Bone grafting in periodontitis: when it may be recommended

Bone grafting in periodontitis may be recommended once the infection has been brought under control, to regenerate certain bone defects, stabilise a natural tooth or restore the volume required for a dental implant. The procedure is not suitable for every patient, and its suitability is determined by the periodontist based on the extent of bone loss and the stage of the disease.

In this article, Dr Alexandru Georgescu – Medical Director at DENT ESTET, a specialist in periodontology, a specialist in dento-alveolar surgery and a Doctor of Medical Sciences – explains the link between periodontitis and bone loss, when bone grafting may be recommended for a patient with periodontal disease, and what DENT ESTET’s approach is in cases of bone loss. 

Bone grafting, also known as bone augmentation, is a surgical procedure in which the dentist places a graft material into an area with a bone defect. Over the following months, the material supports the natural healing process and the formation of new bone tissue. Depending on the case, the graft may be combined with a membrane, usually made of collagen, or with other regenerative materials.

The procedure cannot, in all cases, restore all the lost bone and does not treat periodontitis on its own. The outcome depends on the extent of bone resorption, the condition of the tooth, control of inflammation and oral hygiene. 

How periodontitis affects the bone that supports the teeth

Bacterial plaque that accumulates beneath the gums fuels the inflammation. If left untreated, it progresses towards the deeper structures and gradually destroys the periodontal ligament and the alveolar bone. This leads to the formation of periodontal pockets, in which bacteria accumulate more easily.

Bone loss can be:

• horizontal, affecting the bone around the teeth more evenly
• vertical, forming deeper, localised defects.  

This distinction is important because certain vertical defects have a better potential for regeneration than extensive bone loss.

Signs that the bone support is affected

Persistent bleeding, gum recession, gaps between the teeth or tooth mobility may suggest advanced damage. However, bone loss cannot be assessed on the basis of symptoms alone. Diagnosis requires a periodontal examination and imaging tests.

Regeneration around teeth and augmentation for implants

Around a natural tooth, regenerative treatment aims to improve periodontal support when the anatomy of the defect and the prognosis for the tooth allow this.  

Conversely, if the tooth has been lost or cannot be saved, bone augmentation may be used to reconstruct the alveolar ridge for a future implant. These are two distinct objectives, each requiring different treatment plans. 

To preserve natural teeth

Addition may be considered in cases of intraosseous defects, particularly vertical ones, associated with periodontal pockets that persist after initial treatment.  

The tooth must have a favourable prognosis, and inflammation and bacterial plaque must be under control.  

Mild or moderate mobility does not always rule out regeneration, but the decision is made on a case-by-case basis.

Preparing for implant treatment

Following the loss or extraction of a tooth, the bone in that area may gradually resorb. If the remaining bone volume does not allow for stable implant placement, the dentist may recommend a bone graft.  

“If the patient also has periodontal disease, this condition must be brought under control before the implants are inserted, as a history of periodontitis requires careful monitoring even after treatment has been completed.” – Dr Alexandru Georgescu

When bone grafting is not recommended

Bone grafting may have limited results in the presence of:

• active inflammation;
• poor oral hygiene;
• extensive horizontal bone loss;
• a tooth with a very poor prognosis;
• bone resorption-inhibiting treatments (bisphosphonates, denosumab), which require further assessment of the risk of osteonecrosis of the jaw.

Smoking and uncontrolled diabetes can impair healing. These factors do not always constitute absolute contraindications, but must be assessed and managed prior to treatment. 

The initial assessment will be carried out by a specialist periodontist. This involves:

• the depth of the periodontal pockets;
• whether the gums are bleeding;
• the degree of gum recession;
• tooth mobility.  

At DENT ESTET clinics, the Florida Probe digital system can be used to measure and monitor periodontal status.  

Following the periodontal assessment, the dento-alveolar surgery specialist will analyse bone volume using radiological investigations, such as dental X-rays and CBCT scans, and will determine whether bone augmentation is required.

Bone grafting is not the first step in the treatment of active periodontitis.  

Before this procedure, the dentist may recommend:

• professional cleaning;
• root surface cleaning;
• minimally invasive laser treatments (e.g. decontamination or photodynamic therapy).

“This stage is followed by a reassessment. Sometimes, reducing inflammation and improving oral hygiene can stabilise the situation sufficiently. It is the specialist in dento-alveolar surgery who determines whether a bone augmentation procedure is required.” – Dr. Alexandru Georgescu 

The procedure is carried out under local anaesthetic. The dentist removes the tissue and carefully cleans the area, then applies the graft material. If necessary, this is protected with a membrane, after which the gum is repositioned and sutured.

In the case of implants, the bone grafting and implant placement can sometimes be carried out in the same session, provided there is sufficient bone to achieve initial stability. Where bone volume is insufficient, treatment may be carried out in stages: first, bone reconstruction and healing, followed by implant placement. 

The material used for bone augmentation is chosen according to the type of defect and the aim of the treatment. The main options are:

• autograft – uses the patient’s own bone, harvested from the patient;
• allograft – derived from processed human bone tissue;
• xenograft – uses carefully processed material of animal origin (most commonly bovine, deproteinised);
• alloplastic materials – these are synthetic and biocompatible materials;

combinations of materials – these may be recommended in certain cases, depending on the specific characteristics of the bone defect.

Membranes can be used to:

• protecting the treated area;
• stabilising the graft material;
• guiding the healing and regeneration process.

The specialist is responsible for selecting the appropriate material, based on the results of the assessment and the limitations of each material, in relation to the patient’s clinical condition. 

In the first few days following the procedure, the following may occur:

• localised inflammation
• tenderness
• moderate discomfort  
• bruising.  

These reactions gradually subside if the recovery is normal. The gum begins to heal within a few weeks, but bone formation and maturation take several months.

The patient must follow the recommended treatment, eat soft foods and avoid chewing on the operated side, smoking and strenuous activity. Oral hygiene should be adjusted so as not to irritate the wound, and follow-up appointments must not be missed.

“If symptoms such as pain, persistent bleeding, fever, discharge or an unpleasant taste occur, you must inform your doctor. Prompt assessment allows any complications to be treated before they affect the healing process.” – Dr. Alexandru Georgescu 

The outcome is influenced by the shape of the defect, the control of inflammation and adherence to recommendations. Good oral hygiene, giving up smoking and managing any underlying medical conditions all support the healing process.

Periodontal maintenance remains essential even after bone grafting. The procedure does not eliminate the risk of recurrence, and regular check-ups protect both natural teeth and implants. 

In suitable cases, regeneration can improve the stability and prognosis of severely affected teeth. However, not every tooth can be saved. 

The dentist weighs up the benefits of preserving the tooth against the risks and alternative treatment options, in order to recommend a realistic and stable solution. 

At DENT ESTET clinics, periodontal cases are assessed using imaging studies and digital monitoring technologies. Laser technology can be incorporated into the management of inflammation where medically indicated.

For complex cases, interdisciplinary collaboration enables periodontal treatment to be coordinated with surgery, implantology and prosthodontics. The treatment plan does not end with the procedure, but continues through a personalised maintenance programme.

In conclusion, bone augmentation is a valuable but selective option. A comprehensive periodontal assessment can determine whether the realistic goal is to preserve the natural tooth or to prepare for implant-supported restoration. 

1. Surgical Procedures, American Academy of Periodontology
2. Guideline on the treatment of stage IV periodontitis, European Federation of Periodontology  
3. Guideline on the treatment of stage I–III periodontitis, European Federation of Periodontology