56 Dental implant complications

the collar of the implant (94, 95). This may be especially

important with the rough surface implants in use today
(8, 96). Connective-tissue grafts usually provide a better
esthetic enhancement than full-thickness gingival grafts,
and this should be considered when dealing with esthet-
ically sensitive areas (97, 98).
The intraoral examination should also evaluate tooth
position and occlusion. Since implant dentistry involves
restorative necessity, it is of fundamental importance to
determine the relationship that exists between the pro-
posed implant site, its respective restoration and the
remaining occlusion. If a malocclusion exists, is it one
that will affect the success of the implant restoration?
Will the implant be subject to parafunctional forces,
or stressed by occlusal overload? The intraoral examina-
tion should evaluate the occlusion, tooth malpositions,
tooth supereruption, axial inclination, and rotation. If
infections are present in the soft or hard tissue these
should be addressed before initiating implant therapy.
Periodontal therapy is essential for treating soft-tissue
inflammation and reducing a potential nidus of infection
for future implants. Periodontal therapy should be com-
pleted along with any necessary treatment for caries
before implant placement.
Radiographs used in implant planning should be
evaluated in regard to anatomic proximities. A full
mouth series of X-rays is beneficial in analyzing the over-
all oral condition. Periapical and panoramic radiographs
may both be required to analyze potential implant sites
and avoid complications. A limitation of these radio-
graphs is that they present existing conditions in only
two dimensions (99101) (see Chapter 4). When pathol-
ogy is present on a radiograph, such as a periapical
lesion, this should be treated accordingly. To avoid
implant failure due to an adjacent periapical lesion, the
lesion should be treated before implant placement (10,
102, 103).
Anatomic structures such as the mental foramen, infe-
rior alveolar canal, and sinuses should be located to
determine whether they are at risk with implant place-
ment (Fig. 3.17). If risks appear to be present, further
radiographic examination should be performed to evalu-
ate the site fully. This includes the use of three-dimen-
sional (3D) radiographic imaging, i.e. CAT or cone beam
computed tomography (CBCT).
Root proximity presents a challenge that can impede
implant placement. Radiographs are instrumental in
planning the optimal implant position, and during
placement to help monitor correct positioning.
Radiographs taken during the implant placement drill-
ing sequence can provide necessary visual feedback to
help ensure avoidance of adjacent roots or vital anatomic
structures (Fig. 3.18).
A patients oral hygiene condition presents another
important component to evaluate during the intraoral
examination. If oral hygiene is poor, it could lead to
additional breakdown, which could lead to either the
functional or esthetic failure of the implant prosthesis.
Instituting a program to improve the patients oral
(a) (b)
Fig. 3.16 (a) Edentulous ridge lacking keratinized tissue; (b) keratinized tissue augmented with soft tissue graft around implants.
Fig. 3.17 Limited ridge height superior to inferior alveolar nerve.
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