Bone graft after tooth extraction: Techniques, alternatives, healing, and moreSometimes a tooth is not conservable and must be extracted for various reasons, often because of a dental infection. After extraction, bone loss is the most challenging consequence. It occurs because the bone surrounding our teeth can shape itself over time in response to external factors.
When teeth are missing, the bone will no longer be stimulated by the chewing forces and will eventually collapse, making implant treatment to replace the missing teeth impossible.
To overcome this problem, your dentist will anticipate the amount of bone available and perform a bone grafting technique to preserve and rebuild the bone.
What is a bone graft?After a thorough examination, your dentist may suggest a bone graft during or after the extraction when he deems the bone volume is insufficient to support a dental implant.
Bone grafting is a surgical technique that involves placing bone or a synthetic biomaterial in the area to be restored.
In short, a dental bone graft is used to restore bone volume and strengthen your jawbone so that you can receive an implant. There are different types of bone grafts.
Types of dental bone grafts
Autograft: Bone is taken from another part of your body, usually from the back of your mouth, if the amount needed is small or moderate. However, if a large amount is needed, bone can be taken from extra-oral sites such as the skull or iliac crest.
Allograft: Bone is taken from another person, usually a cadaver. Before being used, it is carefully processed to remove any infectious factors or antigens.
Xenograft: The bone used for the graft comes from another species. Like allografts, they also undergo processing before being used in your jaw.
Synthetic material: This is a bone-like biomaterial that can serve the same purpose as other types of bone grafts.
What happens after a tooth extraction?
After losing one or more teeth, it is just a matter of time before various problems occur.
The first thing you may notice is bone loss. The alveolar bone begins to shrink gradually, losing 40-60% of its original volume in the first two years. Bone loss then continues at a rate of 1% per year.
The teeth bordering the missing tooth will shift to fill the space left. The tooth in the other jaw that opposes the extracted tooth will also shift, causing it to become loose and sensitive.
Chewing with fewer teeth increases the wear process. It can also limit your dietary diversity, which may impact your overall well-being.
When several teeth have been extracted and not replaced, your face may show some signs. The soft tissues will no longer be supported, resulting in a distortion of the facial features, giving the appearance of premature aging.
The role of bone grafting after tooth extraction
Studies have shown that bone grafting directly after tooth extraction reduces bone resorption by 1.89 mm in width and up to 2.07 mm in height compared to extractions alone.
Thus, bone grafting can minimize the problem of bone resorption after tooth extraction. This procedure, also called alveolar ridge preservation or socket preservation, aims to maintain the shape and volume of the bone by using different materials.
The material of choice is autogenous bone grafting as it allows new bone formation. In addition, it contains living cells that contribute directly to bone regeneration.
Bone graft directly after tooth extraction (or socket preservation)Bone loss after a tooth extraction is inevitable and reaches its peak during the first few years.
The horizontal and vertical volume loss makes it hard to integrate a dental prosthesis such as a bridge or an implant.
The socket preservation technique is performed immediately after extraction. It consists of filling the socket with a bone graft or a biomaterial. This technique allows you to overcome the problem of bone shrinkage after the procedure.
If the socket is left empty, the bone will shrink, making implant placement impossible. Restoring the lost bone will require a longer treatment time and additional costs.
Although recommended, it is not always necessary. Chances are, your body can heal properly without needing a bone graft. However, there may be signs that you need a bone graft to preserve as much bone as possible.
- Your dentist will perform a thorough clinical and x-ray examination to determine the best treatment plan for you. When the tooth is deemed unrecoverable, it must be extracted to avoid further complications.
- Your dentist will give you instructions on oral hygiene and can perform professional teeth cleaning if you need one. Then the tooth is extracted as gently as possible.
- The empty socket where the tooth was located will be cleaned and filled with graft material.
- A membrane will be placed over the graft material to protect it and allow for optimal and rapid healing.
- The surgical site is closed with sutures. A temporary dental bridge can be placed to replace the missing tooth during the healing process.
- After the 4-month healing period, your jawbone will be dense enough to receive an implant without complications.
HealingAfter the procedure, you may experience pain, swelling, and bleeding for the first few days. These side effects are temporary and normal and should gradually subside within the first few weeks.
You can manage these symptoms with over-the-counter painkillers. Your dentist may also prescribe antibiotics. Follow them exactly as instructed.
You can apply ice packs to reduce swelling and discomfort. For the first week opt for soft, warm foods and avoid hot, hard, and spicy foods.
After a few weeks, your gums will return to their normal appearance. But it will take a few months for the bone to mature to receive an implant.
What can I expect after the procedure?Usually, after 4 months, your tissues will heal and mature completely. Your dentist will perform a clinical and x-ray examination to assess the healing. The actual bone density and healthy appearance of your gums will allow you to proceed to the next step: implant placement.
Bone grafting months or years after extractionSocket preservation remains the best option to prevent bone loss after tooth extraction. If the alveolus is left empty, it will shrink, requiring another surgical procedure to restore the lost volume to place an implant.
If you have waited too long after a tooth extraction, your jaw will probably be resorbed. Your dentist may suggest bone augmentation surgery. Among the different techniques available:
Inlay and Onlay block grafting
Inlay and Onlay grafts restore the height, width, or both of the bone ridge that has narrowed after tooth extraction. These techniques have a high success rate between 92% and 100%, allowing an appropriate implant integration.
Onlay grafting consists of screwing a block of bone onto your bone ridge where you want to add volume. The bone can be taken from a part of your body (autogenous) or purchased from a bone bank (allogenic or xenogenic). After about 4 months, the graft will fuse to your jaws. The implant can then be placed in good condition.
Inlay graft involves the same principle. Instead of placing a bone block directly on your jawbone, the ridge is first separated in half then the bone graft is inserted between the two segments.
Guided bone regeneration
This technique involves placing a membrane over the bone grafting to protect and isolate it. It prevents the tissues surrounding the bone from proliferating, allowing time for the bone cells to multiply and colonize the bone surface.
In short, guided bone regeneration promotes bone formation and prevents external factors from interfering with this process.
Platelet-rich plasma and growth factorsGrowth factors are proteins that can accelerate and promote wound healing and blood vessel formation. They are therefore beneficial for bone reconstruction.
They can be added to the bone graft to stimulate the cells. This way, bone formation will be faster and of better quality.
The maxillary sinuses are empty cavities located just above the upper molars. Normally, they are separated from the roots by bone. After extracting these teeth, the bone thickness will decrease, making the sinuses larger and implant placement impossible.
The sinus lift aims to solve this problem by increasing the bone volume in this area.
This technique consists of cutting a segment of bone and moving it vertically. The space created will be filled with graft material to increase the ridge height.
Split bone technique
This technique is used when the jawbone has narrowed after extractions.
It consists of separating the ridge into two parts then implants are placed in the space created. A bone graft will be added to support the implants and the jaw bone. The ridge will be stabilized with screws then the surgical site will be closed with sutures to ensure healing.
The advantage of this technique is that it can be performed simultaneously with implant placement in a single procedure, reducing the healing time and treatment duration.
Alternatives to bone graftingBone grafting is not the only option to restore bone volume. Other alternatives may be available if your bone loss is not severe or you have a medical condition that contraindicates bone grafting.
Bone distractionBone distraction is an alternative to bone grafting to increase the height of the bone ridge. This technique has a success rate of 96.7% to 100%.
It consists of separating the ridge into two segments and placing a device that will apply forces to increase the bone's height.
The goal of bone distraction is to promote bone growth by applying tension without the use of bone grafts.
Soft tissue augmentation
This technique can sometimes be a good alternative to bone grafting. It consists of taking a piece of soft tissue, generally from the palate (donor site), and adding it to the recipient site.
However, if the bone ridge is too narrow, this technique does not allow implant placement. Bone grafting is the only solution as implants require a certain amount of bone to stabilize.
Instead, soft tissue augmentation allows dental appliances, such as a bridge or denture to fit correctly.
Adapted implant placementSometimes, very short or narrow implants can be used to avoid bone grafting. Today, technological progress has made it possible to design small implants that are both reliable and resistant. There are now ultra-short (4 mm long) and ultra-thin (3 mm diameter) implants.
The development of small dental implants offers new possibilities for people with severely resorbed jaws who do not desire a bone graft.
- Horváth, A., Mardas, N., Mezzomo, L.A. et al. Alveolar ridge preservation. A systematic review. Clin Oral Invest 17, 341–363 (2013). https://doi.org/10.1007/s00784-012-0758-5
- Willenbacher, M., Al-Nawas, B., Berres, M., Kämmerer, P.W. and Schiegnitz, E. (2016), Alveolar Ridge Preservation. Clinical Implant Dentistry and Related Research, 18: 1248-1268.
- Robert Horowitz, Danny Holtzclaw, Paul S. Rosen, A Review on Alveolar Ridge Preservation Following Tooth Extraction, Journal of Evidence Based Dental Practice, Volume 12, Issue 3, Supplement, 2012, Pages 149-160, ISSN 1532-3382.