Whether you are just extracting teeth or doing more advanced surgical procedures, such as placing implants or preparing sites for future prosthetic reconstruction, the ability to confidently perform bone grafting begins with proper training and acquiring the essential tools and materials. Once you understand what is required for success, these techniques and procedures are straightforward, predictable in their outcomes, and rewarding to provide for patients.

This article clearly defines the materials and instruments needed for the five most common bone grafting procedures. Nearly every product featured in this article is available through Newport Surgical^™ (Glidewell Direct), a streamlined collection of the materials, instruments, membranes and wound dressing needed for the bone grafting procedures typically performed in the general practice.

Socket regeneration, more commonly known as “socket preservation,” is an essential procedure to avert the loss of bone volume and prevent soft-tissue pathology at extraction sites. When a tooth is lost, it is possible to lose 30%–60% of the bone volume in either the width or height — or both — within the first few years. This loss of bone can directly impact the ability to place an implant at a later time without subjecting the patient to further grafting procedures.

The loss of underlying hard tissue — and, ultimately, the soft-tissue support — can lead to periodontal pathology for the adjacent teeth and make the fabrication of esthetic implant or conventional fixed prosthodontic restorations difficult. Thus, it is recommended that socket sites be grafted at the time of tooth loss or extraction.

Grafting material: If the extraction site is intact, with the walls sound 360 degrees around the socket, you can choose from an array of materials, including Newport Biologics^™ Mineralized Cortico/Cancellous Allograft Blend or Bone Graft Putty Mineral-Collagen Composite, or an OsteoGen^® Plug. With the OsteoGen Plug alloplast, no collagen plug is needed, although the plug does need to be confined by suturing the site.

Barrier membrane: If the socket is very large or one of the walls has a defect, then the use of a barrier membrane is essential to not only confine the materials, but also prevent ingrowth of the soft tissue. Newport Biologics Resorbable Collagen Membranes are a perfect fit for the job. Because they are made of cross-linked collagen fibers, these membranes are strong and will resorb over time. The fact that they are resorbable means you do not have to make an incision to remove them at a later time. The membranes are available with two resorption schedules: 3-4 months and 4-6 months. Although these two types of barrier membranes differ in handling characteristics, either membrane can be used. The 3-4 month membrane is more malleable when dry than the 4-6 month membrane, and both will drape nicely once moistened with the patient’s blood.

Surgical instruments: The Newport Surgical Implant and Bone Grafting Instrument Kit includes all of the tools you need to perform the socket regeneration procedure: a large sterilization tray, bone carrier and spoon, 2/4 Molt curette, sinus curette, serrated curette, Adson forceps with serrated tips, Crile needle holder, Goldman-Fox one-blade serrated scissors, scalpel handle No. 3 round, Seldin retractor, Oringer mouth retractor, and bone dish. For blades, GLASSVAN^® Surgical Blades feature newly refined cutting edges that improve the sharpness of the incision and reduce drag.

Other necessary tools and materials: When using the allograft particulate or alloplast putty, I prefer to cover those materials by suturing a Newport Biologics Resorbable Collagen Plug into place. To suture the bone grafting site, I recommend RELI^® sutures, which are available in polyglycolic acid (REDISORB^® PRO) and chromic gut (REDIGUT^® Chromic Pro) with a 3/8 reverse cutting needle.

The ridge augmentation procedure is performed to encourage bone growth along a ridge where significant loss of buccolingual or vertical bone volume has occurred. When bone volume is lost, in many instances there is not enough room to place an implant without the body of the fixture emerging outside the bony envelope or encroaching on a vital structure, such as the inferior alveolar nerve, mental nerve, maxillary sinus or floor of the nasal cavity. In addition, after a tooth is lost, bone loss can occur that results in a concavity or the lack of volume needed to place an implant in the correct 360-degree dimension needed to facilitate a long-lasting and esthetic restoration. To address these situations, the ridge augmentation procedure helps establish the vertical and horizontal bone volume needed to place an implant or create a foundation for prosthodontic restoration.

Grafting material: For ridge augmentation procedures, I prefer to use Newport Biologics Bone Graft Putty Mineral-Collagen Composite, with cortico/cancellous allograft blend as a close second.

Barrier membrane: Before suturing the ridge augmentation site, I typically place a Newport Biologics Resorbable Collagen Membrane 4-6, which prevents ingrowth of gingival tissue along the grafted ridge and provides sufficient time for the site to heal before fully resorbing.

Surgical instruments: The Newport Surgical Implant and Bone Grafting Instrument Kit includes all of the tools you need to perform the ridge augmentation procedure. GLASSVAN Surgical Blades excel in making the surgical incisions required to provide access to the site.

Other necessary tools and materials: Polyglycolic (PGA) or chromic gut RELI sutures are perfect for suturing the site when the ridge augmentation procedure is complete. In some cases, tenting screws — for use in conjunction with resorbable collagen membranes — may be needed to create the necessary space for bone regeneration.

When a tooth is removed and an implant is immediately placed into the extraction socket, there is a gap that occurs between the implant body and the boundaries of the socket walls. This gap should be filled with grafting material at the time of placement to ensure a predictable outcome for the implant restoration. In addition to preserving the bony architecture of the alveolus, this procedure gives the soft tissue a foundation to migrate across.

Grafting material: OsteoGen Plugs are perfect for this type of grafting, and I use them almost exclusively when grafting around an implant immediately placed at an extraction site. You can also use cortico/cancellous allograft or alloplast putty and achieve excellent results, but you will need to use a collagen plug or membrane to keep the graft material in place.

If using the OsteoGen Plug, a collagen plug or membrane is not needed because this graft material is a unique combination of collagen and a proprietary calcium carbonate mineral that is self-contained. The composition of this plug closely resembles the ratios of organic and nonorganic materials found in natural bone. The OsteoGen Plug can be used for all types of grafting, but it is a standout when it comes to socket preservation, grafting the gap around implants and vertical sinus elevations. Its physical properties, which keep it from migrating, are a huge benefit in these situations.

Barrier membrane: If a membrane is needed, I recommend either the 3-4 or 4-6 month Newport Biologics Resorbable Collagen Membrane. Note that a membrane is absolutely necessary if the site has a significant defect, such as a dehiscence or multiple walls missing from the extraction socket.

Surgical instruments: While the Newport Surgical Implant and Bone Grafting Instrument Kit contains the essential instruments for bone grafting procedures, a spade proximator, elevators and atraumatic forceps are also needed for tooth extraction. GLASSVAN Surgical Blades are my go-to for reflecting a surgical flap to access the implant site.

Other necessary tools and materials: For the immediate implant procedure, I typically use RELI REDISORB PRO PGA Sutures 4-0, which are part of the Newport Surgical collection available via Glidewell Direct at glidewelldirect.com or 888-303-3975.

Clinical situations can arise where bone adjacent to an implant is lost after the implant has been placed. This may occur within the first six months or after many years. The most common causes of early bone loss are usually iatrogenic, systemic abnormalities or premature loading of the implant. Later bone loss can be due to prosthetic overload, poor oral hygiene or bacterial infection. The key in grafting these defects is not necessarily the graft material itself, but rather the ability to decontaminate the surface of the implant.

Dental implants are manufactured and treated to have extremely porous surfaces to encourage bone growth. When grafting these peri-implant defects, make sure to thoroughly clean the surface of the implant as much as possible. The organic substances trapped within the porous titanium can be removed using a combination of mechanical debridement, chemical treatment and laser debridement.

Grafting material: Once the surface of the implant has been thoroughly cleaned, peri-implant defects can be predictably and effectively grafted using Newport Biologics Mineralized Cortico/Cancellous Allograft Blend or an OsteoGen Plug.

Barrier membrane: After grafting any defects, place a resorbable membrane to contain the graft. Either 3-4 or 4-6 month resorbable collagen membranes are acceptable depending on the preference of the clinician and the severity of the defect.

Surgical instruments: Most of the tools you need for this grafting procedure beyond your usual armamentarium are included in the Newport Surgical Implant and Bone Grafting Instrument Kit. Additionally, I use GLASSVAN Surgical Blades for incisions. A titanium scaler is commonly used to debride the implant, and I like to use a diode laser as well.

Other necessary tools and materials: For suturing sites where peri-implant defect grafting has been performed, I typically use RELI REDISORB PRO PGA 4-0 sutures.

After the removal of maxillary posterior teeth, there can be a loss of available alveolar bone due to crestal resorption, sinus pneumatization or a combination of both. This loss of hard-tissue volume results in the need to increase the vertical height of bone by elevating the sinus through either a sub-antral vertical approach or a lateral approach utilizing a Caldwell-Luc procedure. Both of these techniques involve detaching the Schneiderian membrane and placing graft material between the sinus floor and the overlying membrane.

Grafting material: This procedure can be performed with predictable results using Newport Biologics Mineralized Cortico/Cancellous Allograft Blend or Bone Graft Putty Mineral-Collagen Composite, or an OsteoGen Plug.

Barrier membrane: For the repair of tears, I like the malleability of the 3-4 Newport Biologics Resorbable Collagen Membrane. For covering the lateral wall entrance, the 4-6 month collagen membrane is ideal because of its additional stiffness.

Surgical instrument: In addition to the Newport Surgical Implant and Bone Grafting Instrument Kit, I use sinus curettes, the Hahn^™ Tapered Implant Osteotome Kit, and GLASSVAN Surgical Blades when performing the sinus lift procedure.

Other necessary tools and materials: This is another procedure where I prefer to suture with RELI REDISORB PRO PGA 4-0 sutures.

A majority of bone grafting procedures can be safely and predictably performed with confidence in the general practice, especially with a clear understanding of the materials and instrumentation required for each indication. Nothing can substitute for training to build the skills, confidence and experience needed to provide the very best treatment for your patients, but with the materials and tools outlined here, you can assemble the armamentarium needed for the most common procedures.