San Diego Center for Oral and Facial Surgery

Bone and Soft Tissue Grafting

Bone Grafting:

Bone grafting to the jaws and facial structures may be necessary in a wide variety of scenarios. Sometimes people are born with certain traits that require bone grafting to the facial skeleton and jaws in order to reestablish proper form and function. Bone may also be required when infection, pathology, or trauma involving the facial bones and jaws have occurred.

Bone grafting is commonly performed by an oral and maxillofacial surgeon to replace or augment bone in areas of tooth loss. Shrinkage of bone often occurs when a tooth is lost due to trauma, severe caries, or periodontal disease. Additionally, bone loss may have already occurred due to infection or pathology around a tooth.

Bone graft materials can be classified as artificial (allograft / allogenic) or natural (autograft / autogenous). Artificial grafts are obtained from non-human sources such as coral and animals. One such product is known as Interpore™. This product is obtained from nonliving coral that is ground up and purified to produce a material known as hydroxyapetite. Hydroxyapetite is very similar to our natural bone structure. Once placed next to existing bone, living bone cells will migrate into the hydroxyapetite creating new living bone structure. BioOss™ is an example of another allogenic bone grafting product. These products are derived from cow bone. The bone is purified and all organic elements are removed using a chemical process. What is left behind is a bone mineral matrix that provides an excellent medium for stimulating and creating new bone formation. These materials are very biocompatible and have been used for many years with great success. Due to the source of these products, some consumers have been concerned about the possible transmission of mad cow disease. Due to the nonorganic nature of these products, transmission of disease is virtually impossible. Current studies show that these products are safe to use and that not a single patient has suffered disease transmission due to the application of these products.

The following table illustrates the available methods for bone replacement and the indications for those methods.

Method Source of Bone Graft Usual Indications
Tooth extraction site graft Bio-engineered product such as BioOss. An empty tooth socket is filled with bone graft material to prevent shrinkage of the bone in the area. This allows for future dental implant placement and enhances esthetics and function in the area.
Onlay bone graft Bone is harvested from the upper or lower jaw in an area that is not vital to form or function. The autogenous graft is harvested in either block or particulate form.  Used when shrinkage of bone has occurred after removal of a tooth.
Bone graft reconstruction Blocks of bone are harvested from the hip or other areas of the upper or lower jaw that are not vital to form or function. For larger areas of bony atrophy or missing segments of bone.
Sinus Lift The sinus floor is lifted and bone graft material is placed in the void that is created allowing placement of dental implants in the premolar and molar region of the upper jaw. See a clinical case. For situations where the sinus floor dips down into the tooth root area of the posterior maxilla and when not enough vertical height of bone exists for implant placement.

Soft Tissue Grafting:

Loss of gum tissue can occur due to periodontal disease, tooth loss, infection, or pathology. Two kinds of gum tissue exist. One type is nonkeratinized, unattached gingiva and the other type is keratinized, attached gingiva. In healthy situations, a band of keratinized tissue exists around the teeth. Keratinized tissue forms a biological seal around teeth and is important for periodontal maintenance and function. Loose gingival tissue, on the other hand, forms a poor seal around the teeth and is susceptible to inflammation and infection when located in direct proximity to teeth, dental implants, and other dental appliances. Keratinized tissue is also important for dental esthetics where the loss of tissue from root surfaces and in between teeth can have adverse effects on a person's smile.

Because soft tissue shrinkage often follows tooth loss and loss of bone, soft tissue grafting procedures are often needed as an adjunct to reconstructive procedures involving dental implant placement.

Keratinzed gingival tissue can be replaced using natural and manufactured sources. The palate is a good natural source of keratinized tissue. Tissue grafts can be harvested from the palate with very little risk or discomfort to the patient.

Tissue engineering products are also available.