Paul L. Child Jr., DMD, CDT and Gordon J. Christensen, DDS, MS, PhD
One of the most frustrating
situations encountered in
dentistry today is the referred
patient desiring an implant for
a recent extraction(s) where
no bone regenerative grafting
procedure was offered or provided. The site usually has a significant
defect, both apico-coronally and bucco-lingually, requiring
more extensive and costly grafting either at the time of implant
placement or in advance (Fig. 1). Situations like the one
described are damaging to patients' confidence in their dental
practitioners, as well as frustrating to the surgeon placing the
implants when the entire situation could have been avoided with
complete patient education at the time of extraction. Prevention
for these and similar situations is simple! Every extraction needs
to be preceded by an explanation of the risks and benefits of
bone grafting in the extraction site.
This article includes various reasons why grafting is not provided
and why it should be offered, makes suggestions for
improved patient acceptance, explains simple informed consent
and offers examples of how different patients were treated and
prepared for future implant placement. This article does not review an exact technique or include a detailed list of materials.
Our goal is to stimulate dentists to find CE courses and become
educated on this vital procedure, and to offer bone grafting as an
ideal treatment to every patient before extraction.
Reasons Why Grafting Is Not Provided
Often, when beginning treatment for an implant after the
tooth has already been extracted, a patient is asked if bone
grafting procedures were explained as an option, the patient
denies any knowledge of being offered this procedure.
Sometimes this is true, but a patient's memory might be clouded
by the emotional trauma of losing a tooth, the level of pain he
or she was experiencing and relative financial priorities that
might have precluded grafting at the time of extraction. Despite
selective patient memory, the following reasons are cited in relation to the dentist for failure to graft a socket (not all reasons are
listed, but these are the most common):
Dentist assumes the patient lacks adequate financial
resources for the procedure. Surprisingly, when full informed
consent is provided, including the risks of not grafting, using
visual aids demonstrating these risks, and the future possibility of
implant placement, many patients will opt for the graft, despite
the added cost. Often, patients are able to "find" money when
they deem something important or necessary. Information about
simple socket preservation needs to be explained to clarify the
procedure to the patient and justify the procedure.
Dentist lacks knowledge of bone grafting options. A dentist
who does not provide simple socket preservation does not need to
know every aspect of bone grafting materials and/or techniques in
detail. However, it is required to know the long-term risks and
benefits of providing this service, so patients can make an educated
decision on which treatment option will best serve them.
Patient desiring maxillary central implants after extractions without
socket preservation discussed or provided. Patient ultimately required extensive
hard- and soft-tissue grafting with pink porcelain as part of the final prostheses. Figs. 2 and 3:
Patient was referred for implant consult one week after general
dentist extracted chronically infected, non-restorable maxillary premolar. Early
referral allowed immediate grafting of the site. Figs. 4 and 5:
Radiographs of grafted site and subsequent implant placement
with crestal approach sinus lift. Figs. 6 and 7:
Final restoration demonstrating good color match and adequate
Dentist desires income of extraction procedure and does
not want to lose revenue by referring the patient to another dentist
or surgeon who provides socket preservation. This scenario
is an ethical dilemma facing a few dentists, and might have risen
due to the slowed economy. Each dentist needs to put the
patient's best interests first by providing full informed consent as
discussed below. Making your personal financial income a priority over the patient's long-term oral health is unethical and
should be avoided.
Ignorance and frustration. Occasionally, the referring dentist
becomes frustrated with those patients who were previously
warned repeatedly not to delay treatment and the potential consequences
of doing so. This can often take valuable practice
time, and leaves the dentist struggling to make-up for the lost
revenue. The result is that dentists feel they have already provided
adequate patient education from the various previous
conversations with the patient, and the dentist starts treatment
by providing the extraction themselves, and referring the patient
to the surgeon for an implant (with the corresponding bony
defect). This scenario can easily be avoided by including staff
involvement in patient education.
Infections. Often, an extraction is provided when the tooth
is necrotic and might have an acute or chronic infection. The
scientific literature leans toward avoiding grafting in an acute
infectious site, yet providing grafting in a chronic site with
appropriate antibiotics. This position has changed over the past
few decades and many surgeons use their own experience as a
guide as to when to graft a site at the time of extraction. For
many dentists, determining whether a site is chronic or acute
can be difficult, so they avoid grafting altogether. In this scenario,
consultation with a surgeon, or extraction and immediate
referral to a surgeon or extraction and recall to your office can
allow subsequent grafting within one to two weeks after the
extraction (Figs. 2-7).
Absolute contraindications. It is commonly stated (and misunderstood)
that a patient who smokes or has a previous history
of periodontal disease, diabetes, blood disorders requiring medications,
osteoarthritis and other chronic illnesses should not
receive an implant. Therefore there is no need to provide bone
grafting. Although the overall success of bone grafting and
implant success tends to decrease in some of the above mentioned
patients, they are not considered absolute contraindications.
Many surgeons today are able to carefully place implants, provide
adequate informed consent about the potential for a decreased
success level, and successfully complete the procedure. In the
1980s and 90s, discussion of absolute contraindications was common,
but with careful planning, excellent patient education and
compliance and ideal surgical preparation and technique, these
patients can receive bone grafts and implants that will improve
their level of long-term satisfaction with the treatment.
Why Bone Graft When Extracting Teeth?
Answering this question requires dentists to forget about
themselves and focus on the patient. Excellent patient education
can easily provide this answer to the patient in 10 to 15 minutes.
The main reasons for socket grafting are:¹
- Future bone loss and ridge resorption
- Support of adjacent teeth and implants
- Planning for future options, such as implants or a fixed
- Some sites require bone grafting for implants
- Fixed-prostheses might have a poor aesthetic result without the presence of adequate bone and overlying soft-tissue.
- Easier to "preserve" now instead of "create" later
- Avoidance of additional surgeries
- Procedure is simple, safe and effective
- Financial situations can change with time
Figs. 8 and 9:
Image and radiograph of failing central incisor next to a previously
restored implant placed too far apically. Patient education is necessary before treatment for potential loss of gingival embrasure papilla fill and aesthetic
challenge. Fig. 10:
Extraction and socket preservation with allograft and soft-tissue
augmentation. Fig. 11:
Patient smile with provisional on central implant
challenge of filling papilla next to implant. Despite secondary soft-tissue augmentation surgery and appropriate contour of provisional, pink porcelain
was necessary. Patient was prepared due to appropriate informed consent.
Informed consent involves six areas and should be provided to
every patient before any dental procedure. Provide a written document
to the patient that explains the various options (as
described below) and obtain a signature indicating that he or she
understands and accepts the treatment. Use visual aids, including:
actual patient photos, casts, educational models and videos to help
patients understand the proposed treatment. Most of the patient
education can be provided by the assistant, with the dentist
answering detailed questions and obtaining the consent. Example
consent forms can be obtained from many sources including the
ADA, many surgical and implant associations, digital patient education
software services (ImplantVision, etc.), continuing education
centers and more. Below are the six necessary areas that must
be discussed for practitioners to obtain legal informed consent.
Present all treatment options. In regard to extraction cases,
all treatment options should include extraction only, extraction
and immediate grafting anticipating later placement of an
implant, extraction with subsequent grafting in one to two
weeks due to infection or other factors preventing immediate
grafting, extraction and referral to a surgeon for grafting, referral
to a surgeon for entire procedure, extraction and grafting
with potential for subsequent grafting later by a surgeon (i.e.
sinus lift, ridge augmentation, etc.), extraction and simultaneous
implant placement with grafting to augment and many other
options that are specific to the patient's condition. Whatever the
option, be honest with the patient as to your ability to provide
the service at the same level as a specialist.
Discuss the advantages of each option. For this example,
the advantages would include improved ability to receive an
implant at the extraction site, decrease of further costly grafting
procedures and improved quality of life with future implant
restoration. Also, discuss the advantages of providing the grafting
yourself or referring to a specialist/surgeon.
Discuss the disadvantages or limitations of each option. Many of the disadvantages were discussed above in the reasons
why bone grafting is not provided. A frank conversation with the
patient should occur, being realistic about potential outcomes.
For those who provide bone grafting, do not forget to include the
risks of rejection or loss of grafts, potential for infection, potential
need to provide additional grafting at a later date or at the implant placement, the potential for continuing shrinkage of
bone and gingival tissues or aesthetic challenges (Figs. 8-11).
Identify and explain the risks of each option. This section
of informed consent usually is explained with the disadvantages
or limitations of each option, as described above. In differentiating
a disadvantage from a risk, it is necessary to explain that a
risk is not necessarily a poor choice or will always lead to a disadvantage.
Each day, most individuals take a risk to drive to work, but it will rarely lead to an accident if caution and safety
are applied. Similarly, a risk is taken to place a foreign substance
in the extracted site, but if good infection control measures are
implemented with careful surgical technique, infection and subsequent
clinical challenges can be avoided.
Provide the cost of each option. Base your cost on the compensation
that is adequate for your time and expertise.
Overcharging a patient initially can result in decreased treatment
plan acceptance, decreased future implant placement, loss of
patient from practice and patient resentment. Some dentists provide
an incentive for those who state they have financial challenges,
such as providing the extraction and grafting now, and if the
patient returns within a year for the implant placement (when they
might be able to obtain the funds or third-party benefit plans
allow), the dentist discounts the implant placement. Plan for your
patient's future implant placement if they cannot afford to have all
of the procedure accomplished at one time (extraction, graft and
implant placement). This preparation is in the patient's best interest
and can be a great source of future revenue.
Discuss the outcomes of no treatment. Although this step
is listed last, it might be best suited to discuss lack of treatment
first. Explaining the consequences of failing to graft now can
motivate treatment acceptance. For a reasonable fee (i.e. extraction
fee plus two to three times the cost of the bone graft material),
the procedure can be easier to accept than the alternative
of extraction, grafting, implant placement and restoration equal
to several thousand dollars.
Dentist Education on Grafting
Simple socket preservation is within the ability of most dentists
who desire to provide this service. This excludes more
advanced procedures, such as ridge augmentation, block grafting,
sinus elevation, etc., although surgically oriented general dentists
can learn these procedures as well. It is important for dentists
to obtain adequate education and training on how to
provide these procedures within their comfort level. Depending
on whom you ask, this education and training can range from a
three- to six-year residency, to a multi-session course or to a
weekend course. Not all dentists are able to complete a residency,
but they might have the potential to provide simple and
predictable socket preservation after taking a shorter course.
The most important factor to remember is if you provide
bone grafting procedures, you are expected to provide it at the
same quality level as a specialist. Know your own limitations, who
to treat, who not to treat and when to refer. If you are a general
dentist who provides bone grafting services, do not abandon your
specialists, upon whom you may need to rely for future assistance.
If you are a specialist, work with your referring dentists and be a
mentor. It has been our observation that working together
improves revenue and overall patient and dentist satisfaction.
For dentists who desire to provide simple bone grafting, we
recommend obtaining the appropriate education, deciding in
what clinical situations they desire to provide socket grafting
and then implementing the procedure into practice. There are
many courses on socket grafting offered to general dentists, most
of which are taught by specialists. One of the best ways to
improve your skills and confidence is to find a surgeon who will
be your mentor. Take time off to observe and learn from him or
her. Develop a relationship where you provide simple and predictable
services and refer more advanced cases to your surgeon.
Most surgeons who develop these types of relationships experience
increased referrals from general dentists.
With the advanced level of implant dentistry, combined
with the large number of patients who need implants, many
teeth are being extracted without full informed consent
regarding socket preservation. Dentists need to fully disclose all
the available options to patients when a tooth or multiple teeth
need to be extracted, even if it results in loss of revenue. Most
dentists can learn and provide simple socket preservation by
developing a close professional relationship with a surgeon.
Ultimately, these changes will benefit the patient, the general
practitioner and the specialist.
1. Taken from Clinicians Report, May 2010, Grafting Extraction Sites: Why, What, and How