Bone graft question
 

i had tooth #31 removed due to a failed root canal where the tooth developed a crack and subsequent infection. The dentist removed the tooth and also did a bone graft to prepare the site for a possible future implant. The removal and procedure went fine but the collagen material that was covering the graft soon 'oozed' out of the sutured graft area and then the sutures fell out a week after the extraction. The dentist said it was fine and the graft was still in place but I'm wondering if it is normal to have the graft 'exposed'? Will the surrounding gum tissue close around the graft? Should I worry that in the mean time the graft material is exposed? I'm reluctant to chew on that side until the graft is completely covered.

Hi Curious,

First of all, DO NOT chew on that area of your mouth until the site has closed over. Secondly, it is not ideal for the graft to be exposed because contamination from food debris can disrupt the healing and infection can occur. Are you sure the graft is exposed?

It is typical for the sutures to come out 7-10 days after the extraction. Sometimes they last a week or so longer, depends on the type of suture material, how it was used and how much tissue closure was able to be done.
The collagen placed over the graft is there for two main purposes. One is to keep the surgical site covered in blood so the clot forms properly. Secondly it is there to protect the graft from becoming exposed or dislodged. So this material is important for the long term healing. It generally becomes one with the clot and doesn't fall out. Are you certain the collagen plug/membrane came out?

If you are in doubt of what has occurred, go back to your dentist and let him look again, ask him to explain what he sees to help reassure you.

Bryanna

Hi Bryanna,

Thanks for the reply. In terms of the graft exposure, I guess it could be the collagen material but it has the texture of the granules used for the graft. I'm diligent about keeping the area clean but the small pocket does sometime trap food that I need to rinse out. Should I have the area re-sutured? The dentist didn't seem to concerned.

I recently had a VERY BAD outcome with reference to work done on tooth #31, but we are all individuals. I too had a root canal and then a graft. In my case, the graft had to be removed due very difficult/troublesome complications.

Along the way, I went to two oral surgeons to get their opinions. They both implied strongly that the graft (in my case) should not have been done probably at all and certainly not on the same day. One strongly implied he never would have done it, PERIOD.

The second oral surgeon is also an MD. I specifically asked him if I had to worry about the teeth crowding, etc. because I had 31 removed and then ended up removing the graft as well. To my surprise, he said "no." He said eventually, after many, many years, there was a possibility, that the tooth above it might move down...but this is usually many years down the road and not a definte.

I have a friend and asked her this as well. This is because both her and her husband have back molars that were removed decades ago with no graft or implant. They have had no problems at all with teeth crowding or the top tooth moving down.

So, I guess everyone is different. Certain things are possibiities, but then again, it is unclear how high the probability might be.

Anyway, I think my graft was "exposed," but am unsure if this was part of my bad outcome or not. I had a little device like a hypodermic needle w/o the needle to squirt water on it gently to keep it clean.

I would be extra careful and not hesitate for one second to call the dentist if you are unsure about things or uncomfortable!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!! !!!!!!! And if you didn't use an oral surgeon for this procedure, I would seriously consider using one in the future, should this type of think come up again.....hopefully not and fingers crossed.

Thanks VL,

I too was unsure whether I needed to have that molar replaced by an implant. I chose to have the graft just in case I changed my mind. I believe (if the graft takes) I have a little more than a year to decide if the lack of a tooth there is causing me any issues and want an implant. Frankly the Dentist wasnt very informative nor forthright with my options. I have an appt with an oral surgeon to get a second opinion on the graft and whether I need a future implant.

Hi Curious,

Long before now the collagen material would be completely absorbed. This material is also not granules, it is soft and thin like a tissue. The bone graft material is granules... so that must be what you are seeing. If you are having infrequent, small granules coming out of the socket, that is normal. If you are "losing" the graft more than just as I have explained, then that is not okay.

How are you cleaning the socket? You should be thoroughly brushing and flossing all of your teeth while avoiding the socket. Only rinse with warm salt water. No irrigation or other mouthwash. Do not put anything in that socket to rinse it out as you will disturb the graft. Did your dentist give you post op instructions? Sometimes they neglect to explain things enough.

It is not usually a good idea to re-suture the surgical site. At this point there would not be enough tissue to suture closed, so they would have to cut and create a flap to suture.

Bryanna

Thanks for your response! I use warm salt water to clean the socket. I do feel the small granules from time to time but its very infrequent. As i mentioned above I plan on getting a second opinion on the graft. But do you feel that a implant is necessary in most cases for molar #31?

Curious,

If you have a tooth above the space of #31 which would be tooth #2, and it's not occluding (biting) against your lower tooth #30, there is a good chance that #2 will drift down toward the open space of #31 simply because there is nothing holding it back. Which means that eventually #2 would have to be removed because it would become very loose and the roots would be exposed. The tooth would slowly avulse from the bone. Depending on the person, this may or may not take years to occur. Your dentist can tell you if #2 is occluding against #30.

Anytime a graft is done with the intent of an implant, it is best to not wait longer than one year to do the implant because the bone will start to recede because it has nothing to hold onto. The graft is done to encourage your own bone to grow and integrate with it as a means of filling up the holes where the roots of the tooth use to be. Without the graft, your own bone would fill in those holes as it collapsed inward from the sides of the holes. So the overall level of bone would be much less. Grafting does not add bone on top of bone.

Let us know how the second opinion goes!
Bryanna

followup
 

I had a followup with an oral surgeon and he felt the extraction and graft was healing fine. He confirmed that he couldn't really re-suture the site and that I just would have to be careful with the area and keep it clean until it closed over. He did recommend that I eventually get an implant and that at my age and the fact that the area has plenty of bone width and structure to accept an implant it would be a good idea. He stated that eventually the tooth above (#2) would start to loosen and migrate down and need removal. It may not happen for a long time but in most cases that is what happens eventually. I have a followup with him in 4 months.

I also asked whether it was advisable to use a GP dentist vs. an oral surgeon for the implant procedure and although he was diplomatic about it, he basically stated that it is advisable to go with a OS.

Thanks everyone for your comments and suggestions.

Hi Curious,

Thanks for the follow up and for reaffirming what I had posted.

Hope the healing continue to go well!

Bryanna