Bone Grafting for Implants
A critical question in determining whether an implant can be placed is, “Is there enough bone to support the implant?” Fortunately, advanced bone regeneration techniques now make it possible to place many more implants than just 10 years ago.
Extraction with socket preservation bone grafting
Many times teeth that require extraction have bone loss that necessitates bone regeneration before a dental implant can be placed. This illustrates how it is done.
The above is an upper bicuspid that is failing, broken and infected. Note the fistula (it looks like a pimple that is a drain hole for pus) on the right photo.
Above shows the extracted tooth. The right photo shows the hole in the facial bone that the infection drained thru. This bone defect must be eliminated for a successful implant.
Bone graft material (in the top row above) was utilized to fill the bone defect.
The middle left photo above shows re-hydrating the bone with sterile saline. The middle right photo shows a few drops of blood from the surgical site mixed with the bone graft material. The above lower row shows the bone graft placed in to the bone defect.
The above top row shows the barrier that will be placed over the bone graft to hold it in place. The lower row of photos shows the barrier in place and sutured. This non-resorbable barrier will be removed in about 4 to 5 weeks.
The above top row shows the area 4 months later, The socket preservation bone graft has regenerated solid bone and the infection is gone. The bottom row shows the implant in place.
The above is a lower molar that is failing, the roots are resorbing, both roots have cysts (note the dark circles at the bottom of the tooth with the root canal and crown) and infected.
The above left photo shows the tooth being extracted. The center and right photos shows the cysts being removed from the extraction sites. These cysts have to be removed and the bone defect must be eliminated and bone regenerated for a successful implant.
Bone graft material (in the top row above) was utilized to fill the bone defect. The top left photo above shows re-hydrating the bone with sterile saline. The top right photo shows a few drops of blood from the surgical site mixed with the bone graft material. The lower row shows the bone graft placed in to the bone defect.
The above left photo shows the barrier that will be placed over the bone graft to hold it in place. The right photo shows the barrier in place and sutured.
The above top row shows the area 4 months later.
The middle photo shows that the socket preservation bone graft has regenerated solid bone and the infection is gone.
The bottom row shows the implant in place.
(bone grafting of a deficient ridge so an implant can be placed later)
This is an example of an area where the bone has receded horizontally from a tooth that was removed and not replaced. There is not enough bone present on the cheek side of the area to place an implant.
To re-build the missing bone, a bone graft was placed using Puros (processed by patented Tutoplast process) cancellous bone graft particulate (out of a jar from a bone bank), mixed with platelet-rich plasma, then was covered with a GoreTex barrier that had a moldable metal strut to keep the bone graft material in place, then sutured tightly closed. The area needs about 8 months to heal new, solid bone before an implant can be placed.
8 months after the ridge augmentation surgery there is solid bone and a dental implant was then placed.
This is 3 months after the implant was placed. Note how wide the ridge is compared to initially. Successful ridge augmentation with bone grafting made it possible to place a dental implant in an area that previously had an inadequate amount of bone to allow an implant to be placed.
Above is the crown placed on the implant by the patient's family dentist.
The above shows a lower front tooth this a root canal. The crown fell off and there was a fistula (hole in the gum draining pus). The dark circle on the x-ray is a cyst causing a loss of bone.
The above photos show the oral surgery that was done using local anesthesia and the gum tissue flapped (pulled back). The upper left photo shows a crack in the root of the tooth. Cracked teeth always lead to bone loss and tooth loss. There are no repair options. Note the cyst at the bottom of the root. The upper right photo shows the hole that is left after the tooth root and the cyst are removed. There is no bone available for placing an implant. The lower left photo shows a bone graft placed covered with a resorbable barrier, to hold the bone graft in place. The lower right photo shows the final suturing.
The above photos were taken 8 months later. They show the temporary partial (called a “flipper”) that this man wore as a temporary tooth replacement.
8 months after the initial extraction and ridge augmentation bone graft surgery to recreate a bone ridge, the gum was pulled away and the bone re-growth assessed. Note in the upper left photo the total regeneration of lost bone. The upper right photo shows the dental implant. The lower left photo is the implant in place. The lower right photo is the final suturing with a temporary abutment (the white cap) that is screwed to the top of the implant to maintain the space of where the final crown will go, so the gum tissue heals around it, allowing for the final crown to be placed several months later by the restorative dentist.
4 months later the integration of the dental implant to bone (the implant is solid in bone, does not move and is totally free of any pain) is verified. This gentleman was then sent to his family dentist, who made him the above crown.
Sinus Bone Grafting
Above the roots of the maxillary (upper) back teeth are the maxillary sinuses. The right and left maxillary sinuses are separate from each other, and are each about 15cc’s (3 tablespoons) of air space with a tissue lining of about 1mm in thickness called the Schneiderian membrane. At the upper portion of the maxillary sinuses, they drain into the other nasal sinuses thru an opening called an ostium.
When upper back teeth are removed, the floor of the maxillary sinus will actually grow downward, called maxillary sinus pneumatization. This can make placing dental implants impossible if there is no longer enough depth of bone for dental implant placement.
The photo on the top is of a "normal" sinus floor located just above the end of the upper back teeth roots. The photo on the bottom shows maxillary sinus pneumatization; that is the floor of the maxillary sinus actually moving downward. In order to be able to place a dental implant, there needs to be sufficient bone depth. If maxillary sinus pneumatization makes that difficult or impossible, it may be possible to do a bone graft to elevate the floor of the maxillary sinus back to where it used to be.
The above x-ray shows what happens when upper back teeth are out for many years. This x-ray shows what happens with enlargement of the maxillary sinus and resorption of the bone ridge when teeth are gone for decades.
Adding 1cc to 4cc of bone graft material to reduce 1 to 4cc of air space in a sinus with over 15cc’s of airspace does not effect normal sinus function. If you are prone to sinusitis before the maxillary bone graft, you still will be after it. If you are not, you still won’t be.
(Clinical Article: Maxillary sinus function after sinus lifts for the insertion of dental implants)
There are 2 primary methods for accomplishing a maxillary sinus bone graft to facilitate dental implant placement, the osteotome sinus bone graft and the lateral window access sinus bone graft.
Osteotome sinus bone graft
If there is enough bone, at least 5mm of bone below the bottom of the sinus floor, to mechanically hold the dental implant in place temporarily on insertion, but not enough to hold it in for the long term, it may be possible to move the floor of the sinus up in this isolated area thru the drill hole made for placing the dental implant. With this method, it may be possible to add up to 3mm of bone depth for the implant. In this method, a hole is drilled in the jawbone to place the implant and is made right to the floor of the sinus. Then about 1cc of bone graft material is placed in the hole and a special tool (osteotome) is placed in the drill hole filled with bone and upward pressure is placed to push bone under the Schneiderian membrane (thick sinus tissue lining). Then an implant can be placed. At least 6 to 9 months are required to allow the bone graft to form new, solid bone. Then a crown can be placed on the dental implant.
The photo on the left is a situation where the floor of the maxillary sinus has dropped The middle photo shows the site is several millimeters short of the sufficient amount of bone needed for long-term dental implant placement. The photo on the right shows a dental implant placed with an osteotome sinus bone graft. Note the whitish halo around the bottom of the implant. That is the bone graft that was placed.
On the top row is a missing upper 1st molar
On the bottom row, the x-ray at the left shows a missing upper 1st molar with some pneumatization (dropping) of the maxillary sinus floor. The middle x-ray shows that a 10mm length implant would protrude several millimeters into the maxillary sinus. The right x-ray shows the post-operative result. The osteotomy (drill hole for the implant) was made to the floor of the maxillary sinus, then the sinus lining (Schnederian membrane) was elevated, and a bone graft placed thru the osteotomy, then the dental implant was placed. Note the whitish halo around the bottom of the implant. That is the bone graft that was placed. 8 months later, the crown can be placed on the implant.
Lateral Window (Cauldwell-Luc) sinus bone graft
If there is not enough bone depth, at least 5mm of bone below the sinus floor, then a different approach to graft bone is used. This is creating a window in the bone on the cheek side of the alveolar bone ridge to access to the maxillary sinus. Approximately 4cc’s of a bone graft material is mixed with platelet-rich plasma (we take about 20cc’s of your blood, the equivalent of 2 small tubes from a routine physical blood test, spin it in a centrifuge and mix it with the bone graft material and place it in the sinus to restore the bone level to it’s original state to allow dental implant(s) to be placed. After a 6 to 9 month wait to allow new bone to form solid, then dental implants can be placed.