Guidelines for Surgical Bone Grafting to Preserve Alveolar Ridge Height and Width Following Tooth Extraction



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Guidelines for Surgical Bone Grafting to Preserve Alveolar Ridge

Height and Width Following Tooth Extraction

Following extraction of a tooth, a dimensional loss of bone height and width is a natural occurrence during the healing phase. “Misch and colleagues speculated that the loss of crestal bone height and labial plate after tooth extraction is due in part to the constriction of clot within the alveolus and the thin labial cortical plates remodeling in response to inadequate blood supply after the extraction”. It is documented that following tooth extraction the loss of bone height and width may be 40% to 60%.



Bone Grafting Materials – Modified from Carl E. Misch: “Contemporary Implant Dentistry 3rd Edition”

  1. Collagen type I – found in human body and is among first products synthesized by the body when bone formation (osteogenisis) first begins

    • Collagen membrane from processed bovine type I collagen membranes used to decrease the invasion rate of epithelial cells or fibroblasts into a graft site

  2. Autologous bone – (osteogenisis activity).

  • Bone harvested from the same person to be used at a site somewhere else in the same genetic autogenous donor

  • The most effective bone material for new bone growth - rich in blood

forming cancellous bone marrow

  • Aggressive Risk management and painful procedure as bone is harvested from the autogenous’ iliac crest or a rib

  1. Allografts – (osteoinduction activity).

  • Bone harvested from human cadaver tissue site (donor) and grafted to a

different genetic human’s recipient site.

  • Best stand alone bone grafting material and 100% safe

  • The allograft may be

  • DFDB (Demineralized Feezed Dried Bone is osteoinductive and more effective in new bone growth; or

  • FDB (Freezed Dried Bone) less effective and more osteoconductive new bone growth

  • The probability of that a particular graft of DFDB might contain HIV has been calculated to be 1:2.8 billion and the literature has reported no incidence occurrence.

4. Xenografts – (osteoconduction)

  • Fabricated from anorganic portion of bone from animals other than humans

  • Graft material harvested from bovine (cows)

  • Bovine anorganic bone good source of bone growth material that must be deproteinated in the fabrication process

  • Very good bone bank grafting material resembling natural human bone

5. Alloplasts – (osteoconductive, not osteogenic or osteoinductive)

  • Synthetic calcium phosphate HA (anorganic materials)

  • PepGen P-15, three stands of 1300 synthetic amino acid combined with bovine anorganic bone matrix

  • Direct bonding with the host’s bone by mechanical contact


Bone Grafting Products

1. MTF– human tissue bank



  • Best stand alone bone grafting material

    • MTF-DBX Putty (FDAB Matrix) (0.5cc)

    • MTF- mineralized cancellous powder (0.5cc)

    • MTF- mineralized cortical powder (0.25cc)

  1. PepGen P-15 Putty in carrier medium with Sodium Hyaluronate (0.5cc) or

Particulate (1.0 gram) granules (Allograft material)

  • A synthetic peptide derived from anorganic bovine bone material (ABM)

  • Very good bone grating material when used as Putty syringe product

  • PepGen P-15 Putty requires mixing-2 syringes supplied (0.5cc)

  • Indication - socket and ridge preservation and perio defects

  • Particulate size 250-420 microns (1.0 gram)

  1. OsteoGraft 300 (LD-300)

  • Synthetic granules

  • Best for ridge preservation for future implant or prosthesis

  • Low Density hydroxylapitite (250-420 microns)

  • Very slow turn over into bone – requires 15 months before reentry before

implant placement

Levels of Bone Grafting Associated with Timing of Implants placement
Level I – Slow Bone Growth Required

  • LD – 300 synthetic bone product is grafting material of choice for Level I – Slow Bone Growth

  • Implant placement undecided at time of extracion

  • Indicated for extraction sockets for implant or prosthesis placement at some time in the future

  • Requires 15- months for grafting material to turn over into dense bone before reentering for implant placement

  • Following atruamatic extraction, complete thorough curettage of socket

  • LD – 300 consists of dry particulate granules

  • Requires hydration with sterile saline

  • Packet firmly into socket to height of alveolus ridge

  • Requires membrane cover with sutures

  • Very inexpensive grafting material


Level II – Medium Bone Growth

2-Options

  1. Option one- Human tissue bank cadaver bone - Mineralized Cadaver Particles (MCP)

    • Best choice for routine socket and ridge preservation bone grafting bone

    • Simplicity in use and very predictable new bone augmentation

    • 4-5 months turn over of grafting cadaver material into dense bone now ready for implant osteotomy and fixture placement

    • MTF, tissue bank source for human cadaver bone powder – highly respected surgical cadaver harvesting company

    • All grafting material certified to be free of any infectious disease (HIV)

    • Particle size 250 – 800 comes combined with mixture of cancellous and cortical particles providing conductive and inductive capability for dense bone growth




  1. Option two – 3 choices

    • PepGen P-15 Powder

      • Reenter in 4 months.

      • Has grainy surface look on reentry that may appear to be poor quality new bone

      • However, histology shows bone venality is higher for PepGenP-15 than MCP

    • Osteograf N-300 (1 gram). 6-12 months turn around of material before opening site to perform osteotomy and implant fixture placement

      • N 300 very good all round bovine bone particulate material (250-420 microns)

      • 6-12 months turn around of material before opening site to perform osteotomy and implant fixture placement

    • Osteograf N-700-N (1gram)

      • acceptable grafting bovine bone particulate material (420-1000 microns)

      • 6-12 months turn around of material before opening site to perform osteotomy and implant fixture placement


Level III – Fast Bone GrowthRequires advanced experience and knowledge in bone grafting and implant placement before attempting Fast Bone Growth Techniques

  • Provides rapid availability of quality bone for implant fixture stability

  • Combination of different types of bone grafting material

  • Mixing MTF DBX Putty and Pepgen P-15 powder 50% of each by volume or 60% PepGen to 40% DBX putty by volume

  • MTF DBX comes in carrier

2- Techniques

Delayed Technique

  • DBX Putty plus Pepgen P-15 Powder

  • Ready for osteotomy within 3 ½ - 4 months turn around of material before ready to open site for osteotomy

  • Requires membrane cover material sutured in place


Marshmallow Ball Technique – combination of Various Bone Grafting Materials

  • DBX Powder plus Pepgen P-15 Flow ( very oily and lose material)

    • “Salt and Pepper” addition of one of the following dried granular particles until have thickening similar to marshmallow ball. Dry particles gives rigidity to the DBX plus Pepgen P-15 Flow grafting material

    • Add as salt and pepper one of three different dry particles

      1. Pepgen P-15

      2. MCP (similar to Purous from Zimmer)

      3. Osteograf N-300

    • Marshmallow Ball consistency acts as “caulking” material to fill voids that may exist between the implant fixture and the bony cortical walls.

    • Eliminates gap defects 1-2mm between socket walls and implants

    • Allows new bone cells to “jump” from bone growth to socket walls

    • As implant fixture tapped into extracted socket, excess material escapes out of socket creating the “caulking seal effect”

  • Marshmallow Ball may also be used for Delayed Grafting Technique and covered with barrier cover material and sutures


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