This document discusses key principles of implant surgery, including atraumatic bone preparation with irrigation to minimize heat, achieving primary stability through bicortical stabilization, and allowing undisturbed osseointegration. It also covers preoperative mouthwash and skin disinfection, antibiotic prophylaxis, and using nerve block anesthesia or infiltration anesthesia. Precise drilling techniques aim to expose bone for osteotomy while minimizing vascular disruption. Implant placement involves creating the osteotomy with intermittent drilling, using correct torque values, and placing the implant fixture by hand or with a controlled drill.

1. Dr R Viswa Chandra MDS;DNB
Reader
Department of Periodontics
SVS Institute of Dental Sciences
Mahabubnagar AP

2. Key Principles of Implant Surgery
• Atraumatic bone
preparation with attention
to minimizing heat
production: constant
irrigation.
• Primary surgical stability
achieved with bicortical
stabilization where possible.
• Allow undisturbed
osseointegration.

3. Basic surgical principles
•Preoperative mouthwash (0.2% CHX).
•Perioral skin disinfection (Povidone
Iodine is preferred).
•Antibiotic prophylaxis 1-2 hrs prior to
surgery.
•Sterile and disinfected surgery
protocols.
•Minimal zone of contamination.

4. Anaesthesia and Pain Control
•Nerve Block anesthesia is the
most efficient.
•Infiltration anesthesia can be
preferred so that the patient
“feels” the proximity to vital
structures and thus avoiding
potential damage to nerves. Its
usage is controversial though.*
Juodzbalys G et al. Injury of the Inferior Alveolar Nerve during Implant Placement: a Literature Review.
J Oral Maxillofac Res 2011 (Jan-Mar);2(1):e1.

5. Anaesthesia and Pain Control
•Studies* have demonstrated that preoperative administration
of analgesics delays the onset of pain (by more than 100
minutes compared with placebo) and lessened the severity of
postoperative dental pain as the effect of the local anesthetic
dissipated, without increased side effects.
•The use of pre-operative analgesics is highly recommended in
Implant Dentistry**
*Dionne RA et al. Suppression of postoperative pain by preoperative administration of ibuprofen in comparison to
placebo, acetaminophen, and acetaminophen plus codeine. J Clin Pharmacol. 1983;23(1):37-43.
**Richard M. Palmer, Leslie Howe, Brian Smith. Implants in Clinical Dentistry. 1st ed .Taylor & Francis.

6. The objective is to expose the bone where the osteotomy is to be
placed and to minimize vascular disruption to sensitive bone
areas.
IMPLANT PLACEMENT
Entry Incision
Two StageSingle Stage

7. IMPLANT PLACEMENT
The Osteotomy
BASIC PRINCIPLES
• Sharp drills.
• Correct RPM: 1200-2500 rpm for cortical & D1 bone; 800-
1200 for expanding the osteotomy sites.
• Copious irrigation to avoid heat necrosis.
• Intermittent drilling/BONE DANCING.
• Correct torque values (15-23 N).
• Bone tap to avoid compression necrosis.
• Bone spreading to obtain as much bone as possible.

8. IMPLANT PLACEMENT
The Osteotomy
•Mark/
check
position
•Assess
bone
quality
Osteotomy
position
and angle
Sets osteotomy
depth first and
width next
Removes
cortical
bone at
ridge crest
to facilitate
pressure-
free seating
of implant
Prepares
dense
cortical
bone for
implant
threads

9. The implant fixture may be placed by hand using a
hand/torque wrench or with a driver utilizing a
controlled drill speed.
IMPLANT PLACEMENT
Fixture installation

10. IMPLANT PLACEMENT
Fixture installation
Removal of the
Abutment Screw
Placing Cover Cap/
Cover Screw with
Submerging the Implant
Single-stage
Healing Abutment Placement.
The implant remains
Non-submerged

11. Case

12. Supracrestal vs Subcrestal
Implant Placement
•With D3 and D4 bone, consideration should be given to placing the
implant supracrestally because of limited cortical bone.
•Pertinently, placement of the implant platform coronal to the crest of
bone facilitates formation of the biologic width surpracrestally with no
concomitant bone loss.*
*Piattelli A et al. Role of the microgap between implant and abutment: a retrospective histologic evaluation in monkeys.
J Periodontol. 2003;74(3):346-352.

13. During drilling, care must be taken NOT TO
•Underdrill of site depth: This can result in thread stripping
•Use Excess drill speed: Burns bone, kills osteocytes, and results in early fixture
loss
•Tip the drill as it widens the osteotomy site compromising initial stability.
•Overdrilling depth or irregular uneven osteotomy can lead to an “disappearing
implant”
•Pull on the Bone Tap to remove it from the site: Can disrupt the threads created
for implant engagement

14. During implant fixture installation, care must be taken NOT TO
Use an unmetered ratchet wrench: fracture buccal plates and/or strip threading
or overcompress site.
Start with high torque of 40 N/cm: The lowest torque required should be used.
Use a hex-driver to seat an implant: can damage the internal hex of the implant.

15. PROBLEM ALTERATION BENEFIT
Lack of Primary Stability Deeper Osteotomy Gain Implant Area
Lack of Primary Stability Wider Osteotomy Gain Implant Area
Limited Cortical Bone Supracrestal placement Preserves Crestal Bone
Soft Bone Bone Compression Compresses soft bone
Soft Bone Undersize osteotomy site Tighter fit
Soft Bone Submerge Implant Protects Implant
Soft Bone Tapered Implant* Increased Primary Stability
*the theory is that if a small osteotomy is created, a tapered implant will compress the bone, especially
in the coronal region, thereby improving initial stability of the implant.