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Complication – Bone Graft is Exposed – Platelet PRF Treatment

Ramsey Amin DDS

I don’t have complications too often but this is one worth sharing. I did a very large block bone graft in the front of the mouth for dental implants. The bone graft was both vertical and horizontal and gained a lot of volume. The block bone graft was held in by screws which will be removed later. This will yield plenty of bone for two front teeth implants.

Complication – Bone graft is exposed

Her temporary Essix bridge inadvertently put some pressure on the gums after the surgery. You never want pressure on top of a newly placed bone graft ! This happened due to a slight tear of clear retaining part of the Essix bridge on the palate. Regardless, it dug into the gum a bit and exposed the newly healing bone.  Now the bone is showing.  You can see how I had to really adjust the Essix temporary to clear all of the bone that was added.

Series of photos showing bone exposure closure technique -Ramsey Amin DDS

I will describe how I closed this open wound using the patient’s own blood platelets-L PRF. (Leukocyte rich platelet rich fibrin)

Series of photos showing bone exposure closure technique -Ramsey Amin DDS

(PLEASE NOTE THAT THIS PATIENT IS NOT COMPLETE — ONE TOOTH WAS EXTRACTED SO THE GAP IS NOW A TWO TOOTH GAP. I PURPOSELY OVER BULKED AND OVER BUILT BONE SO THERE IS EXTRA TO WORK WITH RATHER THAN NOT ENOUGH. THIS WILL LOOK GREAT ONCE THE IMPLANTS AND TEMPORARIES ARE DONE TO SHAPE THE GUMS. THIS IS A VERY LARGE GRAFT BECAUSE IT IS BUILDING BONE VERTICALLY AND HORIZONTALLY)

Series of photos showing bone exposure closure technique -Ramsey Amin DDS

The proper thing here is not to try to reclose the open wound with stitches. That will often make it worse. Usually a noncritical, more basic bone socket graft may fill in on its own. This one was not doing that even though it started off pretty small! You can see the progression over about 7 weeks that it took to close this hole. At first it was not really present, then they got a bit larger> then it shrank down to where pink gum is covering the bone again.

I am always there for my patients. I will do what it takes to correct this. This can happen with block bone graft or GBR membrane techniques….I do both.

Series of photos showing bone exposure closure technique -Ramsey Amin DDS

What I did was remove a very slight bit of surface bone and drew blood from her right arm. With her own blood draw from the arm, special cells in the bloodstream called platelets are concentrated to make a type of gel/membrane call L PRF. I placed the L PRF on the open wound and stitched a web over it to hold in. Over the course of about 2-3 weeks I saw her back 2 times to repeat the blood draw and add more L PRF under the webbing of special Prolene stitches.

The bone graft exposure closed! Complication solved. It is still a bit immature in this last picture but there is pink gum fully covering the bone which is a great sign! Often I get messages from people worldwide with bone exposed that lost their entire bone graft and had to start all over again. This is a very efficient, natural way to close a wound but it does not miraculously close bone grafts that were done with poor technique.

L-PRF and PRP (platelet rich plasma) outside of dentistry heal up wounds that are taking too long such as people with diabetes have open sores.

Your comments and questions are welcome.

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

11 thoughts on “Complication – Bone Graft is Exposed – Platelet PRF Treatment

  1. Hi Dr. Ramsay,

    I have been watching all your Youtube videos and they helped me a lot to understand the bone graft process, I have mine done recently on both sides of my bottom jaw, (15 days ago). However, what concerns me the most is some sort of radiating pain I still experience. I was taking antibiotics for 5 days after the surgery, and I was prescribed another one 4 days ago, however, the pain is not going away. Despite the fact that my gum is still swollen and there is a sharp prominency, I am a bit worried that something is going wrong with the healing process because as far as I am concern taking pain killers after 15 days of surgery it’s not very normal.

  2. How success full are bone grafts for vertical bone loss in the anterior maxillary? I had tooth#11 removed due to an old rootcanal that fractured, original tooth had no enamel and was treated when I was a teen.
    My peridontist attempted immediate implant with bone graft in Feb, it failed after 3 wks. The implant was removed and new graft placed. I also found out #10 compromised, I believe #12 is fine. The original implant on #11 was place deeper in the bone than orinally planned due to bone loss.
    Based on what I have been reading it seems like I should have some other type of bone graft and likely #10 removed. I don’t know what to do, this situation has turned into a nightmare. I’m healthy, non- smoking, no health problems at all.
    I submitted a consultation request via online to see if you could help me. I’m located in Minnesota and willing to travel when it’s safe.

    1. It looks like I am just catching up with your comments on several different posts. This is what I wrote to you on a different thread. I be happy to see you here in sunny California.
      ___________

      Vertical augmentation is certainly more difficult then traditional horizontal bone grafting which just add width. It is certainly possible! It in fact is even more successful in the upper jaw than it is in the lower jaw. This is something that I do all the time. It is very technique sensitive and most dentists do not provide this service as they lack the experience, judgment and/or training.

      That being said growing bone does not happen overnight. Vertical bone grafting often needs 7-9 months of healing and oftentimes secondary bone grafting at the time of implant placement. In addition to that, a gum graft taken from your palate is often needed because the gum has been stretched to fit over all this new bone. It is really going to depend on the health of the adjacent teeth. If the other teeth have truly 0 bone loss then chance of success is very high. This can be done via block grafting, guided bone regeneration-GBR, titanium mesh, vascularized pedicled bone flaps etc. Each case is very unique.

      Stay safe during COVID 19! I would be happy to see you as a patient.

  3. Angie in your office told me to leave you a message here: My 18 yr. old daughter has a similar situation. She lost teeth 7 & 8 due to an accident. She needs bone augmentation to bring bone down for implants. We were told that she would need either GBR or Distraction Osteogenesis. Do you do both procedures? Which one do you prefer for the best long term outcome for implants? Which one has the least complications for this type of situation? Thank you so much for letting me know.

    1. Without an exam there is no way I can tell you which is better. I do all of the ones you described plus about 12 other methods. Which is right depends on her situation and the skill of the implant dentist. She is a bit young though. Often times these are best to wait until 20 years old. Often times I will do block graft to this area along with gum grafting 😊

  4. Hi my name is sam
    I wrote you earlier I am 55 had a week where i went to hospital 3 times was numbed given penicillin pain pills and sent home before an oral surgene could pull my left upper molar. What I forgot to ask is should I be able to see the bone grafting material sticking out that he pushed into the hole left by the roots of the molar? I can see a big blob of what looks like bone paste shoved into the hole left by the roots and he used stiches that I have to go back to have removed in ten days, is this normal? Its very noticeable I don’t know if its just what oozed out from the stiches or what its not moving I just see it there.

  5. Hi, just had my front tooth removed and had bone craft at the same time yesterday morning (in preparation for tooth implant) this morning after removing my flipperto clean it, i noticed three white/yellowish small spot coming from my gums (where the tooth was) i got scared called my dentist but she was not at the office talked to dental assistant and she said not to worry. Tonight after removing again the flipper to clean it and brush my teeth, not the front one. I notice no three spots it was more than that, a lot more. Is my bone craft coming out? Is it normal?

    1. It might help you to read the post and some of the comments above. Without seeing you it is impossible to tell your exact situation but fortunately the body is pretty good at repairing itself

  6. This procedure looks like my situation because I had my Right front tooth extracted on March 26, 2018 — It has been sucking the bone around it for about 13 years — finally a dentist did a CT scan and diagnosed it as “resorption” — I had felt my gums receding and bone loss many years ago. It was freaking me out — with a weird itchy feeling — hard to describe. Then I had soft tissue grafting to fill in the gums, but it melted away pretty fast. Then I had braces, because my bite was off, and possibly contributing to this problem. After I got my braces off, that front tooth refused to move the whole time — but the rest of my teeth were nicely straightened — but I think the resorption started going faster after braces — and finally I got my tooth pulled, and it had holes inside, and the root looked more like broccoli than a carrot. Now — after having granules bone graft the day of the extraction, it has been growing a larger and larger hole — and freaking me out! My periodontist says it will be able to take an implant, but will also need another soft tissue graft. It feels weird — like I don’t know if the synthetic coral granules that he packed in there are really doing anything — I have to wait till the end of July before I get the implant post. My Dr. says it’s in the process of resorbing the coral granules and finding it’s blood supply. I sure hope so! I practically have no bone at all around that tooth — I am praying that I will be able to have an implant, because this flipper is annoying, and there’s a huge hole over the tooth. What is your suggestion?

    1. My suggestion is that you wait longer. March 26 of this year is not enough time elapsed for the bone to heal. Wait until a full 6 months have passed. Any hole that is exposed along the way must be dealt with closure. I would wait far beyond July! Never Rush a front tooth implant bone graft.

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About Ramsey Amin, DDS

Dr. Ramsey Amin has extensive experience in surgical and restorative implant dentistry. As one of only less than 400 Diplomates of the American Board of Oral Implantology/ Implant Dentistry (ABOI/ID) he is considered an expert, and board-certified in dental implants. He is a former instructor at the UCLA School of Dentistry.