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Presurgical Evaluation

Figure 2
The placement and reconstruction of dental implants is a team effort. It usually requires a surgeon who places the implants in the bone and a restorative dentist who then makes the teeth which are to be anchored by the implants. Before anything can be done a thorough oral examination must be done by both members of the team. The restorative dentist will determine the dental needs of the patient and establish the health of the remaining dentition. The surgeon then will look at the areas of bone missing the teeth to determine whether there is sufficient bone structure and quality overlying soft tissue which can support the type of implant reconstruction necessary to replace the teeth. It is at this time that bone augmentation procedures and soft tissue grafts may be planned to establish the proper foundation for the implant. Depending on the location in the jaws, bone grafts can be done simultaneous with implant placement or may need to be done in advance to prepare the bone for locating the implant appropriately. Often, when teeth are lost prematurely, healthy gum tissue, which is necessary to preserve the health of the bone around the implants, may need to be grafted to this area prior to implant reconstruction as well. All of these things should be taken into consideration before implants are actually planned for a particular site. It is much easier to deal with these problems before the implant is in position to be restored than to try and reestablish bone and/or soft tissue after the fact.
Figure 3
Periodontal disease in patients who still have their teeth or in patients who have lost all of their teeth, is important to determine from the history. Many patients have immune systems which cannot deal with some of the bacteria that are known to cause gum disease around teeth. These same types of bacteria can cause similar problems in patients with implants as well. It is very important to have any and all periodontal problems under control prior to the placement of implants in patients who have teeth, and to establish a healthy environment where there is no residual infection in patients who have no teeth.
Hard tissue grafts may include bone that is harvested from the patient, either from a source inside the mouth (figure 2) or from sources outside the mouth such as the hip or lower leg (figure 3). These grafts may be used to augment the sinus (a sinus lift procedure) to increase the vertical height of bone available in the posterior maxilla where bicuspid and molar teeth are missing (insert animation). This is often necessary because of bone loss due to periodontal disease, atrophy due to loss of the teeth, or an excessive size of the sinus where the floor dips down very close to the bony ridge. The purpose of this graft is to increase volume in anticipation of implant reconstruction whether for fixed bridgework or overdentures (figure 4). Onlay grafts using blocks of bone from the jaws may be used to correct a narrow ridge, too thin to accommodate an implant (figure 5 & 6). Newer techniques utilizing banked bone in combination with genetically engineered proteins which induce bone formation, may eliminate most if not all of the traditional bone graft harvest procedures. Your doctor will discuss with you the pros and cons of different types of bone graft sources as it applies to your particular situation.
Soft tissue grafts are often used to bulk out areas that are too thin to help maintain the health of the gum tissue surrounding the implant as it emerges from the bone or to reestablish the normal contour of the gum tissue so that it resembles the natural condition (figure 7). Again, the decision to do these procedures should be in advance of any final restorative effort.


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