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Bone grafting

A bone graft is the addition of a given amount of bone to a place where it has been lost. The most common example is the addition of bone to the hole left by the removal (extraction) of a tooth. There are four types of grafts that can be performed in the mouth in humans:

  • Autogenous bone: the graft bone comes from the patient himself. This type of graft requires the preparation of two surgical sites, the donor site and the recipient site. The patient may prefer it to avoid having a graft from an external source;
  • Allogenic bone: the graft bone comes from a donor external to the patient, i.e. another human. The graft bone is from a cadaveric source and all provisions for disease transmission are controlled by government authorities. Each company must go through a series of rigorous tests and the provenance of each sample must be documented in the patient file. It is possible for the body to reject the material, but this is very rare;
  • Xenogenic bone: the bone of the graft comes from an animal, often from the bovid family. With the arrival of allogenic grafts that are better accepted by the human body, this type of graft tends to disappear. Rejections are very rare;
  • Synthetic material: this material is not bone, but a synthetic material. It looks like bone and can be used to play the same role as the bone graft. This type of material is not yet accredited or available in all countries.

Following all these types of grafts, the body creates new bone cells that will gradually replace the graft until it is completely gone. This process, called remodelling, takes place over a period of several months. In some cases, a larger volume of bone may be inserted to counteract bone loss that occurs during the natural remodelling process, in order to achieve an adequate final bone volume.

Indications for treatment

  • Conservation of the bone ridge after extraction for aesthetic reasons (e.g. future bridge on anterior teeth);
  • Create sufficient space in width and height to allow the placement of a dental implant (ceramic or titanium) immediately or in future years;
  • Restore the jaw to a regular and adequate shape for the fabrication of partial or complete prostheses;
  • Support the maxillary sinus in cases of sinus elevation;
  • Reconstruction of the jaw(s) following a serious accident, congenital deformities or jaw resection in cases of oral cancer.

Advantages

  • Allows the placement of dental implants (ceramic or titanium) in places where it would have been impossible to place them due to lack of bone;
  • Improves the aesthetics of the smile in areas where teeth have been extracted;
  • Improving the emergence profile of the bone of a dental implant so that a crown can be made that mimics the appearance of a natural tooth;
  • Supports the maxillary sinus in order to position one or more dental implants;
  • Gives the surgeon the ability to choose an implant size that is better suited to the patient’s masticatory function (for example, being able to place a larger dental implant to replace a molar);
  • Improving the comfort and aesthetics of fixed bridges, partial or complete prostheses to be manufactured.
  • Allogenic or xenogenic bone: the use of allogenic bone requires the preparation of a single surgical site.

Disadvantages

  • Potential for infection or rejection of bone particles following grafting, especially in the case of allogeneic (non-patient) grafts;
  • Sometimes requires an additional surgical appointment if the graft is not performed at the time of extraction;
  • The procedure is often stressful for the patient;
  • Recovery time is variable depending on the procedure and the patient (age, health status, etc.);
  • The procedure requires a period of rest or a temporary slowing down of activities;
  • The procedure usually requires painkillers;
  • The procedure occasionally requires the use of antibiotics;
  • Autogenous bone: the use of autogenous bone requires the preparation of two surgical sites, the donor site and the recipient site. An autogenous graft therefore involves the healing of two sites in the mouth.

Risks and consequences of not treating

  • Less aesthetic restoration of teeth;
  • Inability to place dental implants to replace extracted teeth;
  • Inability to make certain types of dentures, or less comfortable dentures;
  • Inability to perform sinus lift surgery;
  • Problems with chewing and digestion, if fixed or removable dentures are not ideal.

Processing steps and times

  • First appointment:  
    • Consultation with review of the patient’s dental and medical history;
    • Clinical and radiological examination of the site(s) to be grafted;
    • Cost estimate.
  • Second appointment  (depending on the type of graft):
    •  Autogenous bone graft:
      • Preparation of the donor site, harvesting and preparation of the bone to be grafted (lower jaw ascending limb or chin symphysis, more rarely at hip level);
      • Extraction of the selected teeth (depending on the case);
      • Positioning of the grafted bone;
      • Positioning of dental implant(s) (if possible depending on the case);
      • Positioning of membrane or blood substrate (PRF);
      • Closure of the site with sutures;
      • Prescription of antibiotics and/or painkillers (as appropriate).
    • Grafting with allogenic, xenogenic or synthetic bone:
      • Extraction of selected teeth (as appropriate);
      • Positioning of the grafted bone;
      • Positioning of dental implant(s) (if possible, depending on the case);
      • Positioning of membrane or blood substrate (PRF);
      • Closure of the site with sutures;
      • Prescription of antibiotics and/or painkillers (as appropriate).
  • Third appointment:
    • Follow-up healing and removal of sutures (depending on the type of sutures used).

Postoperative indications

Please note that these recommendations are for information only and that the best recommendations are those of your dentist or specialist who performed the surgery.

The following is a list of the most common recommendations from practitioners:

  • Take prescribed or recommended painkillers;
  • Take prescribed antibiotics;
  • Use prescribed antiseptic mouthwash as recommended;
  • Avoid drinking through a straw, spitting and smoking for the first 24 hours;
  • Apply ice for 10-15 minute periods alternating with a rest period;
  • Avoid brushing the teeth near the wound for a few days;
  • Avoid strenuous sports activities as recommended;
  • Avoid foods that are too acidic, very hot, salty or vinegary;
  • If bleeding occurs, apply a sterile compress to the wound or a moist tea bag and maintain pressure for 15 minutes. When lying down, keep the head elevated by adding an extra pillow;
  • If they have been used, the stitches are fragile. Some are melting, others are not. It is important to find out about the specific care required in each case. Note that sutures often fall out by themselves. Do not pull on the sutures, do not cut them;
  • The recovery period following surgery varies from person to person depending on the complexity of the surgery and how well the patient complies with post-operative advice;
  • Allow approximately two days of rest following surgery. Swelling will usually peak during this time;
  • Discomfort from the surgery often occurs in the first five days.

Restrictions

The risks and consequences versus the benefits are always assessed before the procedure. In some cases, the dentist or maxillofacial surgeon may choose not to proceed with the bone graft.

Examples of untreated cases:

  • Too much bone loss either to contain the grafted portion (loss of bone plate at the buccal side of the tooth, i.e. on the cheek side) or for reasons of excessive resorption of the jaws over time (e.g. in people who have been toothless for many years)
  • Danger of damage to nerve structures with too great a possibility of permanent loss of feeling (paresthesia);
  • Medical condition of the patient.

A consent form will be given to you to inform you of the issues involved in the surgery, to inform you of the possible risks and complications, to provide you with post-operative advice and to ensure that all your questions have been answered.

In the case of a risky extraction or one that is outside the scope of your general dentist’s practice, you may be referred to a maxillofacial surgeon, a dentist who specialises in performing more complex surgery.

Cost

  • Varies according to:
    • The number of sites to be grafted;
    • The type of graft: autogenous, allogenous, xenogenic or synthetic material;
    • The complexity of the surgery.
  • You will be given a written estimate of the procedures and costs;
  • It is possible to request a predetermination from your insurer. This may facilitate the reimbursement of your benefits according to your dental care coverage.

In Quebec, in the case of accidents or grafts performed in a hospital, the Régie de l’assurance maladie du Québec (RAMQ) covers the majority of bone corrections performed.

Alternative solutions

  • Placement of small implants;
  • Compromise in the fabrication of fixed or removable prostheses.
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