#4: Bone Grafting Getting Dental Implants When You Don’t Have Enough Bone
Transcript
Dr. Tanner Townsend 0:00
Welcome back to the Smile Reconstruction Podcast. I’m with Dr. Muir once again, my co-host, and today we’re going to be talking a little bit about bone grafting. Now, first and foremost, we know that implants are wonderful, and they are excellent when you have good health, abundant bone and you are healthy, the implants are a wonderful tooth replacement option. But Dr. Muir, what happens when we don’t have enough bone?
Dr. Josh Muir 0:25
Yeah, you know, kind of like one of the patients we talked about today that came in for a consult. When you don’t have enough bone, you either are no longer a candidate for dental implants, or you have to become a candidate. And a lot of times that takes place by bone grafting procedures.
Dr. Tanner Townsend 0:42
Well, let’s kind of dive into a few different bone grafting procedures. Let’s maybe start with like a very basic one. First, when we take a tooth out, oftentimes, we’ll say, hey, we need to do a bone graft. When we take a tooth out, walk us through how that helps us and what it does for a patient long term that’s looking to get an implant.
Dr. Josh Muir 1:00
Yeah. So if you consider an implant has to go into bone, when we take a tooth out, it leaves a great big hole. If that hole is big enough, if we were to just set the implant in there, it would just rattle around inside there. There wouldn’t be enough bone contact on the implant to hold it in. And so what we’re doing with that bone graft is we’re filling in that hole and allowing the gum tissue to grow over it, allowing your body to turn that bone graft into your own natural bone. Then you have adequate bone for implant. And as you know, we can sometimes engage some of the bone that’s in there, and it’s just the top part that doesn’t have enough bone, and so we’ll graft that, but we’ll do that with the implant in place. Other times we have to let the bone heal and then come back and place the implant at another time.
Dr. Tanner Townsend 1:46
Okay, so I think that those are some really good points. So when we do that bone graft, what does that bone graft do for, like, the width of bone when we take a tooth out, versus when we don’t do a graft,
Dr. Josh Muir 1:58
Yeah, so as we know when we’re not using our bone to hold teeth up, our bone shrinks, and it tends to shrink in widthwise and shrink up on the upper teeth or down on the lower teeth. And so our bone just diminishes. And then, because we’re trying to put the implant in, the smaller that bone gets, the less our chances of being able to utilize that remaining bone for an implant.
Dr. Tanner Townsend 2:23
So we always recommend that bone graft when we take out teeth, typically, because we don’t want to lose that bone. It helps hold that bone structure of the original tooth, which is wonderful. So let’s say we’ve got a patient, kind of like we talked about today, from this patient that came into our office that let’s say they didn’t do a bone graft, and they’ve had this tooth missing for years, and now we’ve got that issue of we don’t have enough width of bone and enough height of bone. Let’s kind of break those into two different things. What do we do when someone doesn’t have enough width of bone but they have enough height to put an implant in?
Dr. Josh Muir 2:54
Yeah, so there’s two methods that we can use when someone doesn’t have enough width of bone. One is called bone manipulation or bone expansion, where you use their existing bone, and our bone is sometimes soft enough that we can just bend it a little bit and still put the implant in there. That’s the ideal way to do it, no additional procedures. The other way, though, is we actually have to go in and place a bone graft that builds it out. And there are different methods to do that, but in essence, they all attach to the outer part of the bone and put the gums back over top. And over the course of about five months, your body will turn that graft material into your own bone.
Dr. Tanner Townsend 3:36
So just to kind of reiterate what you just said there, I love that idea of bone manipulation, and we try to do that a lot for our patients, to help save them time and money, just so that they don’t have that extra procedure where we just kind of flex the bone a little bit, and the upper bone is typically a little bit more flexible than the lower bone, correct. But so that patient that, let’s say, they need a bone graft, they need to expand the width of the bone in order to have an implant there, we have to wait five months for them to heal. So what does that look like in the meantime, while they’re healing during this five month period?
Dr. Josh Muir 4:09
Well, typically, they just leave that area alone and something you don’t want to chewed on, because if that bone graft is being jostled and banged against, it’s going to tell your body that it’s something that shouldn’t be there. If it’s nice and solid against the bone, then your your body should accept it, so just leave it alone. Chew on the other side, chew soft foods, that kind of stuff, and it should heal well.
Dr. Tanner Townsend 4:33
Now, are there any areas in the mouth where we kind of see this happen more often, where, like bone grafts are more needed to expand the width of the bone,
Dr. Josh Muir 4:41
Yeah, you know, a lot of it depends on time. So any part of the mouth, the longer the teeth have been missing, but we see that in the posterior mandible, where that’ll shrink down. And what are you thinking? What other
Dr. Tanner Townsend 4:53
No, I was thinking the posterior mandible, but I was also thinking just the top. I mean, I’ve seen a lot of patients, and we discussed like last week how patient comes in, they need a tooth taken out in the front. And oftentimes those front teeth in the front don’t have tons of bone in front of them, or no bone,
Dr. Josh Muir 5:09
Right.
Dr. Tanner Townsend 5:10
And
Dr. Josh Muir 5:10
Eggshell thin,
Dr. Tanner Townsend 5:11
Eggshell thin bone. And so either, if it breaks at all, we’re grafting nothing, or we have to do that extra graft just to give us enough width. So that’s the other area that I think of oftentimes where we’ll need that.
Dr. Josh Muir 5:23
Yeah, that’s a good point. So, you know another area that it’s harder to visualize, but the posterior Max lab here, typically those molars will have three roots, and when those teeth are taken out the bones surrounding the roots on the upper part of that. We can’t see it or feel it from here, because it’s it’s coming from above, but those will start to shrink as well. And so these molars, it’ll shrink this way, and it’ll shrink this way. And so what we’ll be left with is very short bone. And so even if we do have the width, it’s not enough to put an implant in. And so that’s when we talk about our sinus graft, and as you know, there are two ways to do that. One is called a lateral sinus graft, where we can gain a lot of height. The other is called a vertical sinus graft, where we can gain a little bit of height that sometimes is just enough to allow us to place an implant at that time.
Dr. Tanner Townsend 6:17
So like you said, there’s certain cutoffs, because I’ve had patients ask me this before, with those sinus grafting or bone grafting in the sinus when can I get away with doing a vertical sinus lift versus the bigger lateral sinus lift?
Dr. Josh Muir 6:31
We see the most success with vertical sinus grafts when it’s two millimeters lifting maybe three millimeters if it’s a perfect width and perfect anatomy and density of bone. Sometimes you can get even more than that, but realistically, the two to three millimeters, sometimes we need 10 millimeters, though, or more, and that’s only going to come from that lateral sinus graft.
Dr. Tanner Townsend 6:55
I think that’s a really key thing for patients to understand, that, hey, the healing on that lateral sinus graft is a longer time. We typically say, what? Four to six months? Right?
Dr. Josh Muir 7:04
About five months, yeah.
Dr. Tanner Townsend 7:05
And so letting that bone mature, just so we can come back later and put a good, solid implant in there, just like if we’re gonna graft an area down here in the front, that way we get everything healed up nice. Now we’ve talked a little bit about getting with the bone lifting the sinus up to add more bone in the back. Let’s talk a little bit about adding vertical height to bone. Near impossible to very, very challenging.
Dr. Josh Muir 7:29
Very challenging. More risky, a lot more responsibility falls on the shoulders of the patient to truly leave it alone. I mean, don’t even lick it. Just, just leave it alone. But it’s something that in the right situation can be done a little bit. Yeah.
So very limited situations where I’ve seen that work, but it is an option that is in our toolkit.
And fortunately, there are technologies in implant procedures and in the implants themselves nowadays, where, if we’ve got enough width, we can do a lot more without doing extensive grafting. There are cases years ago where we do three different grafts, and sometimes we still have to do this, even with the modern technology that we have, but three rounds of surgeries, and then we do the implant, and they already had their teeth taken out, so there are potentially five surgeries to get a tooth there. So we really try to avoid that. That’s when that’s when, that’s when it gets difficult on the patients.
Dr. Tanner Townsend 8:23
Yeah, I think the longer the patient has to delay the satisfaction of having their teeth again, you can lose them along the way. And we want patients to have the best, but helping them realize, hey, we do have to go through these extra steps of bone grafting to get there. So I think that is one of the biggest hurdles actually, that I see with my patients as saying, Hey, you’re either not a candidate for an implant, or we need to do this grafting procedure. First.
Dr. Josh Muir 8:48
I had a talk with a patient today, and it basically went like this, look, if you were 70-75, years old, that implant really only needs to last 10 years, but you’re 30 years old, and at 30 years, you’ve got potentially 50 years that you need this to last. And the situation was you can either use teeny little implant, or you can have your bone volume increase and use something larger that’ll help support more forces on it, or long term. And ultimately, that’s what he was moving forward with. But it’s, it’s one of those things that just because you can do something, can force an implant or squeeze a little implant into an area, it doesn’t always mean that it’s right. And so I’m grateful we have these procedures available. You know, I thought it would be good too to talk about that upgradable treatment idea. Yeah. So we have a patient that came in last week who she came in wanting a denture, and she said, I want a denture, because I know people that have dentures, and they’re doing just fine with it. So why would I want anything more? I said, Well, if you would like, you are a candidate for dental implants, either to snap a denture in, or to an all on four or all on eggs, where the teeth stay in all the time, which will be much more natural for you. And she said, “Oh yeah, I’d really like to look at that.” She made the comment, “Also, money doesn’t matter. That’s not my concern at all. I just, I don’t want to go through something if I don’t have to.” And so that was her biggest concern. In the end, she said, “You know what? I’m still just going to do a denture.” But she understood the idea that if she wants implants in the future, she should do those socket grafts now, where we graft, where the roots were, so that she has a better opportunity to have implants.
Dr. Tanner Townsend 10:28
I know I love that you said that upgradable treatment, because it’s so true that we want to prep patients so they don’t have to go through that extra surgery to get the grafting and and like you said, we there’s a lot of factors that go into it. I think one of the primary ones is age, like you had mentioned with that patient that you saw earlier today, is that, hey, if you’re younger and you’re gonna live longer, let’s go through the extra step to make it last longer for you. And that kind of goes along with the upgradeable treatment. We want to make sure that we are setting ourselves up for the future the best we can.
Dr. Josh Muir 10:58
Yeah, and it really it ends up being less cost, less appointments, less pain and discomfort, and a better outcome for the patients that start understanding why and when these grafting procedures are necessary.
Dr. Tanner Townsend 11:12
Totally true. You have any additional things you’d like to add about grafting,
Dr. Josh Muir 11:15
That’s all I’ve got.
Dr. Tanner Townsend 11:16
Okay, well, that is it for today’s episode of The Smiles Reconstruction podcast.