin Periodontol. 2016;43(12):1188-1199. doi:10.1111/jcpe.12623.

SCOTT FROUM, DDS, a graduate of the State University of New York, Stony Brook School of Dental Medicine, is a periodontist in private practice at 1110 2nd Avenue, Suite 305, New York City, New York. He is the editorial director of Perio-Implant Advisory and serves on the editorial advisory board of Dental Economics. Contact him through his website at drscottfroum.com or (212) 751-8530.

FAQs

What should I do after tooth extraction and bone graft? ›

After Tooth Extraction And Socket Bone Grafting
  1. Do not touch or disturb the wound.
  2. Minimize spitting or rinsing for the first 24 hours, to allow the blood clot and graft material to stabilize.
  3. Do not push your tongue or fingers on the grafted area.

Can you wait to do a bone graft after tooth extraction? ›

This type of graft does not cause any additional discomfort during an extraction, as the site is already open and accessible for simple tooth or molar removal. In most cases, the site will need to heal for approximately three to six months before an implant can be placed.

Do I need antibiotics after tooth extraction and bone graft? ›

The most common cause of bone grafting infection is the patient's poor post-operative oral care routine. Patients must make sure to follow their dentist's instructions to prevent infection. After your bone grafting surgery, your dentist will prescribe antibiotics to prevent infection.

How long does a tooth extraction and bone graft take? ›

How long do the procedures take? Including an extraction, the bone graft and membrane procedure may take up to 45 minutes, depending on how cantankerous the tooth is. To place the implant with our guided surgery, that appointment shouldn't take more than an hour.

When can I eat normally after bone graft? ›

For the first 2 days, your diet should be softer, and avoid hot liquids or chewing on the implant or bone graft site. After 48 hours, it is usually safe to resume your normal diet but try to avoid chewing on the surgical site for as long as possible.

What can you not do after a bone graft? ›

Vigorous mouth rinsing or touching the wound area immediately following surgery should be avoided. This may initiate bleeding. Gentle rinsing is encouraged BEGINNING THE NIGHT OF SURGERY. Use the Peridex (chlorhexidine) that was prescribed.

How do I know if my bone graft is healing? ›

In general, you can expect to feel more normal after a few weeks. After your initial recovery, your bone graft will need time to heal and grow new jawbone. You shouldn't feel any pain during this growth process, but know that it may take several months.

How do I know if my bone graft is infected? ›

The signs of an infection usually appear shortly after the bone graft procedure. They include swelling and redness, discomfort, pain and bleeding. While some of the symptoms are normal after the procedure, if they persist it is important to call our office.

How can I speed up bone graft healing? ›

How to Make Bone Grafts Heal Faster?
  1. Protect the graft from infection. Infection is one of the main reasons for graft failure. ...
  2. Take care of your overall oral health. ...
  3. Reduce Swelling by Using Ice Packs. ...
  4. Don't Smoke. ...
  5. Eat Healthy Nutritious Foods. ...
  6. Rinse with Saltwater.
Aug 9, 2022

How long will my gums be swollen after bone graft? ›

Most of the swelling will normally resolve within the first 7 to 10 days. Ice packs are used for the first 24 to 48 hours. Plastic bags filled with crushed ice and wrapped in a towel or a commercial ice bag are convenient forms of application. Apply for 20 minutes each hour while awake (on 20 minutes/off 40 minutes).

How long does pain last after dental bone graft? ›

A patient can expect to experience a level of pain and discomfort after dental bone grafting procedures. Pain following the surgery should subside after three to four days. However, on occasion, pain may persist. If this is the case, you may require further attention and should contact your dental healthcare practice.

How do you clean your mouth after a bone graft? ›

Keeping your mouth clean after surgery is essential to reduce the risk of infection. Start salt water rinses the day following your procedure. Use teaspoon of salt dissolved in an 8 ounce glass of warm water and gently rinse with portions of the solution, taking five minutes to use the entire glassful.

Can I rinse with salt water after bone graft? ›

General Instructions

It may cause bleeding, irritation, or infection. The day after surgery, continue normal brushing and use a warm salt water rinse (¼ teaspoon salt in a glass of warm water) every 2–3 hours for 3 days. Pain may last for 10–14 days following surgery. Usually the third day is the most uncomfortable.

How long will my face be swollen after bone graft? ›

Swelling After Bone Grafting

Swelling around the mouth, jaws, cheeks, and below the eyes is not uncommon. The swelling will usually reach its maximum 2–3 days after the surgical procedure. The swelling can be decreased by the immediate use of ice packs in the first 24 hours.

What helps bone grafts heal faster? ›

How to Make Bone Grafts Heal Faster?
  • Protect the graft from infection. Infection is one of the main reasons for graft failure. ...
  • Take care of your overall oral health. ...
  • Reduce Swelling by Using Ice Packs. ...
  • Don't Smoke. ...
  • Eat Healthy Nutritious Foods. ...
  • Rinse with Saltwater.
Aug 9, 2022

How long does it take for gums to close after bone graft? ›

Tissues and bone are cut underneath the gum line during surgical extractions. In the case of surgical extraction, your tooth hole will be fully or almost fully closed by 6 weeks after surgery. It may take several more months before the indentation fills in and the healing is complete.

How do I know if my dental bone graft is healing? ›

In general, you can expect to feel more normal after a few weeks. After your initial recovery, your bone graft will need time to heal and grow new jawbone. You shouldn't feel any pain during this growth process, but know that it may take several months.

Videos

1. Tooth Extraction and Bone Graft - Part 2 of 2 - External Resorption
(All Things Dentistry)
2. Post Surgery instructions by an oral surgeon [after Tooth Extractions,bone grafting,implants]
(Dr.Indraniil Roy)
3. Bone Graft Procedure: What to expect?
(CenterPeriodontists)
4. Post Operative Guide: Extraction With or Without Bone Grafting | Dr. John Thousand IV DDS MSD
(Dr. John Thousand IV, DDS, MSD)
5. [ENG] Drilling method & Bone graft technique for immediate loading after extraction
(Dental Bean)
6. Bone Grafting After Tooth Extraction in Boise ID | Boise Oral Surgery & Dental Implant Center
(Boise Oral Surgery & Dental Implant Center)

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