Socket graft: what does the CBCT indicate?

I did my first extraction and socket graft case in November 2015. Sectioned and extracted 46, debrided and curetted the site, then placed a Bio-Oss collagen block, cut to size in each of the root sockets. A Spongostan (gelatin sponge) plug was placed on top, then sutured- site was not closed. Healing uneventful.
A CBCT was taken last week, and shown here. Being my first graft case, I’m not quite sure what I’m seeing. I can see radio-opaque areas- are these the outline of remnants of the graft? What are your thoughts on the bone volume here and which size fixture to use for the case? Any other comments?

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5 thoughts on “Socket graft: what does the CBCT indicate?

  1. The appearance of the CBCT would indicate that this patient’s graft did not osseoconvert and is likely a spongy, fibrous mass. You mention that this is your first socket graft, so I will pass on what do when I encounter this issue. When I encounter this in my patients, I advise them of possible need for secondary graftingay the time of implant surgery, and plan accordingly. If osteotomy prep yields poor quality bone, I aggressively currette out the bone to the edges of the socket, fill with cortico-cancellous bone (using L-PRF since this January), and close with a long-term collagen membrane over the socket and good primary closure.

    What you have encountered is not uncommon with socket grafting; the material and methods we use, not to mention host response, significantly affect outcomes. As with any surgery, even the best matrrials and methods can yield an undesirable result. I have found best results when I remember that most extractions heal well without any intervention, and thus I only attempt to affect the course of nature in certain cases, such as loss of facial cortex. I had poor results with collagen plugs early on, and changed to a protocol tha emphasizes more of the precepts of closed grafting including soft tissue exclusion and primary closure. I also advise patients that my socket grafts may require further grafting depending on how they heal. I hope this provides you some guidance, and best of wishes to you and your patient.

  2. I have not used Bio-Oss collagen block in sockets but this result looks typical of a Bio-Oss socket graft which is very radio-dense with more normal density regenerated host bone surrounding the graft. I no longer use Bio-Oss (granules) for sockets because it doesn’t resorb and convert to natural bone over time. I think you will find the ridge and bone fine for the implant especially since it has matured now for 11 months. I worry about this graft material since I’ve noticed in several of my older cases using Bio-Oss granules unfavorable change(breakdown) of bone around a few implants 8 to 12 years following placement.

    I have my CBCT done by a radiologist and have the images oriented so that measures are made perpendicular to the ridge crest and parallel to the adjacent roots. I’m more comfortable with the accuracy of the measures. In this cast you should be able to use a 5.0 mm diameter and 11, 12, or maybe 13 mm length. It should work well.

  3. Yes the research form Ame Mordenfeld and T Albrecktson et al in COIR shows that after 11 years there is little resorbtion of the graft material ……….. hence by common sense as well as the Systemic review by HL Chan and HL WAng et al in JOMI there will be dramatically reduce host bone content in the site which the research by Norton .M in the July issue of Implant Dentistry shows may lead to a sclerotic situation may result ….
    So think Biology … it is not carpentry we are dealing with living tissue , it is not merely Quantity but alos Quality of Bone that is important ….
    Hence I prefer a fully bio-absorbable material ..
    The only way of any meaningful evaluation is a core sample and histo-morphometry..
    Regards
    Peter

    1. Dear Dr. Fairbarn,
      Thinking about biology, l intend to try Ethoss grafting material and have been watching the tutorials on the web.
      I understand the importance of achieving primary closure and compressing the material for a long enough time with a wet gauze, however, It is not clear to me whether cortical perforation is needed when placing the graft.
      Could you please give some advice?
      Thank you

  4. I do not as we have full access to the periosteal blood supply as no membrane is used but you can if you feel the need …some prefer to do it .
    Regards
    Peter

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