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Bone Grafting: Hard Sell or Standard of Care?
Today I was considering a topic that comes up frequently in the dental office. I have often had to explain to patients why I recommend a bone graft for their extraction site or socket. Here is what I tell patients:
“The simple extraction of a tooth leaves a hole that is surrounded by a wall of alveolar bone [I call it, 'tooth supporting bone']. This bone’s sole purpose in the human body is to support a tooth. So, when the tooth is lost the body quickly begins to take this bone back, unless it is immediately replaced with either another tooth, an implant or in this case a 'ridge preservation graft' (socket graft). Sometimes, it is possible to place an implant at the time of a tooth extraction. In these cases, the implant will act almost like a tent pole to hold the surrounding bone up and give it the functional requirements necessary to prevent it from undergoing atrophy. Unfortunately, often it is impossible to place an implant at the time of the extraction. This can be for many reasons. However, it is most frequently due to either the presence of a dental infection or a size discrepancy between the tooth that is being lost and any possibility of an immediate implant replacement. In these cases it is wise to place a 'ridge preservation graft'. The ridge graft is designed to fill the space left by the extracted tooth and hold the volume of this space while natural bone has the opportunity to grow and fill the space with high quality live bone. Depending on the size of the tooth that was extracted, the ridge graft requires between three to six months before an implant can be placed.”
Whether or not an implant is placed, a bone graft will preserve the bone to make an implant or a denture more successful. The material used most often for the “ridge preservation graft” is a xenograft made of bovine bone (cow bone). This bone (BioOss) is harvested from known healthy cows in Indonesia and is processed through a freeze drying procedure that makes a sterile end product containing only the mineral content of natural bone. The graft is applied to the empty hole immediately after a tooth extraction and is secured using a pellet of collagen and one or two dissolvable stitches. The graft material has a granular form when used like this (very like the consistency of sand), it is held in the tooth socket by the collagen pellet and stitches until it heals.
The bone graft is not only a good idea but it is the standard of care. To not offer the graft is considered below this standard. The usual reason patients give for not wanting this procedure is that some of their insurance plans do not always cover the procedure. I recommend that it be done, with the patient's approval, whether or not insurance pays for it. Patients appreciate that kindness.
Why Do They Need A Bridge?
Losing a tooth is quite serious. The lost tooth starts a cascading series of events that are difficult, if not impossible to reverse. The problem is that the teeth adjacent to the one lost tend to collapse into the space left by the lost tooth while the tooth opposite the lost tooth moves into the space as well. All the while that this is going on the teeth next to the opposite one also collapse in toward the opposite tooth which is narrower at the root than at the enamel covered, crown portion.
This "drifting" effect can contribute to cavities, gum disease & bone loss. Severe cases can also result in such a bad bite that it contributes to jaw pain and chronic headaches may result. Another bad result of a lost tooth is the way the bone shrinks away from the empty tooth socket causing the lips or cheeks to sink in, adding years to the appearance.
There are alternative ways to replace a tooth. The best way is with an implant. Implants stimulate the surrounding bone like the tooth that occupied the space before it was lost. Another solution could be a "permanent" bridge. Although the bridge is simple to place, slightly less costly than an implant and has been used successfully over many years, it is not without possible complications like cavities and need for root canal treatments. Also the bridge may need to be replaced from time to time which adds to its overall cost. The boney socket must be grafted to maintain the illusion of the "Pontic" emerging from the gums.
An implant can not get a cavity, will never need a root canal and, with proper care, will not need to be replaced. The implant is muck cheaper in the long run.
Another common way to maintain the integrity of the space left when a tooth is lost is to replace it with a removable partial denture. Most people do not like these because they come with a significant amount of "hardware" such as major connectors, a base and some kind of clasps. However, they are much cheaper than other alternatives but require much more adaptation and maintenance on the patient's part.