On this page9 sections
An implant needs bone to hold it, and bone shrinks once a tooth is gone. Bone grafting keeps it, or puts it back. Most of the grafting we do is the simple kind: preserving the socket at the moment a tooth is removed, so that an implant stays possible later. Adding bone to a site where it has already been lost is a larger procedure, and often a shorter or narrower implant, or a bridge, is the better answer. The scan decides which.
Why we graft when a tooth comes out
When a tooth is removed, the thin bone that held its root begins to shrink within weeks and keeps shrinking for years. The research on this is clear: sockets that are grafted keep more of their width and height than sockets left to heal on their own, and the difference is enough to decide whether an implant fits comfortably later or needs rebuilding first.
Our usual material is donor bone, an allograft processed and sterilized by a tissue bank. It avoids a second surgical site to harvest your own bone, and in our experience it gives the most consistent results. The graft is covered with a membrane, most often a dense PTFE membrane that can be left exposed to the mouth while the socket heals beneath it, sometimes a collagen membrane. The approach is well documented, and we have found it to work very well.
Socket preservation, step by step
- Step 1 of 4 A careful extraction
When a graft is planned, the tooth is removed as gently as possible to keep the surrounding bone intact, under local anesthesia. Any infection left in the socket is cleaned out.
- Step 2 of 4 The graft and the membrane
Donor bone fills the socket, a dense PTFE membrane covers it, and fine sutures hold the membrane in place. If the site allows, an implant can be placed at this same visit, which avoids the later wait.
- Step 3 of 4 Four weeks later
A short follow-up of five to ten minutes to check healing and remove the sutures and the membrane. It needs no anesthesia and does not hurt. This visit is included in the graft fee.
- Step 4 of 4 Healing
The site matures over four to six months. When the time comes, the scan confirms the bone and the implant is placed.
When the bone around a tooth is already badly damaged by infection or gum disease, the socket graft becomes more involved: a titanium-reinforced membrane to hold the shape, sometimes small screws or tacks to fix it. That is the exception. Most socket grafts are the simple version.
Rebuilding bone that is already lost
If a tooth has been missing for years, or the site healed without a graft, the ridge may be too thin or too low for a standard implant. Bone can be added, but not all additions are equal. Adding thickness to a ridge works fairly well. Adding height is difficult, less predictable and more prone to complications, which the research on vertical augmentation confirms, and it is not something we count on.
A ridge graft uses donor bone, a titanium-reinforced dense PTFE membrane and bone screws to hold everything in position while it heals, and sometimes a block of donor bone fixed in place. It is a longer visit, there is more swelling than after a socket graft, and the implant waits four to six months. We do these in the office when they are the right answer, and we refer the unusually complicated ones to a periodontist. More often, before recommending one, we look hard at the alternatives in the next section, because for most patients they are simpler, quicker and less expensive.
Sinus lifts
The upper back teeth sit below the sinus, and when they are lost the sinus often expands into the space, leaving too little bone height for an implant. A sinus lift raises the sinus floor and places bone beneath it. We do internal sinus lifts, through the same small opening used for the implant, which heal with very little discomfort. If about four millimeters of bone remain, we can usually lift the sinus, add bone and place the implant in the same visit.
With less, we add the bone first and place the implant four to six months later. The research on this approach shows high implant survival, and a better prognosis when a few millimeters of natural bone are present to start with, which is why the scan decides the sequence. The larger lateral window sinus lift is rarely necessary; when it is, we refer it.
A shorter implant, a narrower one, or a bridge
Grafting can often be avoided. Implants come in lengths and widths. A standard implant is ten to eleven and a half millimeters long; short implants of six or eight millimeters exist for sites with limited height, and narrow implants for ridges with limited width. The research comparing short implants with sinus lifts and longer implants finds similar survival with fewer surgical complications for the short implant.
When grafting would be extensive, or when other risks are present, such as smoking, a bridge is often the better choice. Implants are straightforward when the bone is good and considerably more complicated and expensive when it is not. A bridge is traditional dentistry: started one day and in place two or three weeks later, with normal chewing from then on.
An implant in grafted bone is a process of up to a year. For most patients the two function equally well. For a tooth at the very back, with nothing behind it, a removable appliance is also possible, though few of our patients want one. Our missing tooth page compares the options.
Recovery and risks
- Every grafting procedure is done under local anesthesia, with sedation available for anyone who wants it.
- Visits run from about forty-five minutes to two hours depending on complexity.
- Socket grafts, internal sinus lifts and implant placement cause little pain or swelling; ridge grafts cause more, and a longer recovery.
- In every case we prescribe pain medication, which most patients need for one to five days, and an antibiotic, which is taken for a week whether or not there is pain.
- For the weeks after a graft, do not chew on that side, and brush the rest of your teeth normally while leaving the grafted area almost untouched, so the membrane is not disturbed.
Grafts that fail are rare with the technique we use. When one does not take, we let the area settle, look at it a little sooner than we otherwise would, and decide whether a further graft is needed before the implant.
Two things raise the risk. Smoking increases the chance that a graft or an implant fails; the research puts the failure rate for implants in smokers at roughly double that in non-smokers. Diabetes matters when it is poorly controlled. We check your hemoglobin A1c, and when it is in the normal range we treat your risk as similar to that of other healthy adults, which is what the research supports. Both are reasons to consider whether a bridge serves you better.
How we decide
The plan is finalized only after a CBCT scan shows the exact amount and shape of the bone. At the consultation Dr. Kottar examines the site and talks through the options in general terms. The scan then tells us:
- Whether a socket graft is enough
- Whether a shorter or narrower implant avoids grafting altogether
- Whether a sinus lift can be done with the implant in one visit
- Whether a bridge is the better choice
You see the scan, and the reasoning, before deciding.
Frequently asked questions
Do I need a bone graft to get an implant?
Not necessarily. If the tooth is still in place and we preserve the socket when it comes out, further grafting is rarely needed. If the tooth has been missing for years, the 3D scan tells us how much bone is left, and often a shorter or narrower implant fits without adding bone at all.
Why graft the socket if I am not sure I want an implant?
Because the bone shrinks once the tooth is gone, and rebuilding it later costs several times more than preserving it now. Almost every patient in our office wants to keep the implant option open, and the socket graft is what keeps it open.
Where does the graft material come from?
We use donor bone, processed and sterilized by a tissue bank, covered with a membrane. It avoids a second surgical site to harvest your own bone, and in our experience it gives the most consistent results. Collagen or dense PTFE membranes protect the graft while it heals.
How long until the implant can be placed?
Four to six months after a graft, in most cases. Where the site allows, we prefer to place the implant at the same visit as the extraction and the graft, which removes that wait altogether.
How much does it hurt?
Socket grafts, internal sinus lifts and implant placement cause little pain or swelling; most patients take pain medication for one to five days. Ridge grafts that rebuild lost bone involve more swelling and a longer recovery. Antibiotics are taken for a week in every case. The membrane is removed four weeks later in a short visit of a few minutes that does not need anesthesia.
I smoke, or I have diabetes. Can I still have a graft?
Often, with care. Diabetes that is well controlled, which we check with a hemoglobin A1c test, carries a risk close to that of other healthy adults. Smoking raises the chance that a graft or an implant fails, and the research bears that out; many smokers do well, but the odds are worse, and sometimes a bridge is the wiser choice.
Sources
Professional guidelines and peer-reviewed reviews this page draws on.
- Avila-Ortiz G, Elangovan S, Kramer KWO, Blanchette D, Dawson DV. Effect of alveolar ridge preservation after tooth extraction: a systematic review and meta-analysis. Journal of Dental Research. 2014;93(10):950-958. DOI
- Hoffmann O, Bartee BK, Beaumont C, Kasaj A, Deli G, Zafiropoulos GG. Alveolar bone preservation in extraction sockets using non-resorbable dPTFE membranes: a retrospective non-randomized study. Journal of Periodontology. 2008;79(8):1355-1369. PubMed
- Urban IA, Montero E, Monje A, Sanz-Sanchez I. Effectiveness of vertical ridge augmentation interventions: a systematic review and meta-analysis. Journal of Clinical Periodontology. 2019;46(Suppl 21):319-339. DOI
- Del Fabbro M, Corbella S, Weinstein T, Ceresoli V, Taschieri S. Implant survival rates after osteotome-mediated maxillary sinus augmentation: a systematic review. Clinical Implant Dentistry and Related Research. 2012;14(Suppl 1):e159-e168. PubMed
- Thoma DS, Zeltner M, Husler J, Hammerle CHF, Jung RE. Short implants versus sinus lifting with longer implants to restore the posterior maxilla: a systematic review. Clinical Oral Implants Research. 2015;26(Suppl 11):154-169. DOI
- Chrcanovic BR, Albrektsson T, Wennerberg A. Smoking and dental implants: a systematic review and meta-analysis. Journal of Dentistry. 2015;43(5):487-498. PubMed
- Naujokat H, Kunzendorf B, Wiltfang J. Dental implants and diabetes mellitus: a systematic review. International Journal of Implant Dentistry. 2016;2:5. PubMed
