Why would you need dental bone graft for implant?
The main qualifier for having dental implants is having enough bone. Your jaw must have sufficient bone material to support dental implants which are used to restore an extracted tooth. This is one of the most important criteria to check if you want to maximize your success rates. Dentists will drill the implants and embed them into your jawbone. So, the better the foundation, the higher chances for your implants to be fully integrated into your jawbone.
Dental specialists will examine your jawbone and look at the following characteristics:
- Width
- Height
- Density
So, they can check if your jawbone has the right dimensions to accommodate a dental implant, which has the following specifications:
| Dental Implant Size | Diameter | Height |
|---|---|---|
| Standard | 3.5 mm – 6.0 mm | 13.0 mm – 16.0 mm |
| Mini-implants | 3.0 mm – 3.5 mm | 8.0 mm – 12.0 mm |
| Narrow | 1.8 mm – 3.0 mm | 5.0 mm – 8 mm |
Please note that the mini implants and narrow ones are alternative dental implant sizes for those whose jawbone dimensions don’t fit the standard size implant.
Density, on the other hand is a completely different matter. No dental implant size will work if the bones to which the implant will be attached are not strong enough. It needs a solid foundation to which it can be attached permanently. Otherwise, the implant will eventually get loose and fall out.
Yet, what if your jawbone is not high enough or wide enough? Does it mean you can kiss your implant dream goodbye?
Well, don’t worry; dentists can perform what they call bone augmentation if the patient’s bones in the mouth do not meet the standards for dental implant.
What is bone augmentation for implants?
The process is also called bone grafting and uses bone or bone-like materials to replace or rebuild the jawbone. The operation can be as simple as adding bone material to the area where a dental implant will be placed or can be as complex as rebuilding the dental ridge’s size and shape.
That means whatever your case: there is probably a solution.
In some cases, a simple bone graft can be placed at the same time that the implant is placed.
But most of the time, it would require a separate operation to be performed beforehand.
In some cases, depending on the complexity of the operation, your dentist would have to let some other dental specialists like periodontists or oral surgeons do it.
You would then have to wait for the graft to be fully integrated to your jawbone. This healing period could take several months (3-6 months) before a dental implant operation is performed.
What you don’t use, you lose
The real question is: how can you lose bone in your mouth area?
Bone loss can be caused by a number of factors like accident, blunt force trauma, infection, or periodontal disease. But, most of the time, it is due to a missing tooth or teeth that can cause deterioration of the bone density in the areas where teeth are not present any longer.
OK, you must be thinking: how can a lost tooth lead to bone loss?
Well, this is pretty simple, when you lose a tooth; the jawbone beneath it begins to shrink and becomes brittle because you no longer have stimulation in this area. Yes, bones are not as solid and inert as we think. Bones do evolve with time depending on the forces that are applied.
The old adage “what you don’t use, you lose” applies to our jawbone. Your bone stays tall and thick when your teeth are there stimulating your bone every day. If you lose your teeth, your jaw bone will start to shrink from disuse. Unfortunately, this also happens with only one missing tooth!
So without the stimulation from the lost tooth that is directing the bite force to the bone, this bone area will atrophy day by day and lead to premature aging.
What is the best thing to do? Prevent losing bone in the first place. If you have to lose a tooth, it would be best to replace it with an implant on the same day if possible or within the first 6 months after losing it.
The implant that will replace the missing tooth will stimulate the bone like a normal tooth. That’s why you often hear dentists say that dental implants can help maintain bone….
Patients who have lost their teeth for a long period of time will more likely need bone augmentation to be able to get dental implants because of bone loss.
Where Do Materials for Bone Graft Come From?
The bone used in augmentation comes from 4 main sources, listed here:
- Your own bone
Using your own bone extracted from other parts of your body is considered as the most effective and safest source of bone for grafting purposes. The collected bone will easily combine with the jawbone because there is very little chance of tissue rejection. The bone can be collected from the chin, other parts of the jaw, shin, hip and tibia.(the bone below the knee). Your bone is usually used without any much transformation, the dentist might have to shape it a little so to fit the target area.
Compared to other sources, the procedure of extracting your own bone for augmentation is quite expensive, as it requires two separate operations—extraction and grafting. And, if the bone is sourced from the hip or shin, you probably need to have general anesthesia and stay in the hospital for recovery. - Bone from human cadaver
Human cadaver bones used for bone augmentation are sourced from trustworthy tissue banks. The bones are freeze-dried and sterilized to preserve them. This option costs less and is generally safe. - Animal bone
Bones from cows are the most widely used animal bone to shore up bone density and dimension in dental implant. The reason for this is that cow bone integrates well with human bone and does not present much complication. As for human donor bone, cow bone is freeze dried . To further enhance safety, the cow bone is cleansed through sterilization. - Synthetic source
Synthetic bone-like material can also be used, it is usually a mineral bone substitute that fuses well with the human bone.
So you know grafted bone can come from 4 different sources, but are all types of bone graft material the same?
Well, you won’t be surprised to learn that the most effective graft material is your own bone, then freeze-dried human bone from a tissue bank, followed by processed cow bone, and lastly, mineral bone substitute
Is any dental bone graft material safe to use?
Using your own bone is definitely the safest choice because it comes from your own body, so there is no risk of rejection and you will not experience the risk of contracting infection disease or contamination.
That was in fact, the main drawback when using graft material from human donor or animals, which can be compared to the same risk as receiving blood for transfusion from a blood bank.
But today, bones are freeze-dried and sterilized so to avoid any risk of infection through these materials.
This is why dentists prefer to work with reputable and trusted tissue banks. Feel free to talk to your dentist about the kind of material that will be used for your bone graft.
And although it is considered the least effective in the long run, the mineral bone susbtitute is completely sterile, so the risk is close to zero.
Bone graft procedure
While most bone grafting used to involve the patient’s own bone, today for smaller areas to fill, dentists use more and more processed bone that has been harvested from animals like cows, so this bovine source is quickly becoming the first dentist choice before the human donor source.
These animal bones are freeze dried and sterilised. So visually, it kinda looks like some white powder with bigger or smaller particule size depending on the brand used.
How does it work ? Dentists will fill the chosen area with this dental bone graft material that will act as a kind of placeholder so that bone healing and remodelling can take place. In fact, the bone healing process will start and your body will see the graft as some natural bone to repair and so over time, it will replace it with your own bone. Smart, isn’it ?
Preparation: You will need x-rays taken before your bone grafting procedure so your dentist can check your jawbone. You will also probably need a CT scan ( a more accurate and 3D X ray picture), which will measure precisely the height and width of your existing bone.
There are 3 main bone grafting procedures :
- The socket graft or alveolar ridge preservation graft
- The block bone grafting
- The sinus grafting or sinus lift
They can also be combined if necessary.
The socket graft or alveolar ridge preservation graft
The extraction of a tooth will leave a hole which is the empty tooth socket. If you leave this hole as it is, your bone in this area will gradually resorb and schrink as mentionned previously, unless it is immediately replaced with an implant or a socket graft also called the alveolar ridge preservation graft – which is pretty self-explanatory, this graft helps to maintain the ridge size and height.
In somes cases, placing an implant at the time of a tooth extraction is possible if the size of the hole is more or less the same as the implant post. But usually, many dentists prefer to be on the safe side, and choose to place a socket graft to fill the hole while your own bone has the opportunity to grow and fill the space.
Then the following phase of the treatment requires a lot of patience. Depending on the size of the extracted tooth, the graft requires between 3 to 6 months to be « healed » and fully replaced by natural bone before an implant can be placed.
The material that is mostly used for the socket graft is a graft made up of cow bone, which is harvested from controlled and healthy cows. This bone material is then freeze dried and sterilised. The end product is some white powder or white sand that is applied to fill the empty hole immediately after a tooth extraction.
The hole is then secured with a membrane or a pledget of collagen and some dissolvable stitches to retain the graft material in the tooth socket for the bone healing phase to start.
Note that during this healing phase, especially if the extracted tooth is at the front, your dentist can propose you to wear a temporary denture with a fake tooth. Once the healing is over, and the bone substitute has been replaced by your own bone, the implant operation can be performed.
The block bone grafting
When the amount of missing bone is too important, the cow bone material is not the best material to provide enough bulk or volume to create the ideal foundation for the dental implant, so dentists will propose to harvest the patient’s own bone to use as a bone graft for the deficient area. This is what we call the block bone graft, because you will need larger amount of bone. It is usually a block of bone that is harvested to replace the missing bone.
What are the possible causes of bone loss that might need this option ?
- Area of the jaw where teeth were extracted without any bone grafting, leading to bone loss
- Area of the jaw where bone has been destroyed due to infection or tumors.
- Dental trauma
Where is the block bone graft harvested ? Well, usually the block of bone is obtained from the chin or the lower jaw. But, if it is not possible, it can also come from the hip or even the tibia.
Your dentist will remove a small block of bone and transfer that graft to the target area. The collected material for grafting will then be placed at the area that needs augmentation. Titanium screws will be used to fasten the graft securely in place. Some cow bone “powder” is placed on the edges of the bone material to facilitate integration or fusion of the material to the recipient area. A collagen membrane will be laid over the grafted area.
As for the socket graft, recovery from this procedure will take around four to six months. Once fully healed, the titanium screws used to secure the graft will be removed and you will be ready for the implant procedure.
Note that dentist will also usually fill the donor site with cow bone material to regrow bone.This is to allow the bone to heal naturally without the gum taking up the space and causing the donor site to weaken.
The sinus grafting or sinus lift
When you consider dental implants in your upper jaw near your molars or premolars (so in a nutshell at the back of your upper jaw), your dentist will need to check the position of your sinuses.
What are sinuses ? Some of your face bones are hollow and contain airspaces called sinuses. The sinuses above the upper back teeth are called maxillary sinuses. They are on either side of your nose and help to warm, moisturize and filter air when we breathe.
The thing is when a tooth is lost, and if no bone substitute is added, the jawbone in this area will resorb and schrink as you know by now, so the floor or the sinus will move downward.
So if the dentist try to drill and embed an implant in the jawbone, there won’t be enough bone. The dental implant won’t be stable enough to work properly.
So what can dentists do ? They will perfom what they call a sinus lift which is an operation that adds bone to the back of your upper jaw.
How do they proceed ?
Dentists will create a small window in the sinus above the roots of the upper jaw teeth, which will enable them to move the sinus membrane upwards. That will create a small cavity that can be filled with cow bone material. A collagen membrane as usual is applied to close and protect the graft. You will have to wait between 3 to 6 months for the graft material to be fully replaced by your own bone before getting the tooth implant.
So dentists pushed back the sinus floor membrane to its original position, which explains this procedure term : sinus lift or sinus floor bone augmentation.
Note that to prevent any complication, if you have seasonal allergies and a runny nose you would have to postpone the procedure when they are not active, so to avoid too much stress on your sinuses.
How to use your own super healing power with PRP ?
In order to speed up the healing process, some dentists have started using proteins called growth factors.
What the heck ! Growth factors ? That sounds scary. No, don’t worry, they are simply obtained from your own blood.
In fact they use PRP which stands for platelet rich plasma (which contains the growth factors). It is a therapy that uses your own blood to stimulate a healing response within a damaged tissue and here the damaged tissue is your bone with the graft material.
In another words, they simply use your body’s own regenerative powers to help grow bone safely and quickly.
PRP is simply made by taking a small sample of your own blood and spinning the sample in a centrifuge machine for fifteen minutes to separate platelet growth factors from red blood cells. Once the PRP is separated, it is transferred to a syringe and ready for injection.
Platelet rich plasma PRP looks like a kind of jelly-like liquid that can be applied to the bone graft right before the collagen membrane.
In a normal healing process, platelets need to migrate to the target area to help and trigger the healing porcess. It usually takes a few days to reach a certain concentration. Here we speed up the process by bringing to the bone grafting site on day one all the elements to help our bone to grow. No need to wait. PRP helps to accelerate the natural process in which the body heals itself.
Besides there is no risk of allergic reaction or rejection because they use your own blood.
PRP treatments are not only used in dentistry they are also used to rejuvenate damaged skin, and also to treat injuries like tennis elbow and ligament damage : PRP helps to speed up the healing process at the cellular level and enables to cut down the time for recovery.
PRP vs. BMP : what to choose ?
In fact, some dentist will also propose you some other « healing helpers » that can be added to your bone graft, like BMP ( bone morphogenetic protein).
It is a protein derived from other human donors, that will also help your bone grow just like PRP.
But the thing is it is pretty expensive… BMP treatments cost around $2000 to $6000 (which, in my opinion is insane…) and that is only for the BMP treatment, the bone grafting is not even included…
If you are given the choice between PRP and BMP, PRP is probably the best choice because it is made from your own blood, not someone else’s and it will cost you maybe $200-300 for the treatment, although some dentists don’t charge a dollar.
Follow up : what to expect
After bone grafting procedure, you will experience some swelling of the area, this is perfectly normal.
You will also bleed from your mouth and a little from your nose if you had a sinus lift. Of course, do not blow your nose forcefully or chew anything hard that could cause the bone graft material to move and loosen the stitches.
You will see your dentist after 6-11 days to have your jaw checked and probably will have to visit him a few times regularly to make sure the area is healing properly for the next 3-6 months.
Post-procedure Recovery and Care
The first 24 to 48 hours after the dental bone graft procedure is the most critical because the incision is still fresh and the bone graft is just in place. Here are some tips that can help you get through the first two days after the operation:
- General care procedures
Avoid touching the area where the procedure was done. You also need to avoid forceful spitting and vigorous mouth rinsing within 24 hours of the operation to prevent further bleeding. Smoking is definitely off the picture. You also will be given pain medicine, an antibiotic and an antimicrobial mouthwash to help prevent infection.Take your pain medications as prescribed, but do not take them without having eaten anything. And of course, it would be best if you could have complete rest for at least two days after the surgery. - Managing bleeding
Bleeding is expected in any surgery so don’t worry. When you notice spots of blood in your saliva, you can use a salt-based rinse to wash off the blood. Mix a half teaspoon of salt with a lukewarm glass of water. Use this homemade concoction three to four times a day for the next five days. You may also want to try to place a wet black teabag over the sutured area for 30-45mn. Tea contains tannic acid that facilitates blood clotting and prevents further bleeding.( your gum will look black due to the black tea, don’t worry, it is just temporary) - Swelling
Post-operative swelling reaches its maximum after two days, so don’t be surprised if your face becomes plump after you go out of the hospital. It will keep swelling till the second day, which is a normal reaction. You can prevent this from happening or at least reduce its intensity by applying ice pack to the part of the face near the area of surgery. Do this in a 30-minute cycle. Three days after surgery, you may use warm towel over the area of the face where you experience swelling. - Bruising
Skin discoloration is often observed after an operation and is usually found in the area that is also swelling. Moist heat pack can help reduce both swelling and discoloration from the 3rd day post-operation. So, first 48hours : use ice pack, then use warm pack… - Take Your Meds
Antibiotics will be prescribed to prevent infection, so take them as scheduled. If you experience rashes or allergies after taking your antibiotics, consult your doctor immediately.
As you will also be given pain medication, it is best not to engage in any activities involving motor skills owing to the drowsiness side effect. If pain persists, you know what to do : call your dentist immediately. - Oral Hygiene
The speed of your recovery will highly depend on how you take care of your mouth. As advised, use the antimicrobial mouthwash. Do not brush your teeth on the same day of the surgery, you can do so the following day using a soft bristled toothbrush, but make sure that you avoid the area of the surgery. Do not brush as vigorously as you did prior to the surgery.
Dental bone graft cost
The first factor that affects the dental bone graft cost is the amount of bone material needed to cover the recipient area and where the source material will come from. Getting the source bone from other parts of the person’s body requires additional operation and, therefore, entails extra cost. That’s why cow bone material is mostly used today.
Synthetic bone substitute or bones collected from cadavers or cows costs around $200 to $1,100 for a single recipient area. Using your own bone as graft material will cost around $2,000 to $3,000 due to the additional surgery, plus the cost of hospital stay and the type of anesthesia used.
Sinus grafting and block grafting are considered complex procedures. Socket grafting with a small area to treat using donor or synthetic bone material will be considered as simple. Other bone augmentation cases with your body bone will usually belong to the complex category.
Bone grafting prices
Lower end cost Average cost Upper end cost
Simple bone graft $200 $600 $1 300
Complex bone graft $1 800 $ 2000 $ 3300
what about insurance coverage ? While dental insurance normally does not cover dental implant because it is cosmetic in nature, some parts of the procedure may actually be claimed against the insurance. This is where your dentist needs to determine which part of the procedure is functional as opposed to cosmetic. Bone loss, for example,may prevent a person from being able to eat normally . If other dental solutions, like dentures, cannot resolve this concern then the bone grafting procedure can be considered as a functional solution and be covered by insurance.
X-rays cost from $50 to $200, while CT scans can run from $300 to $900. Other costs to consider include fees of specialists like anesthesiologists which is around $55 up to $112 per hour. Yes, you read that right! Anesthesiologists are paid every minute they are in the operating room.
So, dental implant procedure is generally costly. The need to undergo bone graft procedure adds to the cost of the implant. Bridges and dentures can be the next best options if your budget is tight or if the healing period is too long for you. In spite of the added cost, however, bone grafting will provide you the assurance that your dental will be long-lasting—and that makes your added expense a cost-effective investment.
Risks of bone grafting
The main risk is infection as for any surgical procedure. That’s why you will be prescribed antibiotics.
In some cases, the bone graft doesn’t intregrate with the jawbone. But this is less and less the case with the new bone substitute and the use of PRP.
Keep in mind the risk of the sinus membrane being punctured or torn with the sinus lift procedure. If this happens, the dentist will either place a patch over it or stitch the menbrane tear. If the tear is too big, then dentists usually prefer to stop the procedure and give more time for the tear to heal. Once it is healed, your dentist can resume the sinus lift procedure.
When To Call your dentist
After bone grafting, you should contact your dentist if:
- bleeding does not stop after the first or second day.
- Swelling or pain gets worse over time. (It should decrease after the first two days or so.)
- You think the graft material may have been dislodged after sneezing or blowing your nose.
- You develop a fever.