Bone Grafting and Jawbone Preservation
Over a period of time, the jawbone associated with missing teeth atrophies or is reabsorbed. This often leaves a condition in which there is poor quality and quantity of bone suitable for placement of dental implants. In these situations, most patients are not candidates for placement of dental implants.
Today, we have the ability to grow bone where needed. This not only gives us the opportunity to place implants of proper length and width, it also gives us a chance to restore functionality and esthetic appearance.
Jawbone and Extraction Site Preservation
When you need to have a tooth or teeth extracted whether it be due to decay, abscess, gum disease or injury it is usually in your best interest to do so in a manner which preserves as much of your underlying jawbone as possible. From the time the teeth are removed, significant degeneration of the surrounding bone begins to take place. You have many options to prevent this, and it is important that you consider them BEFORE any teeth are removed. Some of these procedures are best performed at the time the tooth is removed. Dr. Bailey is an oral and maxillofacial surgeon who specializes in tooth removal, jawbone preservation and dental implant placement.
What happens when a tooth is removed?
There is a special type of bone surrounding your teeth. This bone is called alveolar ridge bone, and exists solely to support your teeth. As soon as the tooth is removed, this bone begins to degenerate and melt away. This occurs in two dimensions. The first is loss of horizontal width caused by the collapse of the bone surrounding the socket. This makes the remaining ridge narrower than when the tooth was present. The second is a loss of vertical height. This makes the remaining bone less tall. This process is faster in areas where you wear a partial or complete denture.
Why is it important to preserve the bone?
You will have several choices of how you can replace the newly missing teeth. All of the options rely on bone support and bone contour for the best function and esthetics. Here is a list of the possible options:
- You may choose to replace your missing teeth with dental implants. These are root-shaped supports that hold your replacement teeth. The more bone support you have, the stronger the implant replacements will be. In some cases, the bone can degenerate to a point where implants can no longer be placed without having more complex bone grafting procedures to create the necessary support. Obviously, preventing bone loss is much easier than recreating the bone later.
- You may choose to replace the missing teeth with a fixed bridge. This is a restoration that is supported by the teeth adjacent to the missing tooth space. The replacement tooth (or pontic) spans across the space. If the bone is deficient, there will be an unsightly space under the pontic that will trap food and affect your speech.
- Other replacement alternatives include removable partial or full dentures. These often perform better with more supporting bone.
How can the bone be preserved?
There are two important phases in retaining your alveolar ridge during and after the tooth extraction. Not all extractions are the same. Dr. Bailey will use the most careful techniques to extract the teeth while preserving as much bone as possible. Secondand key to preventing the collapse of the socket is the addition of bone replacement material to the extraction socket.
There are several types of bone grafting materials and techniques. Dr. Bailey will discuss the most appropriate one with you. After the tooth is extracted, the socket will be packed with a bone-like material and covered with a small absorbable plug or suture. Early on, the grafting material will support the tissue surrounding the socket, and in time will be replaced by new alveolar bone. This bone will be an excellent support should you choose later to have dental implant-supported replacement teeth.
Although the bone created by socket grafting supports and preserves the socket, it will not do so indefinitely. Placing dental implants four to twelve months after the extraction and socket grafting will provide the best long-lasting support for preserving your jawbone and allow you to function as before. Otherwise the graft may melt away or resorb over time.
Immediate Dental Implant placement
In some selected cases it is possible to actually extract the tooth and place the dental implant at the same time. We call that immediate implantation. If you are interested in replacing your tooth with an implant and want to be considered for immediate implantation, please call Dr. Baileys office for a consultation prior to your extraction.
How much does it cost?
All patients receive the most careful bone-preserving extraction techniques at no additional charge. There is an additional charge for performing a socket grafting procedure at the time of the extraction. Charges vary depending on the tooth location and number of teeth. At the time you call Dr. Baileys office for your appointment, you should state that you are interested in jawbone preservation when your tooth is removed. Dr. Baileys staff will be happy to provide you with an estimate of the procedure cost. The final exact cost will be provided at the time of your visit prior to the procedure.
Sinus Augmentation or Lift Procedure
The maxillary sinuses are behind your cheeks and on top of the upper teeth. Sinuses are like empty rooms that have nothing in them. Some of the roots of the natural upper teeth extend up into the maxillary sinuses. When these upper teeth are removed, there is often just a thin wall of bone separating the maxillary sinus and the mouth. Dental implants need bone to hold them in place. When the sinus wall is very thin, it is impossible to place dental implants in this bone.
There is a solution and its called a sinus graft or sinus lift graft. The dental implant surgeon enters the sinus from where the upper teeth used to be. The sinus membrane is then lifted upward and donor bone is inserted into the floor of the sinus. Keep in mind that the floor of the sinus is the roof of the upper jaw. After several months of healing, the bone becomes part of the patients jaw and dental implants can be inserted and stabilized in this new sinus bone.
The sinus graft makes it possible for many patients to have dental implants when years ago there was no other option other than wearing loose dentures.
If enough bone between the upper jaw ridge and the bottom of the sinus is available to stabilize the implant well, sinus augmentations and implant placement can sometimes be performed as a single procedure. If not enough bone is available, the Sinus Augmentation will have to be performed first, then the graft will have to mature for several months, depending upon the type of graft material used. Once the graft has matured, the implants can be placed.
Ridge-augmentation with Onlay Grafting
In severe cases where the tooth-supporting ridge has been reabsorbed a bone graft is placed to increase the ridge width and/or height. In these situations, the graft is taken from another area inside your mouth and transplanted into the deficient area. Once transplanted, it will grow in its new location. This in-office procedure is usually performed using sedative or general anesthesia and takes about an hour.
In severe cases, the ridge has been reabsorbed and a bone graft is placed to increase ridge height and/or width. This is a technique used to restore the lost bone dimension when the jaw ridge gets too thin to place conventional implants. In this procedure, the bony ridge of the jaw is literally expanded by mechanical means. Bone graft material can be placed and matured for a few months before placing the implant.
Major Bone Grafting
Bone grafting can repair implant sites with inadequate bone structure due to previous extractions, gum disease or injuries. The bone is either obtained from a tissue bank or your own bone is taken from the jaw, hip or tibia (below the knee.) Sinus bone grafts are also performed to replace bone in the posterior upper jaw. In addition, special membranes may be utilized that dissolve under the gum and protect the bone graft and encourage bone regeneration. This is called guided bone regeneration or guided tissue regeneration.
Major bone grafts are typically performed to repair defects of the jaws. These defects may arise as a result of traumatic injuries, tumor surgery, or congenital defects. Large defects are repaired using the patients own bone. This bone is harvested from a number of different sites depending on the size of the defect. The skull (cranium), hip (iliac crest), and lateral knee (tibia), are common donor sites. These procedures are routinely performed in an operating room and require a hospital stay.
The inferior alveolar nerve, which gives feeling to the lower lip and chin, may need to be moved in order to make room for placement of dental implants to the lower jaw. This procedure is limited to the lower jaw and indicated when teeth are missing in the area of the two back molars and/or the 2nd premolar, with the above-mentioned secondary condition. Since this procedure is considered a very aggressive approach (there is almost always some postoperative numbness of the lower lip and jaw area, which dissipates very slowly, if ever), usually other, less aggressive options are considered first.
Typically, we remove an outer section of the cheek side of the lower jawbone in order to expose the nerve and vessel canal. Then we isolate the nerve and vessel bundle in that area, and slightly pull it out to the side. At the same time, we will place the implants. Then the bundle is released and placed back over the implants. The surgical access is refilled with bone graft material of the surgeons choice and the area is closed.
These procedures may be performed separately or together, depending upon the individual’s condition. As stated earlier, there are several areas of the body that are suitable for attaining bone grafts. In the maxillofacial region, bone grafts can be taken from inside the mouth, in the area of the chin or third molar region or in the upper jaw behind the last tooth. In more extensive situations, a greater quantity of bone can be attained from the hip or the outer aspect of the tibia at the knee. When we use the patients own bone for repairs, we generally get the best results.
In many cases, we can use allograft material to implement bone grafting for dental implants. This bone is prepared from cadavers and used to promote the patients own bone to grow into the repair site. It is quite effective and very safe. Synthetic materials can also be used to stimulate bone formation. We even use factors from your own blood to accelerate and promote bone formation in graft areas.
These surgeries are performed in the office under IV sedation or general anesthesia. After discharge, bed rest is recommended for one day and limited physical activity for one week.
Platelet Rich Plasma
Platelet Rich Plasma (PRP) is exactly what its name suggests. The substance is a by-product of blood (plasma) that is rich in platelets. Until now, its use has been confined to the hospital setting. This was due mainly to the cost of separating the platelets from the blood (thousands) and the large amount of blood needed (one unit) to produce a suitable quantity of platelets. New technology permits the doctor to harvest and produce a sufficient quantity of platelets from only 55 cc of blood drawn from the patient while they are having outpatient surgery.
Why all the excitement about PRP? PRP permits the body to take advantage of the normal healing pathways at a greatly accelerated rate. During the healing process, the body rushes many cells and cell-types to the wound in order to initiate the healing process. One of those cell types is platelets. Platelets perform many functions, including formation of a blood clot and release of growth factors (GF) into the wound. These GF (platelet derived growth factors PGDF, transforming growth factor beta TGF, and insulin-like growth factor ILGF) function to assist the body in repairing itself by stimulating stem cells to regenerate new tissue. The more growth factors released sequestered into the wound, the more stem cells stimulated to produce new host tissue. Thus, one can easily see that PRP permits the body to heal faster and more efficiently.
A subfamily of TGF, is bone morphogenic protein (BMP). BMP has been shown to induce the formation of new bone in research studies in animals and humans. This is of great significance to the surgeon who places dental implants. By adding PRP, and thus BMP, to the implant site with bone substitute particles, the implant surgeon can now grow bone more predictably and faster than ever before.
PRP has many clinical applications.
- Bone grafting for dental implants. This includes onlay and inlay grafts, sinus lift procedures, ridge augmentation procedures, and closure of cleft, lip and palate defects.
- Repair of bone defects created by removal of teeth or small cysts
- Repair of fistulas between the sinus cavity and mouth
PRP also has many advantages.
Safety: PRP is a by-product of the patients own blood, therefore, disease transmission is not an issue.
Convenience: PRP can be generated in the doctors office while the patient is undergoing an outpatient surgical procedure, such as placement of dental implants.
Faster healing: The supersaturation of the wound with PRP, and thus growth factors, produces an increase of tissue synthesis and thus faster tissue regeneration.
Cost effectiveness: Since PRP harvesting is done with only 55 cc of blood in the doctors office, the patient need not incur the expense of the harvesting procedure in hospital or at the blood bank.
Ease of use: PRP is easy to handle and actually improves the ease of application of bone substitute materials and bone grafting products by making them more gel-like.
Frequently asked questions about PRP
Is PRP safe?
Yes. During the outpatient surgical procedure a small amount of your own blood is drawn out via the IV. This blood is then placed in the PRP centrifuge machine and spun down. In less than fifteen minutes, the PRP is formed and ready to use.
Should PRP be used in all bone-grafting cases?
Not always. In some cases, there is no need for PRP. However, in the majority of cases application of PRP to the graft will increase the final amount of bone present in addition to making the wound heal faster and more efficiently.
Will my insurance cover the costs?
In most cases, no. The cost of the PRP application is paid by the patient.
Can PRP be used alone to stimulate bone formation?
No. PRP must be mixed with either the patients own bone, a bone substitute material such as demineralized freeze-dried bone, or a synthetic bone product.
Are there any contraindications to PRP?
Very few. Obviously, patients with bleeding disorders or hematologic diseases do not qualify for this in-office procedure. Ask Dr. Bailey if PRP is right for you.
Distraction osteogenesis (DO) is a relatively new method of treatment for selected deformities and defects of the oral and facial skeleton. It was first used in 1903. Then, in the 1950s the Russian orthopedic surgeon, Dr. Gabriel Ilizarov slowly perfected the surgical and postoperative management of distraction osteogenesis treatment to correct deformities and repair defects of the arms and legs. His work went mostly unnoticed until he presented to the Western Medical Society in the mid-1960s.
Distraction osteogenesis was initially used to treat defects of the oral and facial region in 1990. Since then, the surgical and technological advances made in the field of distraction osteogenesis have provided the oral and maxillofacial surgeons with a safe and predictable method to treat selected deformities of the oral and facial skeleton.
Dr. Bailey uses distraction osteogenesis to treat selected deformities and defects of the oral and facial skeleton. If you have questions about distraction osteogenesis, please call our office and schedule an appointment with Dr. Bailey.
Frequently Asked Questions About Distraction Osteogenesis
What does the term distraction osteogenesis mean?
Simply stated, distraction osteogenesis means the slow movement apart (distraction) of two bony segments in a manner such that new bone is allowed to fill in the gap created by the separating bony segments.
Is the surgery for distraction osteogenesis more involved than “traditional surgery” for a similar procedure?
No. Distraction osteogenesis surgery is usually done on an outpatient basis with most of the patients going home the same day of surgery. The surgical procedure itself is less invasive so there is usually less pain and swelling.
Will my insurance company cover the cost of osteogenesis surgical procedure?
Most insurance companies will cover the cost of the osteogenesis surgical procedure provided that there is adequate and accurate documentation of the patients condition. Of course, individual benefits within the insurance company policy vary. After you are seen for your consultation at our office, we will assist you in determining whether or not your insurance company will cover a particular surgical procedure.
Is distraction osteogenesis painful?
Since all distraction osteogenesis surgical procedures are done while the patient is under general anesthesia, pain during the surgical procedure is not an issue. Postoperatively, you will be supplied with appropriate analgesics (pain killers) to keep you comfortable, and antibiotics to fight off infection. Activation of the distraction device to slowly separate the bones may cause some patients mild discomfort. In general, the slow movement of bony segments produces discomfort roughly analogous to having braces tightened.
What are the benefits of distraction osteogenesis versus traditional surgery for a similar condition?
Distraction osteogenesis surgical procedures typically produce less pain and swelling than the traditional surgical procedure for a similar condition. Distraction osteogenesis eliminates the need for bone grafts, and therefore, another surgical site. Lastly, distraction osteogenesis is associated with greater stability when used in major cases where significant movement of bony segments are involved.
What are the disadvantages of distraction osteogenesis?
Distraction osteogenesis requires the patient to return to the surgeon’s office frequently during the initial two weeks after surgery. This is necessary because in this time frame the surgeon will need to closely monitor the patient for any infection and teach the patient how to activate the appliance.
In some cases, a second minor office surgical procedure is necessary to remove the distraction appliance.
Can distraction osteogenesis be used instead of bone grafts to add bone to my jaws?
Yes. Recent advances in technology have provided the oral and maxillofacial surgeon with an easy to place and use distraction device that can be used to slowly grow bone in selected areas of bone loss which has occurred in the upper and lower jaws. The newly formed bone can then serve as an excellent foundation for dental implants.
Does distraction osteogenesis leave scars on the face?
No. The entire surgery is done within the mouth and the distraction devices used by Dr. Bailey remain inside the mouth. There are no facial surgical incisions made so no unsightly facial scars result.
Are there any age limitations for patients who can receive osteogenesis?
No. Distraction osteogenesis works well on patients of all ages. In general, the younger the patient the shorter the distraction time and the faster the consolidation phase. Adults require slightly longer period of distraction and consolidation because the bone regenerative capabilities are slightly slower than those of adolescence or infants.