Graft: At Time of Extraction or After Site Heals?

Do it at the time of extraction as you will have a bleeding socket. Bone replacement grafts work because they are in contact with bleeding host bone. Any cells or protiens needed to remodel the graft will come from that blood supply. A simple technique would be to atraumatically remove the tooth, graft with your material of choice, use a collagen plug to hold the material in place and mattress suture. Primary closure may be impossible, but the plug should remain long enough for the soft tissue to heal.

It depends totally on idividual situation.If there is severe osseous sturcture loss due to trauma or perio problem,It is better to wait. Also for extensive immdiate graft you have to make sure you have enough soft tissues coverage. Otherwise plane sockets even with labial plate loss should be grafted at the time of extraction. For delayed graft, waiting period is to allow soft tissues healing for better coverage of graft.

I totally agree with Satish that its individual situaion based -a case in point would be a molar site with severe recession;you could do a heroic job of mobilising a flap after extraction and achieve primary closure but at the expense of losing attached tissue and equivocal or not I like to have as much attached tissue as possible around my restorations

you do augmentation at the extraction site if you are sure of the following 1-the site is not infected 2-you could do good coverage for the socket 3- the amount of bone loss is not severe . and you can make direct insertion of the implant with bone augmentation if the bone loss is not severe

The current trend is grafting the socket at the time of extraction on one condition-complete removal of the inflammation by debridment. The healing potential in immediate socket augmentation is high and the potential for bone resorption in immediate socket augmentation diminishes dramatically. Complete soft tissue is always advised.In certain cases where you do not like to shorten the vestibulum there is a possibility of placing a membrane on top of the grafted socket partially exposed like a collagen one which will be covered by epithelium or a smooth PTFE like Osteogenic has that will be removed 3-4 weeks later.

I Think it depends on your case. I have had some very good results but also some less good results in grafting after extraction. Most of the times the graft didn't go that well I had at least preseve some of the with, making grafting afterwards easier. I always clean the socket after extraction with the er-yag laser and do some deëpitheliasation around the grafted site with the er-yag laser. I use a membrane tocoffer the graft and because most of the times you have short of gingiva I use a palatal graft to coffer it. I don't make an extensionflap at the extracted site because I have seen less good results then with the previous described method in my hands. But there are a lot of different technics which will work and it is up to you to make you confidend with those. Best advice is to follow several courses and see what will work in your hands

As one can see, there are lots of ideas or options. It does depend on each case as to when to regenerate the bone for implant placement. However, it is best to know the wound healing studies. Know how bone regeneration occurs and use a regenerative material and not a filler type material. Don Callan

Bone grafting is more challenging than placing the implants in most cases. Two keys are total soft tissue debridement and adequate closure. Of course every case needs to be evaluated individually, but infection alone is not a contraindication to immediate grafting. I have to again stress soft tissue debridement however. I use hand instruments, rotary and irrigation.

I placed a graft 8 months ago with bio-oss and planing to put in an implant, but I am still not certain if the graft is stable. The soft tissue looks oke and on the x-ray it looks oke, but how can one test if the graft is good enough to put in an implant? The graft was paced in the upper jaw in the area of the extracted 1.4. How does one know if there isn't still some soft tissue ingrowth?

While placing a graft I always make sure of the infection and that the recipient sight has to be thoroughly clean to take into consideration bleeding which is the main criteria for the graft healing process. If the soft tissue coverage is inadequete I cover with ptfe membrane which can be retrieved easily after 3 to 4 weeks, collagen membranes afew times require tacs to stabilize them etc but if asked me the best would be case dependant. There is no thumbs rule that one should graft after extn immediately or later.

I have another tip for you. If you are removing a maxillary molar and have limited bone to the sinus, Oteotome lift the sinus between the buccal and palatal roots. The osteotome will want to drift to the path of least resistance. Take a large round or flat diamond to the center of the trifurcation and break through the laminar bone. Tap up the sinus with graft material( I like Curasan) Fill in the sockets of the extracted tooth and try to slightly over fill. Place a non expanded teflon membrane( I like GBR-200) over the material. Place one horizontal matress and two separate interupted sutres;one mesial through the papilla and one distal the same way. This gets you both height and width and if you are gutsy like me, why not place the implant and graft around it as long as there is good stability. Just a thought.

Ad Drs. Mazor and Callan have stated, the ideal time to regenerate is at the time of extraction and with a REGENERATIVE material, not one that may inhibit healing. See the following article for an outstanding biological study on simulated extraction socket healing - barrier protected, bovine bone and TCP compared to each other. (Artzi Z. Weinreb M. Givol N. Rohrer MD. Nemcovsky CE. Prasad HS. Tal H. Biomaterial resorption rate and healing site morphology of inorganic bovine bone and beta-tricalcium phosphate in the canine: a 24-month longitudinal histologic study and morphometric analysis. International Journal of Oral & Maxillofacial Implants. 19(3):357-68, 2004) As has been shown repeatedly in the literature, site collapse occurs after extraction whether or not an implant is placed at that time. ( Botticelli, Daniele. Berglundh, Tord. Lindhe, Jan. Title Hard-tissue alterations following immediate implant placement in extraction sites. Source Journal of Clinical Periodontology. 31(10):820-8, 2004 Oct.)If you want to preserve the site, graft. If collapse won't affect the aesthetics of the site, place an implant and expect site collapse of 2 - 4mm horizontally. As Dr. Mazor stated, using barriers like dense PTFE (Bartee, Horowitz for literature) will preserve socket width and not require primary closure over the site. Bottom line - as Don stated - KNOW HEALING, know biology, understand regeneration and you will improve the predictability of the results you are obtaining.

I agree with Dr. Callan, know your wound healing studies and you will know the answer. I have found that there are three things that really have to be addressed when grafting. 1. patient complience, you could do the most wonderful job but it will always fail if the patient does not follow instructions, 2. technique, again knowing the wound healing process will give you a heads up, 3. chosing the right patient, I know that I have already said patient compliance but you have to know your patient, are they smokers? are they diabetics? are they COPD? tons of questions could be answered by knowing the patient and how there individual bodies will respond.

While there have been many good comments on this question I would like to add another consideration. Sometimes it makes sense to graft a site not ready to be grafted for the sole reason of maintaining tissue volume to facilitate future grafting.

There were many excellent and useful suggestions related to this topic but I think that the major consideration is the individulality of our patients. Increased systemic complications, patient compliance, site infection and additional negative factors should be alarm bells to go a little slower and use more conservative techniques. However, we have a talented group of publishing clinicians who have shown that we can push the healing envelope by carefully modulating the healing enviorment. I will not graft an active infected/purulent site but I do routinely start my patients on an appropriate antibiotic one to two days prior to extraction and bone grafting. In the case of sinus lifts, the addition of systemic steroids reduces complications and increases success rates. Following atraumatic extraction of maxillary molars I now routinely use trephine burs, of the appropriate size, to separate the remaining furcation osseous segment and elivate this osseous core with osteotomes as part of the sinus lift. The osteotome elivates the segment short of the sinus floor, followed by further hydrolyic lift using incremental portions of your preferred graft material - I prefer beta TCP, autogenous bone if available, or GEM 21S. You are then left with an extraction socket that is filled with your grafting material. I then cover the site with a long term collagen membrane, which is less suscepable to infection, then the PTFE membranes. You don't need to have absolute primary closure over the extraction site, although we try our best, as you will get granulation tissue and epithelial migation over the resorbable membrane. Does this work in all cases?? - NO but I have at least maintained extraction socket width, preserved the apical to crestal bone height and routinely increased crest to sinus floor thickness to the point where I can do another Summers Osteotome Procedure (Summers, A New Concept in Maxillary Implant Surgery: The Osteotome Technique, Compend Contin Educ Dent, Vol XV, No. 2, 152-160, 1994.), at time of implant placement, if necessary. You must keep current with the literature and use new techniques to add to your surgical armentarium and continually try to improve all phases of your surgical proticol. Be all that you can be!!

I have had a complete upper denture for 45 year, I going to have bone graft surgury in Los Algodones could any of you give me any comments to ask my dentists.....???

There are some great comments and techniques to choose from. Its what is in your hands and the compliance of the patient and the patients ability to heal. I graft whenever I can which is almost always at the time of XO unless there is fulmunating pus. I use primarily mineralised bone and a collagen membrane, but there are many coctails and techniques. I am conservative and wait four months, especially on molars. I would like to see the technique to trephine the molar radicular bone and summers it up at the time of EXO, that sounds like a great technique because that is most likely where I am going to place the implant. The last molar I did a summers on, it looked great at the time of SX but the bone disappeared during the six months after placement, so I am looking at the membrane or something close at the apex of the implant. I was probably too conservative with the graft at the time. A nice core of interradicular bone over that would have looked nice prior to implantation! Thanks for the advice. Bill

I have recently learned from my learned implant colegues that the risk of lossing the implant in pathological bone is very real. The residual effects of the effected bone will cause the implant to fail apico-coronally.

Thank you Dr.s for the replies. Just out of curiosity. How do you do bone graft after healing? The socket is already closed and gone! I always do the bone graft at the time of extractions. How do you prep the socket for a graft after a few weeks of healing? Thank you very much.

In the absence of alveolar and/or periapical pathology a well curreted alveolus may be successfully grafted immediately and primary closure with a split thickness flap is best. If there is radiographic evidence of socket pathology ( I have learned from colleges at Georgia Regents University School of Dentistry that the surrounding osseous tissues are replete with inflammatory residual reactive substances and the implant which is eventually placed has a real chance of failure from the apico-coronal direction over the next several years. The take away is let the lesions heal and graft healthy tissue.