Bone/Socket grafting: An Oft Overlooked Advancement
Eric G. Jackson, DDS, MAGD, FICOI, FICOI, FICD, FADI
Over the past several decades there have been numerous amazing advancements in modern dentistry. Cone-beam CAT scans, lasers, “invisible” orthodontics, and metal free ceramic crowns are just a few such leaps forward that garner quite a bit of publicity. Another advancement that rarely gets the press it deserves is the ability for modern dentists to regenerate and grow new bone through grafting procedures. This process can have a profound effect on the present and future treatment of a patient. While there are a variety of different grafting procedures, the focus of this article will be limited to socket grafting at the time of tooth extraction.
When a tooth is removed, the “hole” that remains is referred to as a socket. I advise my patients that in most cases, whenever a non-wisdom tooth is removed, something should fill the socket the same day. This is typically either a socket graft or an immediately placed implant. Empty spaces in the mouth are almost never a sound choice. You would never want to leave a cavity filling “unfilled” and everyone has seen the shifting/drifting of the teeth caused by a missing tooth over years. When a tooth is removed the body shrinks the remaining bone around the socket. Without a tooth to support, strong bone is no longer needed. Patients who have been completely without teeth for decades are an excellent illustration of this reduction in bone volume. The “sunken-in” or collapsed facial appearance of a person not wearing their dentures is strong visual evidence. While it is possible to graft and grow bone after a tooth has been extracted and the bone healed, the outcome is far less predictable than if the graft was placed at the time of extraction. This is because the graft is contained within the walls of the fresh extraction socket. Initially, the walls of the socket provide rigid support to the graft and keep it contained while it sets. Once set, the graft returns the favor and supports the bony walls to prevent the remodeling and reduction in volume.
Once the tooth is extracted, the socket is thoroughly cleaned and the graft material is placed. There are numerous types and brands of bone grafting materials at your dentist’s disposal. Many of the most common grafts have the consistency of wet sand, although the type chosen by the dentist can vary. Once the graft is placed, it is commonly covered with a protective membrane. This membrane serves to contain the graft until it sets as well as prevent the gum tissue from infiltrating the socket. The membrane is typically secured with several sutures. Healing time of the graft varies depending on the type of material used, location of the graft, and volume of graft placed. In general, socket grafts can mature anywhere from 3 to 6 months from the day of surgery. This “healing time” is an extremely useful tool in the hands of a dentist skilled in comprehensive treatment planning. It serves as a built-in buffer to space out dental procedures and allows the patient to make educated decisions regarding the next step in his/her dental treatment (i.e. live with a missing tooth, have a bridge or partial made, or have an implant placed).
Socket grafting is an essential step if you are considering a dental implant because the graft will help maintain the natural contours of your jawbone. By maintaining the maximum volume of bone, the success of the planned dental implant will be far more predictable. Bone remodeling occurs immediately after a tooth is extracted and can last for several years. In the first year the bone can experience a 25% decrease in volume and within the first 3 years after tooth loss there is a 40-60% decrease in width. This loss of bone volume is one of the most important factors in whether a patient is a candidate for dental implants. While only measured in millimeters, these percentage decreases are extremely significant! Imagine losing 25% of your height over the next year and what it would mean to your overall health and how you function! Socket grafting is not confined to the world of implants. It also optimizes a fixed bridge by nearly eliminating the typical “collapsing” or “shrinking” of the bone, providing a very natural look and a very cleansable bridge. Due to a variety of reasons, this important grafting procedure is not done routinely in most dental offices. Low public awareness of the importance and benefits of socket grafting at the time of extraction is a significant factor in this problem. Patients interested in dental implants should discuss socket grafting with their dentist before the extraction even if the implant is only a possibility in the future. Grafting will prevent the initial rapid resorption of the bone, but only a dental implant will maintain it indefinitely. Without an implant, the body will eventually begin the resorption process and destroy bone. This process can begin as early as 9-12 months after the surgery, but always proceeds at a dramatically slower pace compared to if no graft was placed.
Dentistry today is more complex than any point in history and it requires dentists to be more skilled than ever before. Socket grafting has rapidly become a cornerstone of modern dentistry. Whenever I’ve lectured to fellow dentists at their study clubs or students at the dental school, I almost always focus my first topic on socket grafting. I feel it is a skill that should be offered within every dental office, just like filling and crowns. If you would like to speak about socket/bone grafting, or any other dental topic, please feel free to call the office and schedule a complimentary appointment with me. Email and Twitter are also available options. I am extremely passionate about modern dentistry and love discussing it with patients, so don’t hesitate to contact me.
Eric G. Jackson, DDS, MAGD, FICOI, FICD, FADI
Misch, Carl. Contemporary Implant Dentistry. 3. St. Louis, MO: Mosby, 2007