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The patient was in crisis and needed treatment. My student wondered how to handle this patient. The situation was a tough one. The patient needed a bone graft at #5 site, but there was loss of periodontal attachment on the adjacent canine.

Tooth #5 max right first premolar was fractured, decayed, with loose crown-post and significant bone loss. The implant surgeon was concerned about esthetic facial soft tissue loss after extraction and was unsure about the bone graft working due to loss of attachment on the adjacent canine tooth. The patient was in crisis and needed immediate treatment.


My Advice:


I have treated this type of situation on several occasions with good and sometimes excellent success. My advice is to do the following:

1. Extract failed tooth #5 using an open flap approach with a cosmetically concealed distal releasing incision. This will provide access for complete debridement and disinfection of the site by removal of granulation tissue, thereby reducing the risk of post grafting infection.

2. Although detoxification of the exposed root surfaces is necessary using citric acid or Straumann Pref Gel, maintenance of the PDL or remnants of the PDL in the unexposed portions of the adjacent canine tooth is important.

3. I would graft this site using Straumann Emdogain to coat the distal canine root surfaces and a particulate graft of Bio-Oss with autogenous bone harvested from the local area or preferably cancellous marrow harvested from the maxillary tuberosity. I would adapt a non-cross linked membrane such as BioGuide to isolate and protect the graft. Use of PRP in these cases provides the advantage of stabilization of the graft and the technical advantage of allowing you to sculpt the graft with a high degree of precision and “Glue” the barrier membrane in place eliminating the need for sutures or tacks. If you do not have access to PRP, you can collect blood from the local area using a syringe at the surgical site. This is facilitated by minimizing vasoconstrictor in the local anesthetic.

4. You could also consider using Gem21S growth factor enhanced matrix to graft the area. The Gem21S product provides recombinant platelet derived growth factor at a concentration 1,000 times higher than the patient’s own blood. Studies demonstrate 3 times greater bone fill in periodontal defects grafted with Gem21S.  Although off label, mixing the Gem21S with a slow substitution graft material that provides long term structural stability such as Bio-Oss is an approach that has been very successful in compromised sites such as the case you are faced with.

5. After securing the barrier membrane over the graft complex, I would then rotate and secure a VIP-CT palatal pedicle flap over the grafted site and achieve primary closure. This flap provides a vascularized periosteal-connective tissue flap that not only provides additional circulation to the area but also provides a large volume of soft tissue cover and the required mesenchymal cell pool required for maintenance of the graft volume during the remodeling phase of bone graft healing.

6. Allow up to 4-6 months healing time before reentry for implant placement or 3 months if conventional dental restoration is planned.



  1. March 24, 2014

    I’m amazed how detailed your blog is and the work that goes though the process of creating a new tooth for a patient. Thanks for the blog.

  2. May 12, 2014

    Your blog is very informative. This had a great influence on my decision. Im looking for a Well Trusted Dental Implant Package in San Jose, Costa Rica, because my husband and I are going there next week. And I’m planning to book for my dental check-up. Your advice will be much appreciated.

  3. June 25, 2014

    Thank you for sharing your advice, let me also share the procedure done by Sani Dental with regards to bone graft procedure. When we asked them how to perform this, this is their answer: “In a bone grafting procedure, we gently open the gums and place grafting materials onto the areas where the jaw bone has receeded. With ridge preservation techniques, we fill the empty socket with bone material after the tooth has been removed. Depending on the situation, we also apply platelet rich plasma to the site, this material made from a small sample of your own blood, enhances bone growth and speeds healing. We may also place a special membrane over the graft to prevent unwanted tissue from growing into the graft site. Last step is to close the grafting site. All those situations vary, we may need to wait for several months after the procedure for the bone to heal before moving on to the next step of your dental treatment.”

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