This document discusses various aspects of dental implant surgery, including patient preparation, implant site preparation, and one-stage versus two-stage implant procedures. For two-stage procedures, it describes the first stage of submerged implant placement and healing, followed by a second stage surgery to expose the implant. It provides details on flap design, osteotomy preparation using drills, implant placement, closure techniques, and post-operative care. The document emphasizes the importance of achieving primary closure without tension and maintaining keratinized tissue for healthy soft tissue healing.

1. Dr. Firas Kassab

2. • General principles of implant surgery
• Patient preparation
• Implant site preparation
• One stage versus two stage implant surgeries
• Two stage “submerged” implant placement
• Flap designs, incisions and reflection
• Implant site preparation
• Flap closure and suturing
• Post operative care
• Second stage exposure surgery
Dr. Firas Kassab

3. • One stage “non-submerged” implant placement
• Flap designs, incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Postoperative care
• Conclusion
Dr. Firas Kassab

4. Patient preparation
Implant site
preparation
One stage Vs two
stage implant surgery
Dr. Firas Kassab

5. 1. Explanation of risks and benefits to the patient.
2. Written / Informed consent
3. Local or General Anesthesia depending on patient’s needs.
Dr. Firas Kassab

6. 1. Implants must be sterile and made of a biocompatible material (e.g., titanium).
2. Implant site preparation should be performed under sterile conditions.
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.
Dr. Firas Kassab

7. 1. Patient drape
2. Rinsing or swabbing the mouth with chlorhexidine gluconate for 1 to
2 minutes immediately before the procedure.
3. Atraumatic implant site preparation.
4. Avoid damage to bone or vital structures
5. Copious irrigation to avoid heating and debris removal.
6. The implant must be placed in healthy bone.
7. The surgical site should be kept aseptic.
Dr. Firas Kassab

8. 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 torque
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
Dr. Firas Kassab

9. 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.
Dr. Firas Kassab

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In the one-stage approach, the implant or the abutment emerges through the
mucoperiosteum/gingival tissue at the time of implant placement.

12. • Easier Mucogingival management around the implant.
• Patient management is simplified because a second stage
exposure surgery is not necessary.
Dr. Firas Kassab

13. Dr. Firas Kassab
 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.

14. • 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.
Dr. Firas Kassab

15. • 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 postoperative exposure.
• 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.
Dr. Firas Kassab

16. • The first stage ends by
• Suturing
• 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
Dr. Firas Kassab

17. • 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 oral cavity.
Dr. Firas Kassab

18. • Flap design, incisions, and elevation
• Vary slightly depending on the location and objective of the planned
surgery.
• Crestal
• The incision is made from along the crest of the ridge, bisecting the
existing zone of keratinized mucosa
• Adv. Easy to manage, results in less bleeding, less edema, faster
healing.
• Suturing placed generally do not interfere with the healing.
• Remote
• The incision is made some distance from the planned osteotomy site.
• Layer suturing is indicated to minimize the bone graft exposure.
Dr. Firas Kassab

19. Dr. Firas Kassab

20. • 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.
Dr. Firas Kassab

21. • 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 prepared.
• 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.
Dr. Firas Kassab

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Tissue management f or a two-stage implant
placement.
A, Crestal incision made along the crest of the ridge,
bisecting the existing zone of keratinized mucosa.
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 implant.
C, Implant is placed in the prepared osteotomy site.
D, Tissue approximation to
achieve primary flap closure
without tension

24. Dr. Firas Kassab
Sequence of drills used
for standard-diameter (4.0-
mm) implant site osteotomy
preparation:
round,
2-mm twist,
pilot,
3-mm twist, and countersink.
Bone tap (not shown here) is
an optional drill that is
sometimes used in dense bone
before implant placement.

25. • 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.
Dr. Firas Kassab

26. • 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.
Dr. Firas Kassab

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35. • As the final step in preparing the osteotomy site in dense cortical
bone, a tapping procedure may be necessary.
• 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 of implant
binding.
Dr. Firas Kassab

36. • 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.
Dr. Firas Kassab

37. • 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.
Dr. Firas Kassab

38. • 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.
Dr. Firas Kassab

39. Dr. Firas Kassab
Implant site preparation (osteotomy ) for a 4.0-mm diameter, 10 mm length screw-
type, threaded (external hex) implant in a subcrestal position.
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 angulation.
D, Pilot drill is used to increase the diameter of the coronal aspect of the osteotomy
site.

40. Dr. Firas Kassab
E, Final drill used is the 3- mm twist drill to finish preparation of the osteotomy site.
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 handheld driver.
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

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47. • 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 free manner.
• 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.
Dr. Firas Kassab

48. • 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.
Dr. Firas Kassab

49. • 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.
Dr. Firas Kassab

50. • This is particularly true when the periosteum has been incised (released).
• 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).
Dr. Firas Kassab

51. • 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.
Dr. Firas Kassab

52. • 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
Dr. Firas Kassab

53. 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.
Dr. Firas Kassab

54. • 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.
Dr. Firas Kassab

55. Dr. Firas Kassab
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.

56. Dr. Firas Kassab
Clinical v iew of stage two implant exposure surgery in a case with inadequate keratinized
tissue.
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 emerging implants.
D, Gingival tissue coronal to the cover screws is excised using the
gingivectomy technique.
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.

57. Dr. Firas Kassab
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.

58. • 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 keratinized tissue.
• 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 suture
Dr. Firas Kassab

59. • 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 keratinized tissue.
Dr. Firas Kassab

60. Dr. Firas Kassab
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 the implant.

61. • 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
Dr. Firas Kassab

62. • remind the patient of the need for good oral hygiene around
the implant and adjacent teeth.
• 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
avoided.
Dr. Firas Kassab

63. • Impressions for the final prosthesis fabrication can begin about
2 to 6 weeks after implant exposure surgery, depending on
healing and maturation of soft tissues.
Dr. Firas Kassab

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65. • 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 more).
Dr. Firas Kassab

66. • 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 implant/abutment.
Dr. Firas Kassab

67. • 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.
Dr. Firas Kassab

68. • 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.
Dr. Firas Kassab

69. • The keratinized edges of the flap are sutured with single
interrupted sutures around the implant.
• Depending on the clinician's preference, the wound may be
sutured with resorbable or nonresorbable sutures.
• 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.
Dr. Firas Kassab

70. • 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 weeks).
Dr. Firas Kassab

71. • It is essential to understand and follow basic guidelines to
achieve osseointegration predictably.
• Fundamentals must be followed for implant placement and
implant exposure surgery.
• These fundamentals apply to all implant systems.
Dr. Firas Kassab

72. • Newman, Takei, Klokkevold, Carranza. Carranza’s Clinical
Periodontology, 10th Edition and 11th Edition
• Lindhe, Lang, Karring. Clinical Periodontology & Implant
Dentistry, 5th Edition.
• Carle E. Misch. Contemporary Implant Dentistry. 3rd edition.
Dr. Firas Kassab