Grafting an Extraction Site even when the Buccal Cortical Plate is Intact?

A 5 wall extraction site should heal uneventfully as long as the buccal plate is greater than 1.5mm in thickness. The issue for extraction sites is multifold-there is a zone of necrosis within the socket after extraction (this can destroy a very thin buccal wall), there is normal soft tissue contracture(which can put undue pressure on a thin wall)- the result can be a defect. The easiest way to counteract this is to extract the tooth, place either bovine or allograft material, a collagen plug and suture. If this is done, your outcome will be much more predictable.

There is no harm using a graft. It will definitely save embarassment of some threads of the implant showing later and any instability of the implant.

A residual buccal wall of less than 2mm in thickness is likely to leave behind very little cortical bone on the buccal aspect of the "healed" extraction socket at a later date. The usage of Collagen Plugs is likely to minimise the effects of resorption activity on the buccal wall and thereby ensure preservation of this aspect of the residual alveolar ridge for longer. In the event that this residual alveolar ridge is not rehabilitated with an Implant "soon" enough, it is likely that the variables at work will eventually begin to resorb the buccal wall again! Hence the need to restore 'Osteo-stimulatory' forces in the alveolus by having an Implant placed and be loaded (optimally) at the appropriate time to maintain optimal bone volume for the times to come!

If the patient exhibits interest in restoring the lost tooth with an implant,at a later date, then a graft is definately indicated.The ridge will be preserved. Research has shown that my simply drilling some "bleed holes" in the extraction socket, and covering with a membrane, the zone of necrosis mentioned above will not develop. The holes drilled are to irrigate the socket with blood that is coming from deep within the bone ( narrow spaces) that carry osteoblasts to the site. A simple pure PTFE membrane can be used to occlude foreign bodies from invading the site,and control bleeding when sutures are used. An inexpensive and practical method of making your own PTFE membranes can be found in my article published Sept/October 2003 in Implant News and Reviews. For further information contact Dr. Gerald Rudick, Montreal, Canada

The buccal plate is most succeptible to changes in blood supply. It pays to assess the gingival and alveolar morphotype prior to extraction when making this decision.A thick gingival type with a flat alveolar morphology is less likely to show massive buccal resorption than a thin/high scalloped.Additionally,if a flap is raised,resorption is accelerated due to compromised blood supply.Atraumatic extraction,2mm of labial plate and a thick gingival type-shouldn't need to be grafted. when grafting is needed, in situations where the plate is ,1.5 mmthick and/or the gingival type is thin and/or a flap has been raised,it makes more sense to place a material that INTEGRATES and DOES NOT RESORB/resorbs at a slow rate since the object of the excecise is to prevent resorption and here my material of choice is bovine bone. There is no unequivocal evidence to show that immediate placement of an implant will retard bone resorption and even when placed immediately,the implant is spatially oriented to the site that one would chose to place the implant IF IT WERE A COMPLETELY HEALED SITE.

The best way to preserve the height of alveolar ridge is by inserting an implant simultaneously in fresh socket,and if there is any pathologic or bony defect in the area,i prefer to carefully curettage the area and laser the area by blue light then by using artificial bone and membrane i will close the operation field for 3 month.it is nearly always successful. Dr.Hajiheshmati diploma in dental implantology

Dr. Hajiheshmati, with all due respect, your comment is incorrect. The placement of an immediate implant into a fressh extraction site does not preserve the alveolar ridge height nor does it do anything to prevent the normal physiologic remodelling that occurs after an extraction.

I HAVE A PATIENT 35 Y. OLD FEMAL SHE HAD OLD DEFFECT EXTRACTED AREA in upper canin &premolars left side she is edentulous i implant for her with xive system but i put grafting materal as easy graft in deffect area after waiting 3 month i lost all my graft materal with mobility in upper canine implant .... I am asking about reson ??? how can i resolve my problem ??? thnk you

Bottom Line-- The site will not fill in with bone. Sure, there are rare cases that will, most will not. The human body has the ability to repair, but not to regenerate lost parts. Graft with a material that will allow the area to produce real living bone. Bovine bone is only a filler. Use an allograft material--it does have BMP. Autograft may or may not give the result you want. Build the foundation (bone), the place the implant.

Even when there are 5 walls of bone present, a graft should be placed. The clot that forms without a graft, forms in the coronal area last. Through grafting a site a scaffold is created allowing more predicable bone growth in the cerstal area. It is the crestal area that is obviously most important for a dental implant or papillae formation. I agree with dr. Callan that a DFDBA product that offers growth factors is best.

this boils down to one thing for me: it is easy to graft an extraction socket. it is not easy or predictable to graft around an implant. this is why i graft any socket that will recieve an implant. i like to make life easy for me and the patient. yes a graft adds more cost, but it adds a level of reliabilty and simplicity for me and the patient that is worth every penny. once this is clearly explained to the patient, i have never had anyone refuse a graft at the time of extraction. materials and techniques?? whatever works best in your hands.

To sb oral surgeon: Very well stated! Anything we can do to make life easier for the patient and us is worth it. A five wall or even a four walled defect has a more predictable prognosis than a three, two or one walled defect and is less expensive to treat than the three, two or one walled defect. The socket grafting only takes a few minutes to perform.

I have a couple of questions from sb oral surgeon; First, do you really believe that EVERY SINGLE extraction socket needs to be grafted? Is it scientifically supported or ethically justified? Doesn't it impose an additional charge to the patients without a necessity ? Second, primary grafting of the extraction socket does not need a more waiting time for the area to get ready for accepting(surgial insertion) of the fixture? Do you think that this time lapse makes the life even easier for the patients?

I accept the scientific basis for ridge preservation at time of extraction using a graft and collagen plug but what about when the tooth being extracted has a chronic infection discharging though the alveolus. Safe thinking tells me not to graft but I am tempted to pre-treat with systemic antibiotics and then place bovine bone mixed with tetracycline and collagen plug

I agree with sb oral surgeon, almost every socket should be grafted to ensure predictability and make life simpler for the surgeon and the patient. A well preserved site allows better implant size and positioning and reduces the potential need for grafting when the implant is placed. The relatively small additional expense and additional time is worth it considering you're attempting to predictably and permenantly replace an important piece of dental anatomy.

If you believe in grafting extraction site defects, why don't you place the implant and graft the extraction site defect around the implant. In this way, you can place an anatomic healing abutment or provisionalize the implant out of occlusion. You will preserve the dento-gigival complex, and the slight stress on the bone from the provisional will help to maintain bone. When you graft first, then wait 4 months to place the implant, the bone density and quality of soft tissue is diminished. If you attend implant conferences, virtually every clinician shows extraction/immediate placement cases and retention of soft/hard tissue profiles. The use of current generation implant systems, bone graft materials, lasers, and growth factors such as PRF, will help to re-engineer the biology of the osteotomy. Inappropriate choices of implant sequencing, poor selection of bone graft materials, and an adherence to old paradigms will lead you to mediocre clinical outcomes. RJM

Some of the recent literature discusses using medical grade CaSO4 to fill the socket defect at the time of extraction. This material is completely replaced in 3 to 4 months with new bone while all of the other graft materials have residual particles in the socket area for longer and different periods of time. This is not a long term product but a lot depends on if an implant will be placed or not and if so how far out is placement planned. It was mentioned CaSO4 will hold the ridge for about a year if an implant is planned. If not then HA or bovine bone might be used if no implant is ever to be placed. Recent lecture discusses using the CaSO4 mixed with your material of choice (Cadaver bone, Bovine, ??) to fill the socket and hold the material in place. More and more companies are starting to sell you CaSO4 kits to graft with. These kits seem a little expensive for .5 or 1 cc of plaster, small vial of sterile water, vial of ~4% Potassium sulfate to speed up the plaster set. Seems a poor boy socket fill kit might be to buy a pound of medical grade CaSO4 (correct type), Dry sterilize this in small vials or dry heat sterilization bags,get some some sterile water, some accelerator to quicken the set and use this for a less expensive alternative for some patients or patients that do not want cadaver or bovine materials in their mouth or to mix with the graft material as a carrier. Anyone tried this on simple sockets? Results. Wonder if this will hold the tissue back as well as a membrane in an extraction site with bony defects?

Does any one knows where in Europe or the US I could buy CaSO4 in great quantities as a pound of it for example (medical grade)? I do use it for grafting extracion sockets and I would say that in the mayority of the cases the results are good. Sometimes I mix it with DFDBA and covere it with pure CaSO4. The soft tissue seems to like to grow over it conserving the CaSO4 underneath it.

Well. extraction site should be grafted. I agree with Dr. Callan. You need to graft the site. For a site that is well protected from all the sides, simple material like DentoGen would do a good job.