Dentistry/bone graft

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QUESTION: Does an x-ray always reveal if a bone graft is necessary for an implant? Can a dentist tell a patient a graft is not needed and then proceed with an incision only to realize that a bone graft will be required for it to be a successful implant?
Can this other scenario take place? A dentist sees an x-ray of the patient's mouth and tells the patient he is an excellent candidate for the implant. The dentist makes an incision and is  disappointed by the position of the bone/or quality of the bone. The dentist then tells the patient that he can't perform a successful implant.
Thanks very much!

ANSWER: Mark - A xray does not always indicate if a bone graft is completely necessary.  Sometimes it is so obvious when the xray shows a void in the bone, then a graft will be necesary.  The best indication, that I have used to confirm the necessity, even when an an xray shows no need is by direct examination after the gum tissue, where the implant will be placed is pulled back to look at the bone.

A dentist can only say from an xray that in two dimensions, up and down, there is vertical height necessary for an implant, but the doctor cannot say if there is enough width to the bone.  In that situation, grafting or using a microimplant may be appropriate to provide and create bone that would be more receptive.  

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QUESTION: So does a patient always have bone graft ready on hand (or have some handy from a donor-bank) for the implant procedeure, whether or not it would actually be used? Since I had my extraction on #19 ten yrs. ago, does that greatly increase my chances of needing a bone graft?
Will an implant look better for my facial appearance than having a pontic (as part of a bridge?) I had #19 and #16 extracted, and #15 looks like it will be extracted too due to extensive root decay. Will 3 extracted teeth from the left side of my face distort my face, that I should seriously consider having the #19 implant instead of a pontic?  My gold onlay bridge lasted ten yrs. #18 separated and the gold onlay popped out. #19 pontic is held intact with the #20 gold onlay. My dentist proposes to fill #18 with composite, do an implant for #19, and keep #20 as is. He claims it is more conservative than doing a new bridge. I think an implant may be too much of an ordeal especially if a graft is used. In light of the fact that #16 is missing and I won't have #15, an implant for #19 is necessary for the sake of facial appearance? I'm in my mid-40's.
Thanks again!

Answer
Mark - A skilled and knowledgeable surgeon always has materials available to facilitate success in any treatment.  As such, your dentist, although he is not a surgeon needs to be ready.  As far as the cosmetic results, that is a difficult question for me to answer without examining you.  Let me tell you that there are teeth in the mouth that are considered foundation teeth.  If lost, your bite and your face could collapse.  For that reason alone that tooth #19 needs to be retained or a good implant needs to be placed to support the bite.  A new bridge might be good, if there is no periodontal disease or bone loss associated with the teeth.  If there is bone irritation or loss the implant should be placed.  

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Joel S. Teig, DMD, Diplomate ABOMS, retired

Expertise

I am a board certified oral and maxillofacial surgeon and I am available to answer questions related to tooth extractions, implant insertion, facial recontruction, facial and oral tumor removal, TMJ dysfunction and various successful treatments, including surgery if all else fails, and occlusal discrepancy requiring orthognathic or jaw surgery.

Experience

Board Certified Oral and Maxillofacial Surgeon practicine for over 20 years. Assistant Clincal Professor and State University School of Dentistry.

Organizations
American Dental Association, American Association of Oral and Maxillofacial Surgeons, American Board of Oral and Maxillofacial Surgeons

Education/Credentials
BA -University of Connecticut DMD - University of Pennsylvania School of Dental Medicine

Awards and Honors
National Honor Society (OKU), Philadelphia County Dental Society, Mosby Book Award, Oral Surgery Honors, Summa Cum Laude

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