After Extraction and Bone Graft…The Bone is Showing. Now What? Ramsey Amin, DDS Reviews Options

Exposed bone in mouth after graft

Exposed bone in mouth after graft

You may have had your tooth extracted and a bone graft placed at the same time.

About once or twice a week I get emails from around the world with patients that have had this very common (pre dental implant) procedure.

You may be worried because you can see that the bone is exposed inside your mouth.

You may also be worried because small, hard granules, pieces, or particles of bone coming out of the socket. You see white bone showing.

extraction socket bone graph by Dr. Ramsey Amin, DDSDON’T PANIC!

Socket bone grafting is very common and is encouraged when the outer wall of bone is very thin. The goal is to prevent the bone from shrinking and preserve the bone mass.

Most socket bone grafts have particulated bone added to the socket and are covered with some type of membrane at the same time of the surgery. The bone may be from your own body, from a human cadaver, from a cow or synthetic bone.

The bone on your cheek and lip side of your teeth in general is no thicker than 0.5mm to 2 mm at the most. When a tooth is extracted, the thin wall of bone will naturally collapse inward leaving a depression indent in your jawbone. It is that very same bone that you need to have a dental implant.

Ideally over the course of the first week, the gum heals over the top and no bone is showing at all. It is not uncommon for some bone to become exposed during the process of healing. It is also not uncommon to have some of these granules come out during the healing process.

I strongly encourage antibiotic use during most socket bone graft procedures as this will help reduce (not eliminate) the chance of infection. I routinely administer antibiotics right before your appointment so that the blood clot (scab) will have the antibiotics within it.

If you are not allergic to penicillin, then amoxicillin 500 mg is an ideal choice. If you are allergic to penicillin, then clindamycin would be another good choice.amoxicillin

What do you do if you see bone or you are getting small flecks of bone coming out in your mouth? Don’t panic…see your dentist and let them know what you are experiencing. As long as you are not infected then it should not be a problem. If you have an infection of the bone graft and socket then you will likely need to continue antibiotics for a second or third round or sometime switch antibiotic families altogether. I generally prescribe an antibiotic mouth rinse also such as peridex. You will need to have some of the top pieces of bone removed.

Signs of infection would be redness, pus, pain and in some cases fever.

The most crucial thing to ensure your socket bone graft extraction success is that the procedure is done well by someone who specializes in implant dentistry. The correct choice of bone product for your situation is important but not as important as the surgeon and your healing ability.

3d scan burbank ramsey amin (4)

Extraction and bone grafting at the same time is not as simple as just sticking some bone into the socket. The internal cleaning of the socket is super important. All remnants of tooth and inflammatory tissue must be removed. This is not as easy as just scooping it out. The socket must be debrided very well to get down to bare, bleeding bone and is a sensitive procedure especially when you are pulling out a failed root canal tooth.

Fractured root canal teeth are probably the most common extraction that leads to a socket bone graft. Choosing bone that comes from your own body, from a cadaver, from a cow, or totally synthetic all have their pros and cons and you must discuss these with your dentist.

The socket bone grafting for upper front tooth dental implants are critical in establishing the right amount of bone so your front tooth looks great! If there is a dent in the bone, the tooth will look long and may have open black hole triangles near the tooth.

Bottom line…some exposure of bone and bone graft migrating pieces is common, but it is preferred that all of that stays in the socket. It does not mean the graft has failed. Do not confuse a socket graft losing bone with an exposed onlay block bone graft. The rules are different.

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


Leave a Reply

Your email address will not be published. Required fields are marked *

You may use these HTML tags and attributes: <a href="" title=""> <abbr title=""> <acronym title=""> <b> <blockquote cite=""> <cite> <code> <del datetime=""> <em> <i> <q cite=""> <s> <strike> <strong>

28 thoughts on “After Extraction and Bone Graft…The Bone is Showing. Now What? Ramsey Amin, DDS Reviews Options

  1. Josh

    Very informative article. As a periodontist I believe it’s crucial to provide a series of progression photos for the treatment process.

    Reply
    1. Ramsey Amin DDS

      Thank you Dr. Josh!

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

      Reply
  2. Jaime

    This blog is really nice.. it seems like you put in so much time over the last 5 years into educating patients. Thank you so much for all your help!

    Reply
  3. Rebecca

    Your site is helping me put my mind at ease. I have a great oral surgeon, I trust him. However, I wish I could have been provided with some pictures so I could gauge my healing progress- just had #30 extraction October 15 with bone graft, sutures and antibiotics. After four, going on five days now, I still have pain and a bit of swelling. I don’t, and have not seen a blood clot. Because I have a bone graft and sutures I am hoping this is normal. I see yellow and white. Pain is relieved with Motrin. I know one suture definitely came out on the third day. I am worried now because I feel a bit of an indent at the extraction site- I am not sure if I should feel graft material packed to the top or what- I was looking for answers and this is how I came across your site.

    Reply
    1. Ramsey Amin DDS

      Hello Rebecca,

      It sounds like you are 5 days out from the tooth extraction when you wrote this comment/question. Everything you have sounds within range of normal. Even though a suture came out and you feel some small indentation that does not mean that your bone graft has failed or anything needs to be done about this. I’m sure when you see your oral surgeon, he or she will tell you the same.

      There is a chance you may have an infection which would require additional antibiotics or worse case scenario removal of the bone graft altogether.

      Dental Implant Bone Graft healing -What to Expect

      Very respectfully,

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

      Reply
  4. Nicole

    Hello,

    I recently had a bone graft to widen my bone for a tooth implant, I just had a proper look at my teeth after 4 days and am a bit concerned over how much white is actually showing in my upper gum, after reading you article and looking at the pictures I’m still really unsure whether the gum will eventually grow over the bone or if I need to get another procedure done for the gum to cover it all, I know it’s early days but I’m just curious

    Reply
  5. Padmini Ramlal

    I had a upper teeth removal by back of my mouth a few days backand saw a piece of scab fall out when eating. Its not really a big piece but should I be worried

    Reply
    1. Ramsey Amin DDS

      Hello PR,

      Fortunately dry socket which is formally called alveolar osteitis is not common in the upper jaw. I would not worry about it too much. Loss of a blood clot in the lower jaw especially on the lower wisdom tooth can develop a very painful condition which many know as a dry socket.

      Wisdom Teeth Extractions

      Very respectfully,

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

      Reply
  6. Annie

    Had extraction then bone graft a few weeks later, now, after about a month, i see my bone in my lower jaw, on the inside close to the side/under my tongue, about 4mm wide 3mm in ht. Its oval shaped and its as if the bone compacted and wore out my skin. Its tooth #19 and about 6mm down from top of gum line. Feel it continue to get bigger, as in spreading wider. Please help

    Reply
    1. Ramsey Amin DDS

      Hi Annie,

      It sounds like you have what we call a “bony sequestrum.” It is not uncommon for this to happen on the inside of the lower jaw in the back of the mouth. The gum tissue is very thin in that area.

      I am guessing your not taking an intravenous bisphosphonates such as Zometa which is related to the oral medications like Fosamax, Boniva, and Actonel. If so this can be a condition called osteonecrosis of the jaw… But not likely..

      The condition of exposed bone is typically very easy to treat. In my office in Burbank, I would simply apply a strong topical gel and adjust the bone below the level of the gum. It typically would heal up within 3-7 days after doing that. You need to see your dentist ASAP.

      PRP/PRF treatment may help accelerate the wound healing process tremendously. I use it all the time, especially on areas that may not be healing properly.

      Do you take Fosamax, Actonel or Boniva? What You Need To Know Before Having Dental Implants
      PRF/PRP treatment

      Respectfully,

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

      Reply
  7. Kristine

    Thank you for the post.
    My bone graft “failed” in #5 twice.
    I was never given an antibiotic, after grafting.
    I was given one when the implant posts were drilled in, but,
    both times it was days later, because they made me vomit.
    I have had antibiotics before with no problems.
    I was in a ton of pain, that was also ignored.

    Reply
  8. Dee

    Had #3 extracted due to a fracture, dentist packed area with white gauZe and then gave me stiches leaving gauze in my gums. Is this safe? Having stitches removed in four more days. But that will make it 12 days from date of extraction.

    Reply
    1. Ramsey Amin DDS

      Hi Dee,

      This seems a bit odd. Is the gauze infused with some sort of growth factors if it is truly gauze? You sure it is not a bone product?

      I use concentrated blood from your own body to make certain growth factors such as PRF/PRP/PDGF but those are implanted directly into the socket or into grafted bone without the use of gauze to hold in. I would just call your dentist and ask what you had done. It should be very clear before you have the procedure done.

      Growth factors information

      Reply
  9. Debra

    I had a bone graph on a front tooth a year ago. It was out of the state and I will be going back for an implant soon. How do I know before then if it has started to reabsorb or collapsed? Just don’t want to be nervouabout it failing since I’ve waited too long.

    Reply
    1. Ramsey Amin DDS

      Hello Debra,

      The bone graft won’t just fall out. The best way to assess the quality and quantity of the bone graft done 1 year ago would be to take a 3-D scan and have virtual implant placement done. This will allow the dental implant surgeon to know exactly what they’re going into before an incision is ever made. This also greatly depends on what type of bone graft and type of technique that was used for your particular bone graft. In my practice if I have a patient that is going to be delaying treatment for a while, the bone graft is modified in this composition to last longer. Try to get implant done as soon as possible. Waiting beyond 9 months after having the bone graft never really helps.

      wear to the bone come from?
      virtual surgery

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

      Reply
  10. Linda Chronister

    Debra: I had one of my big front teeth extracted in early February and a bone graft done. Except for one stitch coming out later and an appointment since…everything seems to be intact. I was told to hold warm salt water to my upper gum several times a day, every day which I did at first, but slacked off. I didn’t confess to my dentist that I had been lax on that and he said “Just keep doing what you’ve been doing – the salt water..and don’t bite into anything with your front teeth” At that visit, he pulled on a stitch and I yellow “Ow!” and his assistant told me that he was going to remove stitches but because I was still so sensitive, he would wait and that some may come out normally themselves. I’m trying to remember to do the salt water but he never told me that that was actually a ‘healing process’ – I thought it was mainly to relieve discomfort. Now, the past two days, my gum right up under my left nostril, feel swollen and really hurts – esp. if I need to wipe my nose! If it is infection or rejection…was I at fault for not religiously using the salt water? My next appointment is not until April – it is March now.

    Reply
    1. Ramsey Amin DDS

      Linda,

      You should not wait until April to see your dentist. You should see him or her now in case you have developed an infection that can dissolve away your bone graft!!!

      Ramsey Amin DDS

      Reply
  11. Tiffani Stewart

    Hi there,

    I had a bone graft and tooth extraction done two weeks ago. They took a piece of the bone to use in the graft from my lower jaw, right hand side. *Sigh* I took the antibiotics the whole way through, one stitch broke about 7 days in, and one broke where they took the bone from. Anyway, it’s been 15 days today and my lower jaw is still a bit swollen. It’s also a bit inflamed on the inside of my mouth where they took the bone from. I cannot open my mouth as wide as usual, and I feel when I try to like a hard ball is going to break. I am freaking out a bit and can’t see my surgeon for another week. There isn’t much pain, once in awhile it feels sharp for a second but immediately goes away. I also didn’t brush this area the entire time I had the stitches because it was painful and I was afraid of breaking them, bad idea. My dentist was slightly unhappy about that. He also said I created an indentation within the area of my bone graft due to me pressing on it with my tongue. He said this was classic. I’m a bit nervous and worried, I’m hoping I don’t stay like this forever. I’m only 27. I don’t want to have trismus or osteomyelitis….. Is it normal for it to be swollen in this area after 15 days.

    Reply
    1. Ramsey Amin DDS

      Hello Tiffani,

      It sounds like you had an autogenous bone block graft. I have done many of these. Nowadays, I mostly use bone from a tissue donor rather than having to take it from your jaw.

      Depending on how complex the surgery was, you could possibly have pain and swelling for 15 days if it was a really severe case. I’m guessing it was taken in the back of your mouth where you wisdom teeth used to be. This is called the ramus. It is attached to a muscle that makes are mouth open and close called the temporalis. During the procedure, if the muscle attaches to where the bone is being taken from, it has to be stripped off which causes this limited mouth opening for a while.

      As long as the stitches did not open up in the area where the bone graft was placed, it is probably okay. Definitely keep the area clean by brushing it well…. Give it time. It will also heal. I am guessing you just had a very complex case.

      Attached is a link to a post about block bone graft for dental implants.
      Block Bone Graft for Dental Implants 2015 Update-Ramsey Amin DDS Reviews

      Very Respectfully,

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

      Reply
  12. Rob Blake

    I think My implant membrane came out after about a week or week and a half. Not sure. Had an xray yesterday 3 weeks in. I thought I may have had an infection. I didn’t Doctor says bone graft looks good. Is membrane coming out going to cause me a problem and is there anything that can be done at this point? Thank you.

    Reply
    1. Ramsey Amin DDS

      Hi Rob,

      I think this post will help you the most. Make sure you see your dentist too!

      basics of membranes and exposures

      Every case is very unique. Sometimes an exposed membrane is done on purpose while sometimes it can be extremely detrimental to the healing of the bone graft. It depends on the technique of the bone graft more so than the type of bone graft material. also keep in mind that many dentists have a wide variation of training, experience and judgment in the discipline of dental bone grafting for dental implants.

      Very respectfully,

      Ramsey Amin DDS

      Reply
  13. Amy Maldonado

    I had 5 extractions and 5 bone grafts done on the 18th of March #’s 7, 14, 15 18, and 19 and after 5 days had to call to schedule myself a follow up appt. something didn’t seem right I had the partial plates in and they didn’t fit right first of all but my breath was beyond what myself or anyone around me could handle! Absolutely horrifying! When I removed the partials to clean with warm salt water I notice greenish yellow stuff oozing from the incision so I went to dentist to see if I had an infection she said oh no everything is healing nicely. I went home and just felt I needed to check the extraction sites of 14 and 15 and placed a mirror in my mouth to look and what I saw were huge black holes with green and yellow pus outside of the holes. # 14 has a hole big enough to stick my finger in. I don’t know if this is normal obviously my dentist thinks so but I was suppose to have had bone grafts and I don’t understand where there would be such a big hole. I took pictures and I was thinking about making an apt with another oral surgeon to find out if the bone grafts were even done and exactly what is going on. Can you please give me some advice

    Reply
    1. Ramsey Amin DDS

      Hello Amy,
      Without seeing you personally, I would not be able to definitively tell you whether things were healing well or not. Your descriptions make it seem as if you do have an infection….. But white coloration is considered normal healing inside of the mouth. Oozing fluid is not considered normal healing.

      Depending on the method and materials of grafting, the hole may feel large to you. Bone is grafted just below the level of the gum tissue and may feel concave…. This would be considered normal for a socket bone graft if this is what you had done. Eventually, your gum will heal over top of the concavity into a very flat ridge like structure which will be perfect for the dental implant.

      I have trained many dentists on bone grafting techniques. Some dentists do this all the time and some only dabble in it…. Those to do a lot of these procedures understand what is normal and what is not and can help you have an ideal dental implant situation.

      Signs of infection would include fever, bad breath, limited mouth opening, swelling, heat around the area. Make sure your dentist for a second follow-up visit if you feel that things are not healing normally. I’m sure they will be happy to accommodate you.

      Socket Bone Grafting….Do I Need It for My Dental Implant? Ramsey Amin DDS Reviews

      Very Respectfully,

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

      Reply
  14. yannic

    thanks for this article, it really helped me a lot 😀 I just got a decayed tooth removed and all is going well (has been nearly 7 days now) but yesterday some bone got exposed (a tiny pike on the front) and seems like also a little fragment is coming out, so I was a little afraid, but this article helped me calm down a lot and is very informative. since it’s not hurting or anything I guess I have nothing to worry about, in any case I have an apointment with the dentist in a week to check my progression.

    Reply