Big Bone Graft For Molars

This patient presented to my office in Burbank, CA  after seeing numerous “dental implant dentists.” He was told that implants are not possible by three different providers!

Bone Loss Needs Large Graft

The preoperative image shows that he has very skinny bone in the area where the teeth were lost many years ago. The bone went through a process of atrophy… It just melted away because it’s not being used. In order to have implants properly placed in your jaw the bone has to be rebuilt. Not only that, the gum tissue needs to be rebuilt as well.

Bone Expanding Graft

On this particular patient I did a bone expansion graft. This is a technique sensitive procedure that some dentists call “bone manipulation.” In the course of two visits I was able to “bend” his bone outward. This leaves an intentional  trough or gap in the center where additional bone from a human tissue donor is packed in between the outer plate and the inner bone plate of the bone. The area is covered with dense polytetrafluoroethylene membrane and stitched closed tightly.  The membrane is removed a few weeks later.

What is unique about this procedure is I can gain bone and gum at the same time without having to harvest gum from the roof of the mouth. Sometimes the bone graft and implants can be done simultaneously but on this case I decided to only do the bone graft and I placed the implants about four months later. This is called “staging.” Rome was not built in a day!

Big Bone Graft Options

There are numerous ways to build bone when there is major loss. This is just one of them. A short list would include:

1. Bone expansion/manipulation -discussed above
2. Segmental osteotomy — moving a section of your jaw with the gum still attached
3. GBR – guided bone regeneration… Bone particles placed under a membrane
4. block bone grafting — bone screwed in place. This bone can be your own or from a tissue donor
5. titanium mesh– bone particle placed under a titanium cage
6. Bone plating which is similar to block grafting
7. Nerve repositioning-moving the nerve under the lower jaw out-of-the-way to make room for dental implants
8. sinus lift bone grafting

For this particular patient this was the best solution. He was treated with IV sedation anesthesia and able to sleep through it. Afterwards Tylenol and ibuprofen along with an Arnica Montana supplement for bruising/swelling. An intravenous steroid is also given right before the surgery.

I was able to enhance the bone graft with L PRF ( platelet rich fibrin) which I make from your own blood when I start the IV. The PRF acts as a attractant for growth factors and accelerated healing to the bone graft area.

During any of these major bone grafting procedures it is best to not wear a temporary at all if it is in the back of the mouth. You don’t want to have the wound open up, exposing the bone then causing an infection. On these large bone grafts, antibiotics are necessary.

Your comments and questions are welcomed!

Ramsey A. Amin, D.D.S.
Diplomate of the American Board of Oral Implantology /Implant Dentistry
Fellow-American Academy of Implant Dentistry
Burbank California

16 thoughts on “Big Bone Graft For Molars”

  1. Hi Dr. Amin,

    I lost my 2nd molar (31) when I was 18 years old and did not get an implant immediately. This led to bone loss. I received a bone graft in 2022 (after ~13 years of not having anything in that space). Now that I am dealing with an implant crown that (1) is too tall, (2) causes large black triangles (gaps) on each side of the implant. This leads to a lot of food getting caught there while chewing and causes some “suction” feeling when talking. Is it normal for implants to have such large spacing on the sides? I really do not want to deal with the maintenance and hassle this is creating for me. Would receiving additional bone grafts help? I never received any gum grafting.

    Here are a few pictures from the lab on their 3rd attempt at remaking the implant crown: https://imgur.com/a/4yP7N4S (posting link as I’ve seen other posts where pics are requested. Please let me know if not permitted and I will remove!).

    I am willing to travel to get this right. Thank you!

    Reply
    • The only thing that would really help this would be to have orthodontic correction of the misaligned teeth. Yes adding a gum graft on the cheek side may help as well but it is the uneven “marginal ridges” that or more of the problem and the open triangles on the bottom. Did you ever resolve this?

      Reply
      • Thank you for your reply, Dr. Amin. I currently just have the post but no implant crown (they tried to get it to fit but it was just too tight and led to spacing in the back, which was causing food to get impacted. We opted to remove it and I am on the search for a provider in North Carolina. If you know of anyone you would recommend, I would be immensely grateful.

        I’m definitely willing to get more orthodontic work to address the two molars that have shifted but I think I would still have a tall implant crown given the bone loss. Do you think additional bone grafting would help address this other issue?

        Reply
  2. Hi Dr. Amin,

    I lost my 2nd molar (31) when I was 18 years old and did not get an implant immediately. This led to bone loss. I received a bone graft in 2022 (after ~13 years of not having anything in that space). Now that I am dealing with an implant crown that (1) is too tall, (2) causes large black triangles (gaps) on each side of the implant. This leads to a lot of food getting caught there while chewing and causes some “suction” feeling when talking. Is it normal for implants to have such large spacing on the sides? I really do not want to deal with the maintenance and hassle this is creating for me. Would receiving additional bone grafts help? I never received any gum grafting.

    Here are a few pictures from the lab on their 3rd attempt at remaking the implant crown: https://imgur.com/a/4yP7N4S

    I am willing to travel to get this right. Thank you!

    Reply
  3. Dear Dr. Admin,

    I visited a oral surgeon for implants on missing teeth and he said that the bone is thin. I just review your article and the first case you presented looks a similar case like mine. He reluctantly offered the 2 step surgery using titanium mesh and harvested the bone from the jaw.
    After I read the article I really like your approach. Do you harvest the bone from the jaw? How long the procedure take?
    I live in New Jersey/ New York area and I would like to see if you could recommend a Oral surgeon that is performing your method with Bone expansion/manipulation. I really wish I leave in CA and use your service.
    My last question is can you have 2 implants and bridge where the bone is receding if nothing works?
    I would truly appreciate any advice you can give me moving forward! Thank you.

    Reply
  4. My dentist is telling me such a bone graft cannot be done successfully. How much do you charge for such a bone graft to restore bone where an upper wisdom tooth was extracted ~4 years ago? My insurance is Humana Medicare HMO and does not cover unless in their network.

    Reply
      • Yes, there is bone loss where the wisdom tooth was extracted, which I’m told will lead to pockets and infections in the next tooth (#15) and is given as a reason to extract the damage #15 molar.

        Reply
      • I’ve been told that there is bone loss where my impacted wisdom tooth was surgically extracted, and that has left unrepairable pocket next to the adjacent tooth. They are recommending extraction of that adjacent tooth instead of a crown due to the risk of infection from that deep pocket. I am thinking I could save that tooth with a crown if a bone graft restored the missing bone next to it where the wisdom tooth was extracted, if it’s not too expensive.

        Reply
  5. Hi Dr Ramsey,

    Thank you for all the helpful information that you have provided on your blogs and YouTube.

    I will be getting an extraction done on #19 because this previously root canal treated tooth has a VRF that caused an abscess and fistula. I have the infection for 2 months already so it really needs to be taken out.

    Initially, I was planning to get an extraction and bone graft together. Then after that’s healed, head to your office to get the implants done. Unfortunately, the dentist that I went to here is making things complicated and has delayed my appointment for more than a month already. To keep it simple, I’m now thinking of just getting the extraction only.

    I was wondering if the bone graft and abutement placement can be done on 1 single appointment in your office? I think I have watched one of your YouTube videos that mentioned that this is possible but I’m not sure if it could also be done on my particular tooth.

    Also, Would you recommend that I get a partial denture in the meantime while I wait for the extraction to heal? So that the placement of my other teeth would be preserved.

    Lastly, after the extraction is done, how long is the recommended healing time before doing the next procedure of bone graft and implant ?

    My apologies for the lengthy post. I do appreciate any feedback you could give. Thank you.

    Reply
  6. Dear Dr. Admin,

    Thank you for all of the information you have provided! I have read many of your articles and watched several videos. Other than you, I have not been able to find many sources relating to my issue, which I know is a difficult one. About 6 years ago, I had a root canal done on tooth #14. Unfortunately, a quarter of it broke below the gum line before I was able to get it filled. At the time, I mentioned crown lengthening to my dentist but he didn’t sound too optimistic and recommended that I get it pulled. I had an invasive and traumatic surgical extraction performed by an oral surgeon who removed a section of my alveolar bone to get the tooth out. This, of course, left a large depression in my ridge and gum line which bothers me greatly! Not that it can be seen when I smile but I feel it. The inside of my cheek sinks in there and I just hate it. This oral surgeon was aware that I would be getting an implant to replace the tooth, however, no bone grafting or socket preservation was done or mentioned. An atraumatic extraction wasn’t even attempted and I didn’t know any better. The periodontist I went to for the implant did perform a sinus lift. A crown was placed but the tooth looks long and big because of the high gum line. Now, 5 years later, the teeth on both sides of the implant, #15 and #13 have decay. I have learned that this is implant induced decay because they were fine prior and I’m told #15 needs a root canal. It is all very upsetting to me because I feel that there were other alternatives. Would a block bone graft be possible to augment the ridge above #14 or maybe just a gum graft to make it look more natural? And now what to do about the health of my two adjacent teeth? I know this is long but I would truly appreciate any advice you can give me moving forward!

    Reply
  7. Dear Dr. Amin,

    I’m about to undergo a major bone graft in my right posterior maxilla.
    For these large bone grafts, how long do you recommend not wearing a temporary? Would it be possible after 6 months when the wound has healed?

    Thanks and thanks for the wealth of information!

    Reply

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