General principles of implant surgery
Implant site preparation
One stage versus two stage implant surgeries
Two stage “submerged” implant
Flap designs, incisions and reflection
Implant site preparation
Flap closure and suturing
Post operative care
Second stage exposure surgery
One stage “non-submerged” implant
Flap designs, incisions and elevation
Implant site preparation
Flap closure and suturing
One stage Vs two
stage implant surgery
1. Explanation of risks and benefits to the
2. Written / Informed consent
3. Local or General Anesthesia depending
on patient’s needs.
1. Implants must be sterile and made of a biocompatible material
2. Implant site preparation should be performed under sterile
3. Implant site preparation should be completed with an atraumatic
surgical technique that avoids overheating of the bone during
preparation of the recipient site.
4. Implants should be placed with good initial stability.
5. Implants should be allowed to heal without loading or micro-
movement (i.e., undisturbed healing period to allow for
osseointegration) for 2 to 4 or 4 to 6 months, depending on the
bone density, bone maturation, and implant stability.
1. Patient drape
2. Rinsing or swabbing the mouth with chlorhexidine
gluconate for 1 to 2 minutes immediately before the
3. Atraumatic implant site preparation.
4. Avoid damage to bone or vital structures
5. Copious irrigation to avoid heating and debris
6. The implant must be placed in healthy bone.
7. The surgical site should be kept aseptic.
1. Good operating light
2. Good high volume suction
3. A dental chair which can be adjusted by foot controls
4. A surgical drilling unit which can deliver relatively high speeds (up to 3000
rpm) and low drilling speeds (down to about 10 rpm) with good control of
5. An irrigation system for keeping bone cool during the drilling process
6. The appropriate surgical instrumentation for the implant system being
used and the surgical procedure
7. Sterile drapes, gowns, gloves, suction tubing etc.
8. The appropriate number and design of implants planned plus an adequate
stock to meet unexpected eventualities during surgery
9. The surgical stent
10. The complete radiographs including tomographs
11. A trained assistant
12. A third person to act as a get things in between to
and from the sterile and non-sterile environment.
13. Light handles should be autoclaved or covered with
sterile aluminum foil.
14. The instrument tray and any other surfaces which
are to be used are covered in sterile drapes.
In the one-stage
approach, the implant or
the abutment emerges
tissue at the time of
Easier Mucogingival management around
Patient management is simplified because
a second stage exposure surgery is not
In the two-stage approach, the top of the
implant and cover screw are completely
covered with the flap closure.
Implants are allowed to heal, without loading
or micro movement, for a period of time to
allow for osseointegration.
The implant must be surgically exposed
following an undisturbed healing period.
In areas with dense cortical bone and good initial implant
support, the implants are left to heal undisturbed for a period
of 2 to 4 months, whereas in areas of loose trabecular bone,
grafted sites, and sites with lesser implant stability, implants
may be allowed to heal for periods of 4 to 6 months or more.
Longer healing periods are indicated for implants placed in less
dense bone or when there is less initial implant stability (i.e.,
slight looseness caused by limited bone-to-implant contact),
regardless of jaw or specific anatomic location.
In the second-stage (exposure) surgery, the implant is
uncovered and a healing abutment is connected to allow
emergence of the implant/abutment through the soft tissues,
thus facilitating access to the implant from the oral cavity.
The restorative dentist then proceeds with the prosthodontic
aspects of the implant therapy (impressions and fabrication of
prosthesis) after soft tissue healing.
Situations that require simultaneous bone
augmentation procedures at the time of implant
placement because membranes can be covered by
primary flap closure, which will minimize
Prevents movement of the implant by the patient, who
may inadvertently bite on the healing abutment during
the healing period (one-stage protocol).
Mucogingival tissues can be augmented if desired at
the second-stage surgery in a two-stage protocol.
The first stage ends by
So the implant remains submerged and isolated
from the oral cavity.
Mandible implants – 2 to 4 months
Maxillary implants – 4 to 6 months
Longer periods –
less dense bone
Less initial implant stability
Shorter periods –
More dense bone
Altered surface microtopography
In second stage
The implant is uncovered and a healing
abutment is connected to allow emergence of
the implant through the soft tissue, thus
facilitating access to the implant from the
Flap design, incisions, and elevation
Vary slightly depending on the location and
objective of the planned surgery.
The incision is made from along the crest of the
ridge, bisecting the existing zone of keratinized
Adv. Easy to manage, results in less bleeding, less
edema, faster healing.
Suturing placed generally do not interfere with the
The incision is made some distance from the planned
Layer suturing is indicated to minimize the bone
A mucoperiosteal (full-thickness) flap is
reflected up to or slightly beyond the level of
the mucogingival junction, exposing the
alveolar ridge of the implant surgical sites.
Elevated flaps may be sutured to the buccal
mucosa or the opposing teeth to keep the
surgical site open during the surgery.
The bone at the implant site(s) must be
thoroughly debrided of all granulation tissue.20
Once the flaps are reflected and the bone is prepared
(i.e., all granulation tissue removed and knife-edge
ridges flattened), the implant osteotomy site can be
A series of drills are used to prepare the osteotomy
site precisely and incrementally for an implant.
A surgical guide or stent is inserted, checked for
proper positioning, and used throughout the
procedure to direct the proper implant placement.
Tissue management f or a two-stage
A, Crestal incision made along the crest of
bisecting the existing zone of keratinized
B, Full-thickness flap is raised buccally and
lingually to the level of
the mucogingival junction.
A narrow, sharp ridge can be
surgically reduced/contoured to
provide a reasonably f lat bed f or the
C, Implant is placed in the prepared
D, Tissue approximation to
achieve primary flap closure
Sequence of drills used
(4.0-mm) implant site
3-mm twist, and
Bone tap (not shown
here) is an optional drill
that is sometimes used
in dense bone
A series of drills are used to prepare the
osteotomy site precisely and
incrementally for an implant. A surgical
guide or stent is inserted, checked for
proper positioning, and used throughout
the procedure to direct the proper
A small round bur (or spiral drill) is used to mark
the implant site(s). The surgical guide is
removed, and the initial marks are checked for
their appropriate buccal-lingual and mesial-
distal location, as well as the positions relative to
each other and adjacent teeth.
Slight modifications may be necessary to adjust
spatial relationships and to avoid minor ridge
defects. Any changes should be compared to the
prosthetically-driven surgical guide positions.
Each marked site is then prepared to a depth of 1
to 2 mm with a round drill, breaking through the
cortical bone and creating a starting point for the
2-mm twist drill.
As the final step in preparing the osteotomy site
in dense cortical bone, a tapping procedure may
With self-tapping implants being almost
universal, there is less need for a tapping
procedure in most sites.
However, in dense cortical bone or when placing
longer implants into moderately dense bone, it is
prudent to tap the bone (create threads in the
osteotomy site) before implant placement to
facilitate implant insertion and to reduce the risk
It is better to allow the threaded implant to
“cut” its own path into the osteotomy site.
Bone tapping and implant insertion are both
done at very slow speeds (e.g., 20 to 40
rpm). All other drills in the sequence are
used at higher speeds (800 to 1500 rpm).
It is important to create a recipient site that
is very accurate in size and angulation.
In partially edentulous cases, limited jaw opening or proximity
to adjacent teeth may prevent appropriate positioning of the
drills in posterior edentulous areas.
In fact, implant therapy may be contraindicated in some
patients because of a lack of inter occlusal clearance, lack of
interdental space, or a lack of access for the instrumentation.
Therefore a combination of longer drills and shorter drills, with
or without extensions, may be necessary.
Anticipating these needs before surgery facilitates the
procedure and improves the results.
When wide-diameter drills are used for implant
site preparation, it is advisable to reduce the
drilling speed, according to the manufacturer's
guidelines, to prevent overheating the bone.
Copious external irrigation is critical. In the case
of wide diameter implants, a specific pilot drill is
often indicated as a transition between each of
the subsequent wider drills.
Implant site preparation (osteotomy ) for a 4.0-mm diameter, 10 mm
length screw-type, threaded (external hex) implant in a subcrestal
A, Initial marking or preparation of the implant site with a round bur.
B, Use of a 2-mm twist drill to establish depth and align the implant.
C, Guide pin is placed in the osteotomy site to confirm position and
D, Pilot drill is used to increase the diameter of the coronal aspect of
the osteotomy site.
E, Final drill used is the 3- mm twist drill to finish preparation of the osteotomy
F, Countersink drill is used to widen the entrance of the recipient site and allow
for the subcrestal placement of the implant collar and cover screw.
G, Implant is inserted into the prepared osteotomy site with a handpiece or
note: In systems that use an implant mount, it would be removed prior to
placement of the cover screw.
H, Cover screw is placed and soft tissues are closed and sutured
Once the implants are inserted and the cover screws secured, the
surgical sites should be thoroughly irrigated with sterile saline to
remove debris and clean the wound.
Proper closure of the flap over the implant(s) is essential.
One of the most important aspects of flap management is achieving
good approximation and primary closure of the tissues in a tension
This is achieved by incising the periosteum (innermost layer of full-
thickness flap), which is non-elastic.
Once the periosteum is released, the flap becomes very elastic and
is able to be stretched over the implant(s) without tension.
One suturing technique that consistently provides the
desired result is a combination of alternating
horizontal mattress and interrupted sutures.
Horizontal mattress sutures evert the wound edges
and approximate the inner, connective tissue surfaces
of the flap to facilitate closure and wound healing.
Interrupted sutures help to bring the wound edges
together, counterbalancing the eversion caused by the
horizontal mattress sutures.
Simple implant surgery in a healthy patient usually
does not require antibiotic therapy.
However, patients can be premedicated with
antibiotics (e.g., amoxicillin, 500 mg three times a day
[tid]) starting 1 hour before the surgery and
continuing for 1 week postoperatively if the surgery is
extensive, if it requires bone augmentation, or if the
patient is medically compromised.
Postoperative swelling is likely after flap surgery.
This is particularly true when the periosteum has been
As a preventive measure, patients should apply an ice
pack to the area intermittently for 20 minutes (on and
off) over the first 24 to 48 hours.
Chlorhexidine gluconate oral rinses can be prescribed
to facilitate plaque control, especially in the days after
surgery when oral hygiene is typically poorer.
Adequate pain medication should be prescribed
(e.g., ibuprofen, 600 to 800 mg tid).
Patients should be instructed to maintain a
relatively soft diet after surgery.
Then, as soft tissue healing progresses, they can
gradually return to a normal diet.
Patients should also refrain from tobacco and
alcohol use at least 1 week before and several
weeks after surgery.
Provisional restorations, whether fixed or
removable, should be checked and adjusted so
that impingement on the surgical area is avoided.
For implants placed using a two-stage
“submerged” protocol, a second-stage
exposure surgery is necessary after the
prescribed healing period.
Thin soft tissue with an adequate amount of
keratinized attached gingiva, along with
good oral hygiene, ensures healthier peri-
implant soft tissues and better clinical results
1. To expose the submerged implant without
damaging the surrounding bone.
2. To control the thickness of the soft tissue
surrounding the implant.
3. To preserve or create attached keratinized
tissue around the implant.
4. To facilitate oral hygiene.
5. To ensure proper abutment seating.
6. To preserve soft tissue aesthetics.
In areas with sufficient zones of keratinized tissue, the
gingiva covering the head of the implant can be
exposed with a circular or “punch” incision
Alternatively, a crestal incision through the middle of
the keratinized tissue and full-thickness flap
reflection can be used to expose implants.
This latter approach may be necessary when bone has
grown over the implant and needs to be removed.
Clinical view of stage two, implant exposure surgery in a case with
adequate keratinized tissue.
A, Simple circular “punch” incision used to expose implant when
sufficient keratinized tissue is present around the implant(s).
B, Implant exposed.
C, Healing abutment attached.
D, Final restoration in place, achieving an esthetic result with a
good zone of keratinized tissue. 55
Clinical v iew of stage two implant exposure surgery in a case with inadequate
A, Two endosseous implants were placed 4 months previously and are ready
to be exposed.
B, Two vertical incisions are connected by crestal incision.
C, Buccal partial thickness flap is sutured to the periosteum apical to the
D, Gingival tissue coronal to the cover screws is excised using the
E, Cover screws are removed, and heads of the implants are cleared.
F, Abutments are placed. Visual inspection ensures intimate contact between
the abutments and the implants.
G, Healing at 2 to 3 weeks after second-stage surgery .
H, Four months after the final restoration. Note the healthy band
of keratinized attached gingiv a around the implants.
If a minimal zone of keratinized tissue exists
at the implant site, a partial-thickness flap
technique can be used to fulfill the objective
of the second-stage surgery (exposing the
implant) while increasing the width of
A partial-thickness flap is then raised in such
a manner that a nonmobile, firm periosteum
remains attached to the underlying bone. The
flap, containing a narrow band of keratinized
tissue, is then repositioned to the facial side
of the emerging head of the implant and
sutured to the periosteum with a fine needle
and resorbable suture such as a 5.0 gut
A partial-thickness flap is apically
displaced and sutured to the periosteum
without exposing the alveolar bone.
A free gingival graft may be harvested
from the palate and sutured to the
periosteum on the labial surface of the
implants to increase the zone of
A, Partial-thickness f lap is created from the lingual aspect of the
crest toward the labial surf ace in order to preserve the keratinized
tissue on the crest (over the implant). note: This tissue might be
excised in a simple implant exposure.
B, The split-thickness f lap is repositioned to the labial surf ace.
C, The f lap is sutured to the periosteum at a more apical position
preserving the amount of keratinized tissue (arrows).
Finally , the remaining connectiv e tissue over the cover screw (B) is
excised with a sharp blade to expose the implant. Care should be
taken to avoid removing keratinized tissue from the lingual aspect of
After the flap is repositioned and secured
with periosteal sutures, the excess tissue
coronal to the cover screw is excised, usually
with a surgical blade.
When the excess tissue over the cover screw
is removed or displaced, the outline of the
cover screw is visible.
A sharp blade is used to eliminate all tissues
coronal to the cover screw.
The cover screw is then removed, the head of
the implant is thoroughly cleaned of any soft
or hard tissue overgrowth, and the healing
abutments or standard abutments are placed
on the implant
remind the patient of the need for good oral
hygiene around the implant and adjacent
rinse can be used to enhance oral hygiene for
the initial few weeks after implant exposure.
oral hygiene procedures to avoid dislodging
any repositioned or grafted soft tissues.
any direct pressure or movement directed
toward the soft tissue from a provisional
prosthesis can delay healing and should be
Impressions for the final prosthesis
fabrication can begin about 2 to 6 weeks
after implant exposure surgery,
depending on healing and maturation of
In the one-stage implant surgical approach,
a second implant exposure surgery is not
needed because the implant is exposed (per
gingival) from the time of implant placement
In the standard (classic) implant protocol, the
implants are left unloaded and undisturbed
for a period similar to that for implants
placed in the two-stage approach
(i.e., in areas with dense cortical bone and good
initial implant support, the implants are left to
heal undisturbed for a period of 2 to 4 months,
whereas in areas of loose trabecular bone, grafted
sites, and/or minimal implant support, they may
be allowed to heal for periods of 4 to 6 months or
In the one-stage surgical approach, the
implant or the healing abutment
protrudes about 2 to 3 mm from the bone
crest, and the flaps are adapted around
The flap design for the one-stage surgical
approach is always a crestal incision
bisecting the existing keratinized tissue.
Facial and lingual flaps in posterior areas
should be carefully thinned before total
reflection to minimize the soft tissue
thickness (if needed or desired).
The soft tissue is not thinned in anterior
or other esthetic areas of the mouth to
maintain tissue height and to minimize
metallic implant components from
showing through tissue.
The primary difference is that the coronal
aspect of the implant or the healing
abutment (two-stage implant) is placed
about 2 to 3 mm above the bone crest
and the soft tissues are approximated
around the implant/implant abutment.
The keratinized edges of the flap are sutured
with single interrupted sutures around the
Depending on the clinician's preference, the
wound may be sutured with resorbable or
When keratinized tissue is abundant,
scalloping around the implant(s) provides
better flap adaptation.
However, if minimal keratinized tissue exists
in an area, tissues should remain thick and
soft tissue augmentation may be indicated.
The postoperative care for one-stage
surgical approach is similar to that for the
two-stage surgical approach except that
the cover screw or healing abutment is
exposed to the oral cavity.
Patients are advised to avoid chewing in
the area of the implant.
Prosthetic appliances should not be used
if direct chewing forces can be
transmitted to the implant, particularly in
the early healing period (first 4 to 8
It is essential to understand and follow
basic guidelines to achieve
Fundamentals must be followed for
implant placement and implant exposure
These fundamentals apply to all implant