When to Re-Do An Extraction Site Bone Grafting ?
This is a case report on a treatment scenario that I've seen many times and I hope it helps those who perform extraction site bone grafting.
This patient had an extraction and site bone grafting done by her dentist. Six months later upon re-entry for implant placement, patient was told the bone graft is 'not ready and still soft'. The site was closed and patient was told to return another 6 months for implant procedure. No CBCT was obtained during this treatment. Is that a sound advice? Patient presented to us for a second opinion.
The periapical x-rays showed calcified granules and the clinical evaluation showed relatively good soft tissue architecture and ridge form. CBCT showed unevenly distributed calcified tissue layered with radiolucent gaps. With this appearance after almost 8 months since bone grafting, the calcified tissue is most likely a granulation tissue. The treatment plan was to explore the site and examine the tissue clinically. The following treatments were done:
1. Exploration of the site noted a soft granulation mass in the extraction site lined with connective tissue and dispersed with white bone particulates. The mass was enucleated completely.
2. The extraction site was further debrided with peripheral ostectomy using a diamond bur and then perforated to induce site bleeding.
3. Autogenous particulate bone and mineralized allogeneic bone complex with PRF was prepared for grafting and placed along with resorbable GTR membrane and PRF membrane.
4. Tensionless closure of soft tissue flap using softbrush technique
The key point is that if the bone has not healed after 4-6 months from extraction and site grafting (depending on type of bone graft), waiting longer does not offer any benefits. Once the bone undergoes soft tissue infiltration and transforms to a granulation mass, it must be excised, site cleaned, and re-grafting using conventional GBR technique. Also, Pre-implant placement CBCT is a must for not only implant planning and guide fabrication, but also to examine the bone quality before subjecting patients to an un-necessary surgical procedure.
Fig.1 : Autogenous bone / Allogeneic bone / PRF
Fig.2 : Excised granulation mass
Fig.3 : Autogenous bone / Allogeneic bone / PRF
Fig.4 : Extraction site defect
Fig.5 : CBCT
Fig.6 : PA X-ray with grafted material