Bone Grafting

Major & Minor Bone Grafting

Over a period of time, the jawbone associated with missing teeth atrophies or shrinks in size. This often leaves a condition in which there is poor quality and quantity (amount) of bone needed for the placement of dental implants. In these situations, a patient cannot have an implant supported replacement tooth without a bone graft to restore the jawbone into which the implant is placed.

Today, we have the ability to grow bone where needed. This not only gives us the opportunity to place implants of proper length and width, it also gives us a chance to restore functionality and esthetic appearance.

Jawbone and Extraction Site Preservation

When you need to have a tooth or teeth extracted—whether it be due to decay, abscess, gum disease or injury—it is usually in your best interest to do so in a manner which preserves as much of your underlying jawbone as possible. From the time the teeth are removed, significant degeneration of the surrounding bone begins to take place. You have many options to prevent this, and it is important that you consider them BEFORE any teeth are removed. Some of these procedures are best performed at the time the tooth is removed. Dr. De Tolla is an oral and maxillofacial surgeon who specializes in tooth removal, jawbone preservation and dental implant placement.

What happens when a tooth is removed?

There is a special type of bone surrounding your teeth. This bone is called alveolar “ridge” bone, and exists solely to support your teeth. As soon as the tooth is removed, this bone begins to degenerate and “melt away.” This occurs in two dimensions. The first is loss of horizontal width caused by the collapse of the bone surrounding the socket. This makes the remaining ridge narrower than when the tooth was present. The second is a loss of vertical height. This makes the remaining bone less “tall.” This process is faster in areas where you wear a partial or complete denture.

Why is it important to preserve the bone?

You will have several choices of how you can replace the newly missing teeth. All of the options rely on bone support and bone contour for the best function and esthetics. Here is a list of the possible options:

  • You may choose to replace your missing teeth with dental implants. These are root-shaped supports that hold your replacement teeth. The more bone support you have, the stronger the implant replacements will be. In some cases, the bone can degenerate to a point where implants can no longer be placed without having more complex bone grafting procedures to create the necessary support. The prevention of bone loss is much easier than recreating the bone later.
  • You may choose to replace the missing teeth with a “fixed bridge.” This is a restoration that is supported by the teeth adjacent to the missing tooth space. The replacement tooth (or pontic) spans across the space. If the bone below is deficient, there will be an unsightly, noticable space under the pontic that will trap food and may affect your speech.
  • Other replacement alternatives include removable partial or full dentures. These often perform better with more supporting bone. How can the bone be preserved?
Normal Tooth Loss
Grafted Bone Dental Implant

There are two important phases in retaining your alveolar ridge during and after the tooth extraction. Not all extractions are the same—Dr. De Tolla will use the most careful techniques to extract the teeth while preserving as much bone as possible. In certain cases, bone replacement material is then added to prevent the collapse of the socket.

There are several types of bone grafting materials and techniques—Dr. De Tolla will discuss the most appropriate one with you if it appears your extraction site will benefit. After the tooth is extracted, the socket will be packed with a bone-like material and covered with a small absorbable plug or suture. Early on, the grafting material will support the tissue surrounding the socket, and in time will be replaced by new alveolar bone. This bone will be an excellent support should you choose later to have dental implant-supported replacement teeth.

Although the bone created by socket grafting supports and preserves the socket, it will not do so indefinitely. Placing dental implants four to twelve months after the extraction and socket grafting will provide the best long-lasting support for preserving your jawbone and allow you to function as before. Otherwise the graft may “melt away” or resorb over time.

Immediate Dental Implant placement

In some selected cases it is possible to actually extract the tooth and place the dental implant at the same time. We call that immediate implantation. If you are interested in replacing your tooth with an implant and want to be considered for immediate implantation, please call Dr. De Tolla’s office for a consultation prior to your extraction.

How much does it cost?

All patients receive the most careful bone-preserving extraction techniques at no additional charge. There is an additional charge for performing a socket grafting procedure at the time of the extraction. Charges vary depending on the tooth location and number of teeth. If it is determined at your initial visit that you will benefit from a socket grafting procedure, Dr. De Tolla’s staff will be happy to provide you with an estimate of the procedure cost before treatment begins.

Sinus Augmentation or Lift Procedure

The maxillary sinuses are behind your cheeks and on top of the upper teeth. Sinuses are like empty rooms that have nothing in them. Some of the roots of the natural upper teeth extend up into the maxillary sinuses. When these upper teeth are removed, there is often just a thin wall of bone separating the maxillary sinus and the mouth. Dental implants need bone to hold them in place. When the sinus wall is very thin, it is impossible to place dental implants in this bone.

There is a solution and it’s called a sinus graft or sinus lift graft. The dental implant surgeon enters the sinus from where the upper teeth used to be. The sinus membrane is then lifted upward and donor bone is inserted into the floor of the sinus. Keep in mind that the floor of the sinus is the roof of the upper jaw. After several months of healing, the bone becomes part of the patient’s jaw and dental implants can be inserted and stabilized in this new sinus bone.

The sinus graft makes it possible for many patients to have dental implants when years ago there was no other option other than wearing loose dentures.

If enough bone between the upper jaw ridge and the bottom of the sinus is available to stabilize the implant well, sinus augmentations and implant placement can sometimes be performed as a single procedure. If not enough bone is available, the Sinus Augmentation will have to be performed first, then the graft will have to mature for several months, depending upon the type of graft material used. Once the graft has matured, the implants can be placed.

Ridge-augmentation with Onlay Grafting

In severe cases where the tooth supporting ridge has been resorbed and reduced in height, a bone graft is placed to increase the ridge width and/or height. This in-office procedure is usually performed using sedative or general anesthesia and takes about an hour.

Ridge Expansion

In severe cases, the ridge has been resorbed and a bone graft is placed to increase ridge height and/or width. This is a technique used to restore the lost bone dimension when the jaw ridge gets too thin to place conventional implants. In this procedure, the bony ridge of the jaw is expanded by mechanical means. Bone graft material is placed and matured for a few months before placing the implant.

Major Bone Grafting

Bone grafting can repair implant sites with inadequate bone structure due to previous extractions, gum disease or injuries. The bone is either obtained from a tissue bank or your own bone is taken from the jaw, hip or tibia (below the knee.) Sinus bone grafts are also performed to replace bone in the posterior upper jaw. In addition, special membranes may be utilized that dissolve under the gum and protect the bone graft and encourage bone regeneration. This is called guided bone regeneration or guided tissue regeneration.

Major bone grafts are typically performed to repair defects of the jaws. These defects may arise as a result of traumatic injuries, tumor surgery, or congenital defects. Large defects are repaired using the patient’s own bone. This bone is harvested from a number of different sites depending on the size of the defect.

Nerve repositioning

The inferior alveolar nerve, which gives feeling to the lower lip and chin, may need to be moved in order to make room for placement of dental implants to the lower jaw. This procedure is limited to the lower jaw and indicated when teeth are missing in the area of the two back molars and/or the 2nd premolar, with the above-mentioned secondary condition. Since this procedure is considered a very aggressive approach (there is almost always some postoperative numbness of the lower lip and jaw area, which dissipates very slowly, if ever), usually other, less aggressive options are considered first.

Typically, we remove an outer section of the cheek side of the lower jawbone in order to expose the nerve and vessel canal. Then we isolate the nerve and vessel bundle in that area, and slightly pull it out to the side. At the same time, we will place the implants. Then the bundle is released and placed back over the implants. The surgical access is refilled with bone graft material of the surgeon’s choice and the area is closed.

These procedures may be performed separately or together, depending upon the individual’s condition. As stated earlier, there are several areas of the body that are suitable for attaining bone grafts. In the maxillofacial region, bone grafts can be taken from inside the mouth, in the area of the chin or third molar region or in the upper jaw behind the last tooth. In more extensive situations, a greater quantity of bone can be attained from the hip or the outer aspect of the tibia at the knee. When we use the patient’s own bone for repairs, we generally get the best results.

In many cases, we can use allograft material to implement bone grafting for dental implants. This bone is prepared from cadavers and used to promote the patients own bone to grow into the repair site. It is quite effective and very safe. Synthetic materials can also be used to stimulate bone formation. We even use factors from your own blood to accelerate and promote bone formation in graft areas.

These surgeries are performed in the office under IV sedation or general anesthesia. After discharge, bed rest is recommended for one day and limited physical activity for one week.

Bone Grafting Overview

For a brief narrated overview of the bone grafting process, please click the image below. It will launch our flash educational MiniModule in a separate window that may answer some of your questions about bone grafting.

Bone Grafting Overview

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