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Bone graft and Inplants

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sujatabyahatti's picture
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Joined: 19 Dec 2010

When reading the most prestigious dental implant publications, it appears that the solution to most of the difficult partial and completely edentulous situations with inadequate bone lies in grafting the defective sites, waiting for healing, placing dental implants, and restoring the defects. In such cases, significant amounts of autogenous bone (the patient’s own bone), allograft (human cadaver bone), alloplast (synthetic graft materials), or xenograft (animal bone) are placed into the defective site.
There is no question that these procedures are desirable, and sometimes successful. However, the process can be extremely expensive. If the grafting material is autogenous, it is often painful at both the site from which the graft was taken and the site into which it was placed. Grafting large defects can be time consuming, often unpredictable overall, and can sometimes result in a less than perfect aesthetic result. We, as educated dentists, are the most knowledgeable clinicians concerning these situations. Are we providing adequate information to patients to allow them to make an educated and informed decision about their complex therapy? Is informed consent education providing all of the alternatives for such difficult situations being delivered to them? Often, patients see restorative dentists and prosthodontists after the grafting and implant placement has already been accomplished by a surgical specialist. At that late time, there are no alternatives except to proceed with whatever the surgical clinician accomplishing the grafting and implant placement envisioned. The clinical result may range from adequate to disastrous.
In recent months, we have seen clinical examples that have caused concern about apparent overtreatment or mistreatment. In the following cases, more conservative plans would have been possible and potentially better than those planned:

Older teenagers with partial anodontia and stable remaining primary teeth treatment planned for removal of all functional and stable primary teeth, extensive iliac crest bone grafting in to all 4 quadrants, placement of many implants into the edentulous jaws, and fixed restorations on both jaws. Each of the jaw restorative rehabilitations had the planned cost of a new automobile. The cost of an entire oral rehabilitation such as this often equals the cost of an average house in the United States.
Partially edentulous patients with inadequate bone for standard-diameter implants (3 mm or larger in diameter), who were planned for extensive ridge augmentation using chin or ramus grafts; followed by implants, abutments, and crowns; when a simple, predictable fixed or removable prosthesis would satisfy the clinical situation from both a functional and aesthetic standpoint.
Edentulous senior patients with inadequate bone for standard-diameter implants who were planned for major autogenous bone grafting into the anterior mandible and maxilla, before rehabilitation with removable overdentures; when placement of small, up to 3 mm in diameter, implants would have been ideal in the resorbed, mostly cortical bone that was present.
Planning for the removal of functional and aesthetically acceptable 3-unit fixed prostheses; grafting of the single tooth edentulous site; and placement of an implant, abutment, and crown; under the guise that an implant in the edentulous single tooth areas would serve the patient better than the currently functional 3-unit fixed prosthesis.
Planning for an active chemotherapy/radiation therapy patient to remove all remaining teeth, graft defective sites, place 4 implants on each arch; followed by a fixed prosthesis on each arch.
Planning for placement of single implants between treated, previously periodontally involved mobile teeth. These patients are often in a maintenance stage, but the long-term prognosis for the teeth is questionable. These patients often have several remaining teeth on each arch, several implants between the teeth, and a full-mouth rehabilitation is planned. Removal of the remaining teeth and placing conventional complete dentures or implant supported dentures often satisfies such situations more adequately, less expensively, and with more predictability.
Planning for 4 or more implants with flattening of the bone on the crest of the ridge, and placing several over 3 mm diameter implants and a fixed prosthesis, when numerous other more conservative treatment plans could be considered.

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