Dental bone grafting and socket preservation in Costa Rica

When a tooth comes out, the bone that held it shrinks, and that's exactly the bone an implant needs later. Before I take a tooth out, I plan what comes next: preserving the socket at the same visit, rebuilding later, or choosing an implant that doesn't need a graft. It's a subject I teach: in 2018 I gave a talk on atraumatic extraction and socket preservation at the National Autonomous University of Honduras. I'm an oral and maxillofacial surgeon (UNAM), certified by the Mexican Board of Oral and Maxillofacial Surgery, a University of Costa Rica professor since 2006, and I see patients in Tower 1 of Hospital CIMA.

Imaging

X-ray or 3D CT scan (CBCT)

Material

Your own, donor, animal-derived or synthetic

Healing

Measured at 3 to 6 months in socket preservation studies

Consultation

60,000 colones · by video, 20,000

When it's indicated

• You're having a tooth removed and want an implant there later, not the same day.
• It's an area where losing width would compromise the implant or the appearance, like the front teeth.
• It's a molar: in a review of molar sites, preservation reduced extra grafting when the implant went in.
• The bone is too narrow or too low for the implant, because the tooth was lost long ago or after an infection, a cyst, an injury or a failed implant.

Before surgery

• Already have X-rays or a CT scan? Send them ahead: we can review them by video.
• If you take blood thinners, don't stop them on your own: I coordinate with your doctor. Tell me if you take bisphosphonates or denosumab, or have had head and neck radiation.
• If you have diabetes, I order an HbA1c test, as a review recommends when planning implants.
• If you smoke, stop before surgery and while you heal: it's linked to more implant failures and bone loss.
• If you'd rather avoid animal or human materials, tell me: there are synthetic options.

How I plan it

How I do it

1. 01AnesthesiaLocal and, if we agree on it, sedation, with fasting and someone to take you home. You feel pressure, but it should not hurt.
2. 02Atraumatic extractionI remove the tooth protecting the socket walls, without levering against the bone. When possible, without lifting the gum: in trials this gave similar bone changes, with less pain.
3. 03Filling and sealingI fill the socket with particulate graft and cover it with a collagen membrane or sponge.
4. 04If bone is already missingI do guided bone regeneration (particulate graft under a membrane that keeps the gum out of the defect) or fix a block with small screws, and close without tension.
5. 05Follow-up and imagingI check the wound and, before the implant, confirm with an image that the bone is ready.

Recovery

• The first few days feel like an extraction: pain, swelling and some redness.
• Cold packs outside, soft food and medication on schedule; no smoking, straws or forceful spitting.
• A few graft grains may come out; if many do or the membrane shows, message me.
• Socket preservation: studies measured the bone after 3 to 6 months of healing; before the implant, I confirm it with an image.
• Ridge augmentation: usually more months, with no well-supported number; with your own bone the donor area heals too.

Risks and how I prevent them

Wound problems or infection

Pain, swelling, slow healing, an exposed membrane and partial graft loss are described, with no serious adverse events in the Cochrane review; infection can also occur. I close without tension; if it happens, I clean the area and consider antibiotics.

Needing more graft anyway

Preservation reduces shrinkage; it doesn't eliminate it. Cochrane found no evidence of a difference in extra grafting; a small review of molar sites did find less. If needed, it goes in during the implant surgery.

The graft shrinking or failing

In one review, animal-derived blocks failed in 6.82% and blocks of your own bone in 6.1% (far fewer of these were studied). Your own bone shrank more; animal-derived blocks had fewer sensory problems and slightly lower implant survival. If volume falls short, I add more graft.

Donor-site discomfort

Taking bone from the chin caused pain, changes in skin sensation and healing problems; patients preferred the back of the lower jaw (the ramus), taken under local anesthesia. When the case allows, I choose the ramus or a substitute.

A nearby nerve or sinus

In the lower jaw the lip can be left numb; in the upper jaw an opening into the sinus can form. I prevent it by measuring those distances on the CT scan and, if it happens, follow it closely.

Other options

Letting it heal on its own

If you're not getting an implant (say, with a bridge or a removable denture), preservation often isn't needed. If surgery isn't needed, I'll tell you.

Same-day implant

If the socket is healthy and the bone allows it, the implant goes in at the same visit as the extraction.

An implant that avoids the graft

With 4 to 9 mm of bone in the upper back teeth, at one year it's unclear whether a sinus lift does better or worse than a short implant (5 to 8.5 mm), and sinus lifts had more complications. With extensive upper-jaw bone loss, zygomatic implants, anchored in the cheekbone, are frequently indicated instead of major reconstructions.

Frequently asked questions