This document discusses principles of implant dentistry including flap design, implant placement, soft and hard tissue healing, and suturing techniques. It notes that ideal implant flaps are minimal, spare the papilla if possible, allow for primary closure without tension, and can replicate gingival anatomy. Different flap designs like trapezoidal or papilla inclusion/exclusion are discussed. Suturing techniques like figure-of-eight or vertical mattress sutures are covered. Flap advancement of less than 3mm, 3-6mm, or greater than 7mm is described for different surgical procedures.

1. Dr R Viswa Chandra MDS;DNB
Consultant Periodontist and Implantologist

2. Introduction
Basic Implant Principles include the following
•Conservative flap design
• Evaluation of existing bony architecture
• Esthetic osteotomy preparation
• Knowledge of timing for implant placement
• Correct spacing between adjacent implants or teeth
• Understanding the time needed for implant loading and soft tissue healing
• Formation of the emergence profile
• Knowledge of abutment selection

3. Zola* stated five basic points to consider in the design of a
soft tissue flap for intraoral surgery:
1. anatomy
2. access
3. replacement
4. closure
5. blood supply
Introduction
*Zola MB. Methods of designing, elevating, and suturing the intraoral flap. Oral Implantol. 1972 Summer;3(1):5-18.

4. Gingival Biotype* and its importance
• Relatively flat soft tissue
and bony architecture
• Dense fibrotic soft tissue
• Relatively large amount of
attached gingiva
• Thick underlying osseous
form
• Relatively resistant to acute
trauma
• Highly scalloped soft
tissue and bony
architecture
• Delicate friable soft tissue
• Minimal amount of
attached gingiva
• Thin underlying bone
characterized by bony
dehiscence and
fenestration
*Patil R et al. An exploratory study on assessment of gingival biotype and crown dimensions as predictors for implant-esthetics
comparing Caucasian and Indian subjects. Oral Implantol. 2012 Jan 3.
THICK THIN

5. THICK GINGIVAL BIOTYPE THIN GINGIVAL BIOTYPE
Inflammation Soft tissue: Marginal
inflammation, cyanosis,
bleeding on probing,
edema/fibrotic changes
Hard tissue: Bone loss with
pocket
Soft tissue: Thin gingiva
with marginal redness and
gingival recession
Hard tissue: Rapid bone
loss associated with soft
tissue recession
Surgery Predicable soft and hard
tissue contour after
healing.
Difficult to predict where
tissue will heal and stabilize
Tooth Extraction Minimal ridge atrophy Ridge resorption in the
apical and lingual direction
Gingival Biotype and its importance

7. • Trapezoidal Flap
• A Full thickness flaps which should
be reflected cleanly
• No tension during procedure
or after suturing
Stage I Surgery
Ideal Flap
• The ability to ‘fillet’ or incise the
periosteum to mobilise it coronally

8. Ideal “Implant Flap”
The minimal the better; don’t “mouse-hole” the flap
Spares the papilla if possible
Effects easy primary closure
Heals without complications
Can replicate papillary anatomy/gingival anatomy

9. Implant Flaps
Location Papilla criteria
Specialized flaps
•Crestal/
Mid-crestal
•Remote
•Papilla inclusion
•Papilla exclusion
•Palacci flaps
•Advancement flaps
•Addition flaps
Trapezoidal flaps Envelope flaps
•Second stage Surgery

10. Crestal Incision
An incision on the crest of the edentulous ridge is extended in
the gingival crevices of the adjacent teeth to allow adequate
exposure of the ridge.

11. Remote Incision
If augmentation procedures are thought to be required, it is prudent to
base incision lines more remotely to avoid exposure of grafted
materials.

12. It is advised to avoid placing oblique
relieving incisions over prominent
root surfaces because recession may
result if there is an underlying bony
dehiscence.
A broad base to the flap is not
necessary for survival because the
blood supply and nutrient bed for
mucosal flaps are excellent so don’t
overextend the vertical incisions.

13. Importance of the Papillae
Vertical Tissue Loss
*Palacci P, Ericsson I. Esthetic Implant Dentistry Soft and Hard Tissue Management. Chicago: Quintessence Books, 2001.
CLASS I- Intact or slightly reduced papillae CLASS II- Limited loss of papillae (less than 50%)
CLASS III- Severe loss of papillae CLASS IV- Absence of papillae - edentulous ridge

14. Importance of the Papillae
Horizontal Tissue Loss
CLASS D- Extreme loss of buccal tissues often
accompanied by limited amount of attached mucosa
CLASS C-Severe loss of buccal tissues
CLASS B- Limited loss of buccal tissuesCLASS A- Intact or slightly reduced buccal tissues
Intact Papillae can be seen only in this situation

15. PAPILLA SAVING INCISION
Avoidance of papilla reflection aims to preserve the aesthetics of these
structures which are difficult or impossible to reconstruct if lost.

16. PAPILLA SAVING INCISION

17. PAPILLA- When to include?
1. In sites that are less than or equal to 7 mm
mesiodistally, reflecting the papillae is indicated.
2. In sites that are 8 mm or greater, a mesiodistal crestal
incision of 5–6 mm will allow non-reflection of an
adequate width of papillary tissue.
3. If augmentation techniques are indicated, then the
wider flap design incorporating papillae is again
recommended.

18. Do not attempt a papilla saving incision if
the single tooth space is narrow
mesiodistally.
The narrow strip of soft tissue on
the proximal surfaces of the adjacent teeth,
it may have its blood supply compromised
to such an extent that full reflection of the
tissue would be no more damaging.
Use a remote incision if the tissue is
extremely thick to permit easy elevation of
the flap.

19. Stage II Surgery
Decision Tree
Band of
keratinized tissue
Adequate
Tissue Punch
Full-thickness Flap
Sufficient Partial thickness flap-
gingivectomy technique
Deficient Tissue augmentation

20. Tissue Punch
Adequate Keratinized Gingiva

21. Adequate Keratinized Gingiva
Full Thickness Flap

22. Sufficient Keratinized Gingiva
Partial Thickness Flap-Gingivectomy Technique
Initial incision to made approximately 2mm coronal to the facial/lingual mucogingival
junction, with vertical incisions both mesially and distally.

23. Sufficient Keratinized Gingiva
Partial Thickness Flap-Gingivectomy Technique
A partial thickness flap (PT) is then raised in such a manner that a
relatively firm periosteum (P) remains. The flap, containing a band of keratinized
tissue, is then placed facial to the emerging head of the implant fixture.
Excess tissue coronal to the cover screw is excised, usually using a
gingivectomy technique
PT
P

24. Sufficient Keratinized Gingiva
Partial Thickness Flap-Gingivectomy Technique
Suturing of the flap and post-operative view

25. Deficient Keratinized Gingiva
Connective Tissue Grafts can be
used not only to increase the
dimensions of attached tissue around
the natural dentition and dental
implants but also as a
predictable method for covering
denuded root or abutment surfaces.

26. SUTURE MATERIALS AND
SUTURING TECHNIQUES

27. Sutures
Suturing is performed to
1. Provide an adequate tension of wound closure without dead
space but loose enough to obviate tissue ischemia and
necrosis.
2. Maintain Hemostasis
3. Permit primary intention healing
4. Provide support for tissue margins
5. Reduce post operative pain
6. Prevent bone exposure resulting in delayed healing and
unnecessary resorption.
7. Permit proper flap position.

28. 1. Adequate strength, elasticity
2. Low tissue irritation and reaction
3. Low capillarity
4. Good handling and knotting properties.
5. Sterilization without losing its properties.
CLASSIFICATION
Requisites for suture materials
1. Absorbable
2. Non-absorbable
1. Monofilamentous
2. Multifilamentous
1. Natural
2. Synthetic

29. Absorbable suture materials
• Plain gut
• Chromic gut, monocryl
• Coated vicryl, polyglycolicacid
• Polydioxanone, collagen
Non-absorbable
• Linen, surgical silk,
• Surgical cotton, surgical steel
• Nylon, polypropylene, polyester
• Goretex, Dacron

30. Suture
Suture
tensile
strength
Tissue reaction
Knot tensile
strength
Types Uses
Plain gut
+ (least)
Moderate
++++
+++ Plain
Rapidly healing mucosa
Avoid suture removal
Chromic gut
+
Moderate but less than
plain gut ++++
+++ Chromic
As above
Slower absorption
Coated vicryl
polyglactin 910
+++ Mild ++ ++ Braided coated
Subepithelial
Mucosal surfaces
Vessels ligation
All types of general closure

31. Suture
Suture
tensile
strength
Tissue reaction
Knot
tensile
strength
Types Uses
Surgical silk ++
Moderate
++++
+ (Least) Braided Mucosal surfaces
Nylon
Duralon
Ethilon
+++ Extremely low 0-+ ++ Mono filament Skin closure
Nylon
Nurolon
Surgilon
+++ Extremely low 0-+ ++ Braided
Skin closure
Mucosal surfaces
Polyester
Mersilene
Dacron
Ethibond
+++ Minimal + +++ Braided
Cardiovascular and plastic
surgery General surgery
Prolene
(polypropylene) +++
Minimal + transient acute
reaction
++ Mono filament
General, plastic, cardiovascular,
skin, ophthalmology

32. POINT BODY EYE
When the suture is
attached via a hole drilled
through the end of a
needle and the end is
swaged, they are called as
Atraumatic Needles.
Shape  straight, half curved,
curved (1/4, ½, 3/8, 5/8).
Straight- microsurgery for nerve
and vessel repair.
Curved 3/8  commonly used, ½
 OMFS
Conventional : 3 cutting
edges, triangular in cross
section.
Reverse cutting : 3rd
cutting edge is on the
outer convex curvature of
the needle (Inverted
triangle).

33. Basic Suturing Techniques
Figure-of-8 suturing technique
1. Common and easy
2. Tension free closure
Contraindications:
1. Not suitable in regenerative
procedures
2. Suture microleakage and wicking
are common

34. Basic Suturing Techniques
Direct Vertical Mattress
1. Everts the tissue
2. Best in Regenerative
procedures
Contraindications:
1. Difficult to execute
2. Flap necrosis if knots are tight

35. Basic Suturing Techniques
Coronally Repositioned
Vertical Mattress
1. Virtually no suture in between
the tissue
2. Best in GBR/GTR/Advanced
regenerative procedures
Contraindications:
1. Difficult to execute
2. Sutures loosen easily

37. Flap advancement may also
be an integral part of
implant surgery more so
during
1. Ridge augmentation
procedures
2. For simple primary
closure
3. GBR and Regenerative
procedures

38. Amount of buccal flap advancement required is based on complexity
of the Surgical procedure*
*Greenstein G et al. Flap advancement: practical techniques to attain tension-free primary closure. J Periodontol. 2009 Jan;80(1):4-15.
Minor Flap
Advancement
(<3mm)
Moderate Flap
Advancement
(3 to 6 mm)
Major Flap
Advancement
( ≥7 mm)

39. Minor Flap Advancement
• In Implant surgery, this can be
accomplished by elevating a full-
thickness flap (periosteum included)
apically to the buccal vestibule and
extend the release mesially and
distally under the periosteum
beyond the boundaries of the flap.
• In Augmentation surgery, simply
raise a partial thickness flap.
• This technique works well in the
buccal vestibule.

40. Minor Flap Advancement

41. Partial-Thickness flap

42. Periosteal suturing to hold the
flap in place

44. 1. In conjunction with a horizontal
incision across the edentulous
area, create two vertical
releasing incisions on the buccal
aspect.
2. If vertical incisions do not
facilitate optimal tissue
advancement, hold the flap
under tension with a tissue
forceps, and score the
periosteum across the whole
flap.
Moderate Flap Advancement
1
2

45. Moderate Flap Advancement

47. p

49. • If buccal vertical releasing incisions
and periosteal fenestrations do not
provide enough flap advancement
to achieve tensionless primary
closure, it is necessary to cut
deeper into the sub mucosa.
• This is done only when necessary
as the patient experiences
increased morbidity with regard to
swelling, hemorrhage, and
discomfort.
Major Flap Advancement

50. Major Flap Advancement

53. p
sm

56. Requirements for Bone Regeneration

57. GUIDED BONE REGENERATION
The use of membranes to guide bony tissue formation by
separating the underlying bone from the overlying
connective tissue and by creating a space into which the
desirable bone cells can migrate.

58. Basic mechanism of GBR
Epithelium
Corium
Bone
PDL
In GBR, the osseous defects are covered with a barrier membrane, which is closely adapted to the surrounding bone surface. Thus
the non-osseous cells (i.e.) epithelial cells and fibroblasts are prevented from migrating into the space between the bone surface
and the barrier membrane.
Osteoblasts derived from the PDL and bone are selectively induced on the osseous defect area facilitating new bone formation.

59. Indications of GBR
PRE-OPERATIVE INDICATIONS
Extraction site preservation
Correction of ridge inadequacy
INTRA-OPERATIVE INDICATIONS
Dehiscence defects
Apical fenestration
Residual intraosseous defects
POST-OPERATIVE INDICATIONS
Periimplantitis

60. “Ideal”GBR membrane
• Biocompatibility & safety
• Cell occlusiveness
• Space-making ability
• Tissue integration
• Clinical manageability & cost effectiveness

61. Classification of barrier membranes
• RESORBABLE MEMBRANES
• Collagen barriers
- BioGuide, BioMend, Healiguide
• Synthetic polymers
- Vicryl Mesh, Resolut, Resolut XT
• NON-RESORBABLE MEMBRANES
Expanded polytetrafluoroethlene ( e-PTFE )
- Goretex
Nonexpanded polytetrafluoroethlene
- Tef Gen-FD
Titanium-reinforced expanded
polytetrafluoroethlene
Titanium membrane with microperforation

62. Approaches to GBR implant therapy
Simultaneous approach
Fixture placement and GBR are performed simultaneously to
create increased bone around the fixture.
Staged approach
GBR is used to increase the alveolar ridge or improve ridge
morphology before fixture placement. The fixture is
placed after healing.

63. Which Membrane?

64. Flap considerations in GBR
Flap design in GBR requires the covering of the membrane by
thick soft tissue with sufficient blood supply and avoiding
membrane exposure. Therefore, the flap must include
sufficient keratinized mucosa and a mesiodistal extension
of more than one tooth.

65. Flap considerations in GBR

66. Stabilization of GBR
Passive placement
The proper size membrane
to cover the defect area
completely by the inner
portion is chosen, then
the membrane is cut with
3-5-mm extension
laterally and apically from
the defect margin to
obtain close adaptation
to the bone. This can be
tucked under the tissue
Membrane Tacks Sutures

68. STAGED APPROACH
Ridge augmentation using guided bone
regeneration
• Insufficient vertical and buccolingual bone for fixture placement and
stabilization.
• Bone resorption extending to one third of the root apex of the
extracted tooth due to a severe defect.
• A large and flat osseous defect with insufficient bone width (less than 5
mm) such that fixture placement cannot be achieved in the proper
prosthetic position and angle.
• Maxillary anterior ridge morphology leading to an unpredictable esthetic
result after fixture placement.
• Extreme loss of facial bone plate with gingival recession.
• Severe circumferential osseous defect and vertical osseous defect.
• Simultaneous fixture placement with barriers membrane difficult due to
a large osseous defect around the fixture.

75. SIMULTANEOUS APPROACH
Indications
• The osseous defect around the fixture is not extensive and proper
prosthetic placement and good primary stabilization can be achieved
• More than one wall around the fixture is lost
• More than 5 mm of fixture surface is exposed through dehiscence on
fenestration defects.

76. B
B
B

79. HARD TISSUE AUGMENTATION PROCEDURES

80. In 1983, Seibert classified the different types of alveolar
ridge defects that a clinician may encounter while planning
a prosthetic rehabilitation.

82. HARD TISSUE GRAFTS
Hard tissue grafts/Bone grafts are primarily used when an
implant supported restoration is planned.
The choice of materials is usually dictated by the existing
anatomy, the patient’s medical history, and the size of the
defect.
The use of a barrier membrane is recommended with the
placement of a bone graft to minimize resorption and enhance
the outcome of the procedure (Antoun et al. 2001; Von Arx et al.
2001).

83. IDEAL CHARACTERISTICS OF A BONE GRAFT
• Nontoxic
• Nonantigenic
• Resistant to infection
• No root resorption or ankylosis
• Strong and resilient
• Easily adaptable
• Readily and sufficiently available
• Minimal surgical procedure
• Stimulates new attachment

84. Bone graft materials are generally evaluated based on their
osteogenic, osteoinductive, or osteoconductive potential.
• Osteogenesis refers to the formation or development of new
bone by cells contained in the graft.
• Osteoinduction is a chemical process by which molecules
contained in the graft (bone morphogentic proteins or BMPs)
convert the neighboring cells into osteoblasts, which in turn
from bone.
• Osteoconduction is a physical effect by which the matrix of the
graft forms a scaffold that favors outside cells to penetrate the
graft and from new bone.

85. TYPES OF GRAFT MATERIALS
Grafts are generally classified according to their original source as
follows:
• Autograft – intraoral and extraoral: tissue transferred from one
position to another with in the same individual.
• Allograft – freeze-dried, fresh: tissue transferred from one
individual to another genetically dissimilar individual of the
same species.
• Xenograft –tissue transferred from one species to another
species. E.g. Kielbone (oxbone).
• Alloplast – a synthetic graft or inert foreign body implanted in
to tissue.

86. AUTOGENOUS BONE GRAFTS
Autogenous grafts, which are harvested from the patient’s own
body, are considered the gold standard among graft materials
Bone from intraoral sites
•Osseous coagulum
•Bone blend
•Intra oral cancellous bone
•Bone marrow transplants
•Bone swaging

87. Autogenous bone can often be harvested
from intraoral sites including,
• Edentulous ridges
• Tori
• Maxillary tuberosity
• Healing bony wound or extraction sites
• Bone trephined from within the jaw
without damaging the roots
• And bone removed during osteoplasty
and osteotomy.

88. ALLOGRAFTS
Allografts are bone taken from one human for transplantation
to another. These grafts, procured from deceased persons, are
typically freeze-dried and treated to prevent disease
transmission and are available from commercial tissue banks.

89. Two types of Allografts
1. UNDECALCIFIED FREEZE DRIED BONE
ALLOGRAFT(FDBA) – an osteoconductive material.
2. DECALCIFIED FREEZE DRIED BONE
ALLOGRAFT(DFDBA). – an osteoinductive and has
higher osteogenic potential than the undecalcified
freeze –dried bone allograft.

90. XENOGRAFTS
• CALF BONE - treated by detergent, sterilized and freeze dried. Used
for treatment of osseous defects.
• KIEL BONE - Calf or Ox bone denaturated with 20% H2O2, dried with
acetone, and sterilized with ethylene oxide.
• ANORGANIC BONE - Ox bone from which the organic material has been
extracted by ethylene diamine. Then sterilized by autoclaving.

91. Non-bone Graft Materials
Non bone graft materials have been tried for restoration of
the periodontal defects. Such as SCLERA, DURA, CARTILAGE,
CEMENTUM, DENTIN, PLASTER OF PARIS, PLASTIC MATERIALS,
CERAMICS and CORAL-DERIVED MATERIALS.
Growth Factors like BMPs, PDGF in the form of PRP, PRF are
commonly being used.

92. BONE GRAFT APPLICATIONS*
• Socket Preservation Application
• Sinus Augmentation Application
• Bone Augmentation ± Barrier Membrane Technique
1. Particulate Bone Grafting Technique
2. Block Grafting Approaches
3. Combination Approaches
4. Ridge Expansion Techniques
*AAP. J Periodontol 2007;78:377-396.

93. What Graft?*
• Osteogenic > Osteoinductive > Osteoconductive
• If autogenous bone grafts are used Blocks > Particles as they do
not provide sufficient rigidity to withstand tension from the
overlying soft tissues.
• Calvarial > Iliac > Oral sites
• Oversized grafts should be harvested to maintain enough graft
volume after the initial resorption phase.
• Bone resorption is greater in the first year after the
reconstruction and in the first year after loading of implants, with
a significant reduction in the following years.
*Chiapasco et al. Bone Augmentation Procedures in Implant Dentistry. Int J Oral Maxillofac Implants 2009;24(SUPPL):237–259.

94. Timing of Implant Placement*
Implant placement both in conjunction with bone grafting and
after consolidation of bone grafts have been proposed.
Those who advocate simultaneous implant placement base their
opinion on the fact that resorption of an onlay graft over time is
not a linear process but is most pronounced soon after its
transplantation.
Simultaneous implant placement will shorten the waiting time
before rehabilitation, thus potentially reducing the risk of bone
resorption.
*Chiapasco et al. Bone Augmentation Procedures in Implant Dentistry. Int J Oral Maxillofac Implants 2009;24(SUPPL):237–259.

95. Timing of Implant Placement*
Conversely, when a delayed protocol is performed, it will be
possible to place implants in a revascularized (albeit partly) graft.
Since the regenerative capacity of bone is determined by the
presence of vessels, bone marrow, and vital bone surfaces, a
delayed approach will permit better integration of implants
(higher values of bone-implant contact) and better stability of
implants, as compared to immediate implant placement.
*Chiapasco et al. Bone Augmentation Procedures in Implant Dentistry. Int J Oral Maxillofac Implants 2009;24(SUPPL):237–259.

96. Loading Time of Implants Placed in Grafted Areas*
Initial reports recommended longer waiting times (6 to 12 months)
between implant placement and subsequent loading to allow
some extra time for graft incorporation, but not too long, taking
advantage of the theoretical ability of implants to provide a bone
preserving stimulus in the same way that the presence of healthy
teeth preserves the alveolar bone.
However, no conclusive recommendations can be made due to the
wide range of waiting times proposed and to the different
characteristics of macro, micro, and nanogeometry of different
implant systems.
*Adell R et al. Int J Oral Maxillofac Implants 1990;5:347–359.

97. Socket Preservation with autogenous chips