The Decision You Make Before the Tooth Comes Out

Quick answer: Once a tooth is removed, the bone around the empty socket starts shrinking within weeks, and most of the loss happens in the first six months. If you might want an implant later, the socket should be grafted at the time of extraction — not discussed a year afterwards.

The call

Reuven, 52, from RBS Bet, came in with a lower right first molar that had broken down over several years. He knew it was coming out. What he had not been told, at two previous consultations elsewhere, was that anything happened to the site afterwards.

His plan had been to have it out, save up, and think about an implant "in a year or two". That plan works, but it usually costs more and delivers less than doing it in the right order.

What we found

The molar was unrestorable — decay below the bone on the front surface, with a poor long-term prognosis for any attempt at rebuilding.

The important part of the examination was not the tooth. It was the site. A CBCT scan showed adequate bone height above the nerve canal, a reasonably thick cheek-side bone plate, and a healthy neighbouring tooth. This was a good implant site — provided it stayed one.

Here is what happens to a socket left to heal on its own. The bone immediately surrounding a tooth root, the bundle bone, exists only to hold that tooth. Remove the tooth and it loses its purpose and resorbs. Studies of untouched sockets show substantial loss of ridge width in the first six months — commonly around half of the original width — with most of that in the first three months. The cheek-side plate, being thinner, loses the most.

The practical consequence is that an implant placed a year later often needs bone grafting anyway, sometimes as a separate surgical stage, sometimes with a longer healing period. You end up paying for grafting either way; the difference is that grafting at the time of extraction is simpler, cheaper and more predictable than rebuilding a collapsed ridge afterwards.

What we did

An atraumatic extraction — the key word. We used fine periotomes to sever the ligament fibres around the root and eased the tooth out along its long axis, sectioning it into two pieces so that neither root had to be levered against the thin cheek-side bone. Preserving that plate is the whole point; snapping it removes the very structure you are trying to keep.

Then we cleaned the socket thoroughly, placed a bone graft material, covered it with a resorbable membrane and sutured the gum to hold everything in place.

We were explicit about the choice. If he was certain he did not want an implant, grafting was unnecessary and we would have skipped it. Because he wanted the option open, grafting was worth doing that day.

The outcome

Healed uneventfully. At four months the ridge had held its width and height. The implant was placed at five months without any additional grafting, and the crown went on four months after that.

What to do if this happens to you

1. Decide about replacement before the extraction, not after. Implant, bridge, denture or nothing — each has a different implication for the socket.
2. Ask whether socket preservation is worth it in your case. It is not always.
3. Ask about an atraumatic technique, especially for front teeth where the thin bone plate matters most cosmetically.
4. Do not rush an implant decision under pressure — but do know the clock is running on the bone.
5. Ask about total cost, extraction and graft and implant and crown, so you can plan.
6. Follow aftercare precisely. A graft that gets infected is a graft that fails.

Facing an extraction? Ask Ramat Beit Shemesh Urgent Dental Care about the site before the tooth comes out. 055-985-8845 · WhatsApp https://wa.me/972559858845 · Harav Kook 28/1, Beit Shemesh.

Based on real cases treated at the clinic. Names have been changed.