Bone Grafting at Time of Extraction: Can This Get Costly?

I have exactly the same concern ( I am relatively new to implant dentistry).I noticed that if I graft the socket at the time of extraction, very often I have to do the grafting again anyway as the bony ridge is simply too narrow for the implant to be fully surrounded by bone.I feel that I should let the site heal leaving the bone formation entirely to the natural body cells and graft when placing a fixture if required.

I am also relatively new to implant & bone grafting. What I have come to realize is that each case must be evaluated individually, so there can be no one answer. Sometimes it makes sense to graft at time of extraction, and sometimes it does not. Whether to do so depends on case planning and evaluation which should bring to bear both biological and mechanical principles and whether the site in question is in the esthetic or non-esthetic zone. In a molar site with a fully intact socket with adequate height and width it makes little sense to graft as normal extraction site healing should fully fill the socket with bone within several months, but the same situation with a central incisor may require grafting (or even immediate implant placement if possible) in order to preserve the buccal bone plate and the soft tissue profile. One thing is for certain grafting does add a high cost to the procedure and therefore must be planned for carefully and be incorporated into the treatment plan for the patient.

There is tons of literature on site grafting, techniques, and its results. Proper tissue management, in-depth understanding of types of bone grafts, techniques, and list of diagnostics indicators provides a clinician with key information about when, where, how, and if site grafting can be done and its success, and whether to avoid site grafting and opt for secondary grafting later, or sometimes perform both. The cost, although, important is not the real factor to consider. Of course a patient must be educated on all of the factors above and be given a choice in their treatment.

You have to consider the situation at the time of extraction. It can be more difficult and costly to graft post extraction. In particular when you already have a 5 or 4 walled defect.

For single rooted teeth, unless there is very extensive bone loss, the best results protocol as far as I am concerned is to extract, thoroughly debride, make immediate implantation with a profiled healing abutment or temporary crown and also simultaneously to provide grafting by a mimimumly invasive method such as tunneling to place a barrier membrane along with grafting material. If there is controlled infection present as often accompanies a fractured root, the immediate approach is still viable. I have found this protocol to expediently mimimize the number of surgeries, mimimize the cost, mimimize the time interval and in the end will provide excellent control and stability of the hard and soft tissue complex. In the case of multi-rooted teeth a delayed implant procedure is a better protocol because primary fixation is usually not possible to achieve. Ridge preservation grafting at time of extraction is a very dependable and proven technique. Even if some width dimension is lost, in the multiple rooted situation there is almost always still adequate bone to implant after the 5 to 6 months wait interval without having to resort to secondary grafting.

If possible, I found it is best to graft at the time of the extraction.

I normally try to place a product to try and minimize epithelial infiltration into the socket and allow for bone matrix and bone formation to start. I have had success and not so successful results but the question is, does this have to do with the products used or just the differing response of good ole mother nature in each individual patient.

by the wording of your question it sounds more like you're concerned about recouping cost of the grafting and time for the procedure than best way to graft. explain to the patient prior to initial surgery that subsequent grafting at the site may be required on top of the socket grafting being done and there will be an additional charge for it if it comes to that.fortunately for us in dentistry, much of our work has very predictable outcomes, but healing times, bone growth rates,systemic healthof patient,oral hygiene,and other factors vary greatly from patient to patient making predictability of this procedure much less srtaightforward than traditional dentistry.

My response to Dr. R. Sir, On reading your question, I see you seeking predictability both for you and your patient. There is not a single answer unfortunately for the question you ask.As Dr.Hughes said....the key is how many walls are there in the socket you are dealing with. So you want to understand graft site classification. If you can calssify then you can adopt a treatment protocol that will grant you the predictability you are seeking. Primary to this is "understanding". With this you will really understand why Dr.Hughes said what he said. His answer is loaded. In his answer is the subject of growth factors, osteogenesis,osteoconduction, osteoinduction, regional acceleratory Phenomenon, bone recycling, classifications of different types of bone and their characteristics and behaviour to mention just few things. Please consider buying this text book - "Contemporary Implant Dentistry" by Prof. Carl.E.Misch. It will cost you around 200 bucks but its money well spent.The book is worth its weight in Gold and you will still come out a winner. You will have a very thorough understanding on what should be done where and why and what you can expect. Better still I would highly recommend you consider going to the Misch Int'l Implant institute. This will equip you for plenty more than socket grafting. Quickly though to answer:- 5 wall defect= resorbable graft material(RGM) 4walldefect = Autograft or RGM & barrier membrane 2-3wall defect= Autogenous bone+RGM+Membrane 1 wall defect= Onlay block graft of Autogenous bone +/- membrane. Are there other ways? sure, but if you want predictability follow this protocol which Dr.Misch prescribes based on research, science and predictability.Opinions are good but science beats everything 99% of the time. Carpe diem my friend.

Dr.Varghese P. John, DMD, FICOI, FMIII, description of wall defect is quite good. But will it work ? How does the implant influence bone alimentation in its next proximity ? If bacteria and bacterial toxines are involved how do you ensure their dismission ? If bone is a compartment how will the obstacle (implant/diameter/surface/threads influence this)influence which graft on basis of witch factor ? As in deed you can not- I think its the localy mortified bone who can not answer with resorption to. Milled bone has a loss of 80 % vitality after milling. As the remaining osteocytes will be dead by the time they have been reached by the proliferation of new vessels (for alimentation) are you sure it is necessary to graft with autologuos bone ? Some people say demineralized bone matrix will do same ! Others say bovine also. As it seems to be no difference- though primary there is one- why not PMMA or gips (calciumsulfate/anhydrit). Has anybody tried ?

Grafting at extraction , even when placing an immediate implant has many benefits and especially now that there are graft materials that are their own membrane (cell occlusive) and bacterio-static. Initially a socket preservation sceptic I now routinely graft and have been very impressed with results. This year has been interesting in the reaserch relating to these concepts and materials , with papers from Jung, Podoropolus, Smeets , Stein etc

I have used Demin Cortical mixed w/ CaSO4 for the past 2 years and have had INCREDIBLE results. There are some instructors teaching this technique all over the world. Some might teach Mineralized Cort mixed w/ CaSO4. My experience and knowledge on bone histology is Mineralized takes longer to turn over as the body have to remove the calcium content through osteoclastic activity... When you use a Demineralized the body can jump right into Osteoblastic activity... So one is not better than the other... it becomes a time game... how fast do you want it to heal for. Also some will say the Demin loses its osteoinductivity through the HCL wash at the tissue bank. I can assure you if you are working with an AATB certified graft material this is FALSE!!! Also some will say they have higher osteoinductivity than others... Again there are multiple tests to show osteoinductivity, and they all deliver different results. The bottom line is ALLOGRAFTS are the best to use in 90% of all grafting procedures. You will receive better results and better foundations to support implants. It all comes down to what you are trying to achieve. The key is to use an AATB certified tissue... They all follow by the standards set by the FDA and AATB... The top tissue banks have raised their standards internally to provide extra sterility and safety... NOT BETTER BONE THAN THE NEXT! The latest material I have seen in this industry is one tissue bank is stating they are better than the other... MARKETING MARKETING MARKETING!!! The points you need to look into selecting an allograft tissue is the following: 1.) AATB certified 2.) Track record (this is PUBLIC knowledge... GOOGLE it!!!) 3.) Can they meet the public supply or are they a small tissue bank that may have back orders... this is big because tissue banks are only as good as the amount of donors they receive per year... and most tissue banks use the donors for orthopedics first then dental. 4.) After you have the top 3 points answered it comes down to PRICE!!! I have been using CTS for the past 2 years, and my mentor in Tennessee has been using them for the past 10 years. Best price in the industry. All AATB certified tissue is a great source. Ask your dental reps because they might be already carrying a AATB certified tissue. Also look into courses which will help you in deliver the best results and the lowest cost. CTS helped me out with this. Since I work both in the hospital setting and in a private practice, I get to use the expensive materials as well. I just don't see a big difference from what I am getting in my private practice. With that being said I will say the Infuse product is nice but very expensive, and sometimes I grew too much bone (yes I said it TTO MUCH...I never knew there was such a thing) I believe it needs more studies underneath it before we dive in, but it did deliver results. Good luck!

does anybody know about doing socket preservation withOUT membrane? just adds another 100$ or so to the treatment and i was considering skipping it if possible. i mean in a 5 walled socket....

You can use gelfoam or PRF as a membrane and they are cheap and easy to use.

The whole idea of using a graft material in the extraction site defect when placing an immediate implant is to prevent epithelialization down the body of the implant before bone bridging. You can do that by placing a bone graft (additional expense) or by using PRF in the space. The advantage of a fibrin plug is that coagulated fibrin prevents epithelial cell downgrowth. In addition, unlike graft materials, it is osteoinductive. PDGF recruits early macrophages, VEGF begins the process of angiogenesis, and TGFb potentiates osteoblastic synthesis of type I human collagen (the necessary scaffold for bone mineralization). It will dramatically speed up both soft and hard tissue healing and increase mineralization of the new bone that forms. We do not have to wait for turnover/resorption of a foreign material and the fibrin is autologous (no patient issues). We also do not need tissue closure to the implant body or a collagen membrane to cover the grafted space (another expense). Our outcome assessments have shown that PRF is superior to graft material in a multi-walled defect. RJM

Dr NJHamp, Can you elaborate about the CTS courses and how do you order allograft from CTS if you are just a small office? I have seen PRF membrane mentioned a lot. What is it? Is it appropriate to be used in an extraction site with buccal bone defect and no primary closure?

T Smith, I should let Dr Miller or Dr Choukroun jump in, since they can offer a more detailed explanation, but I'll give you a brief description. PRF is a process developed by Dr Choukroun and others that utilizes a centrifuge to spin collected blood to create a fibrin clot that can be molded into a membrane, a socket plug and mixed with graft material. This PRF membrane has many osteoinductive factors and angiogenic properties that facilitate faster healing in surgery. Unlike the PRP process, it does not require chemicals and the process is very simple. In reference to your question, you can use it in areas where you cannot obtain primary closure, but in an extraction site with a buccal bone defect it does not have the rigidity that may be needed to maintain the graft space if the defect is too wide. For a good introduction paper to the PRF process see here: http://www.pesgce.com/pde/pdf/2009_09_PRF_Toffler.pdf

When whole blood is centrifuged at about 200g, it separates out into it's constituent parts. PPP (platelet poor plasma or serum), PRF (platelet rich fibrin), PRP (platelet rich plasma), and RBC's at the bottom. Each of these fragments has been used in regenerative medicine, but certain fractions are more appropriate for the types of procedures we are involved in. The most widely used is PRP. The problem with PRP is that it releases growth factors so quickly that is has almost no effect on bone. The specific fraction we now use is L-PRF (leucocyte containing platelet rich plasma). L-PRF has the distinct advantage of a longer term sustained release of growth factors (PDGF, VEGF, TGFb1, and the clotting factor thrombospondin). You will NOT get early bone growth unless you have a fibrin network through which bone cells can migrate. This compressed fibrin membrane, made from the yellow fraction in the collection tube,is ideally suited to promote bone growth and prevent the migration of epithelial cells. It is tenacious, durable, and can be sutured. The density and mineralization of newly formed bone is superior to that created by bone grafts. Dr. Choukroun is returning to the US shortly, sponsored by Intra-Lock, for another PRF lecture series. This will be posted on Osseonews. RJM