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Standard surgical procedure for implant placement
- 1. Dr. Diana Abo El Ola
- 2. Components of implant • 1- Implant body(fixture): threaded , non threaded • 2- Healing screw: in superior surface of the body(facilitate suturing of ST) • 3- Healing caps: dome shaped screw placed over sealing screw (after 2nd stage of surgery) • 4- Abutments(resemble tooth prepared)
- 3. 1- The screw-shaped (threaded implants ) • Are rotated into the bone recipient site like a screw with a hand piece or handheld wrench after preparing an osteotomy site…..provide good 1ry vertical stabilization(threads). 2- Cylindrical shaped (non threaded implants) Pushed or tapped into a recipient site. The implant achieves a tight “press-fit” Vertical stability comes from the apical end (the bottom of the osteotomy site) IMPLANT SELECTION AND DESIGN CONSIDERATIONS 1- Implant Geometry (Macrodesign)
- 4. 2- Implant Surface Characteristics (Microdesign) • adsorption of serum proteins, mineral ions & cytokines cellular migration & attachment. • retention of a fibrin clot accelerate the differentiating osteogenic cells to reach the implant surface. Modifications in surface energy Chemical composition Surface topography
- 5. General principles of implant procedures Patient preparation Implant site preparation One stage vs 2 stages implant surgery
- 6. Health status-Complexity of case-Treatment plan-Informed consent to achieve osseointegration 1. Implants must be sterile and made of a biocompatible material (e.g., Ti) 2. Sterilization of site(no inf.- no infl.). 3. Atraumatic surgical tech. + avoid overheating (sharp incision-proper flap design-proper coolant + intermittent moderate speed). 4. Initial stability . 5. Healing period without loading or micromovement for 2- 4 or 4-6 m, depending on the bone density, bone maturation, and implant stability. Implant Site Preparation Patient Preparation
- 8. Bone-implant contact at time of placement Adequate BS and bone remodeling. Proper coolant
- 9. implant heals under the ST. After healing period , accessed through 2nd surgery. the implant heals without protection of gingiva. Accessibility is during healing. :placement of implant into extraction sites. is placement of implant following tooth extraction
- 10. • The top of the implant + cover screw ➤ completely covered with the flap closure➨ decrease postoperative exposure + micro-movement. Then ,the implant is surgically exposed(after the undisturbed healing period). N.B For a “knife-edge” alveolar ridge a large round bur is used to flatten the bone giving wider surface for the implant. .
- 11. Flap Design, Incisions, and Elevation 1. CRESTAL INCISION; along the crest of the ridge, bisecting the k. mucosa. Adv.➨ easier closure management + less bleeding+ less edema + faster healing. 2. REMOTE INCISION, distance from the planned osteotomy site. • ➥minimize bone graft exposure in bone augmentation.
- 13. Implant Site Preparation A surgical guide or stent Proper positioning and placement 1. Round Bur/spiral drill 2. The 2-mm Twist Drill (of final length): to establish the final depth of the osteotomy site. • Drilling speed ≃800-1500 rpm+ irrigation + intermitted pumping of the drill (up and down). y?
- 14. The Guide pin : • If multiple implants it should be placed in the prepared sites to check: 1. Alignment 2. Parallelism 3. Proper prosthetic spacing. 4. The relationship to neighboring vital structures (Nerve /tooth roots) use periapical x-ray with a guide pin.
- 15. 3. Pilot Drill: • A noncutting 2–mm-diameter “guide” at the apical end and a cutting 3–mm-diameter (wider) midsection to enlarge the osteotomy site at the coronal end to facilitate the insertion of the subsequent drill 4. The 3-mm Twist Drill • It is last drill used to widen the entire depth of the osteotomy to final diameter 3 mm for a standard-diameter (4 mm) implant. 5. Countersink Drill (Optional) used to shape or flare the crestal aspect of the osteotomy site for cover screw.(at or below crest)
- 16. 7. Implant Placement • inserted with slow speed rotating handpiece (e.g., 25 rpm) or by hand with a wrench 6. Bone Tap (Optional) create threads in case of implant placement in moderate dense bone to facilitate implant insertion and to reduce the risk of implant binding. NB Bone tapping and implant insertion are both done at very slow speeds (e.g., 20 to 40 rpm). All other drills are used at higher speeds (800 - 1500 rpm)
- 17. Flap Closure and Suturing • The Full-thickness flap make flap very elastic and able to be stretched without tension good approximation and primary closure of the tissues without tension. • A combination of horizontal mattress & interrupted sutures . • Horizontal mattress sutures Evert the wound edges and approximate the inner CT • Interrupted sutures bring the wound edges together
- 20. Postoperative Care • Antibiotics (e.g., Amoxicillin, 500 mg [tid] for 1 week) Starting 1 hr before the surgery and continuing for 1 week post. In case of extensive surgery(ex: bone augmentation), or compromised patients • Ice packsfor Postoperative swelling (20 min for 2 days) • Chlorhexidine gluconate mw. • Pain medication (e.g., ibuprofen, 600 - 800 mg tid) • Soft diet • No tobacco and alcohol at least 1 week before and several weeks after.
- 22. One-Stage “Non-submerged” Implant Placement • Full thickness Flap Design, Incisions, and Elevation • Implant Site Preparation • Flap Closure and Suturing Implant is 2-3 above bone crest • Postoperative Care • Avoid chewing in the area of the implant • If removable appliances are used adequately relieved and a soft tissue liner should be applied.
- 24. • Clinical examination Visual inspection & palpation (color, contour & consistency) Peri-implant probing (no BOP/3mm=healthy tissues) • Microbial testing (=same pathogens in periodontal pockets)(limited in use )
- 25. • Measuring stability Periotest Resonance frequency analysis Radiographic examination
Editor's Notes
- Cover healing screws…..after implant replacement ….covered by tissues Healing caps ……placed cover sealing screw above the tissues Abutment …..then crown then screw
- Root form endosseous dental implants can be divided into two basic groups: (1) screw shaped with threads and (2) cylindrical and threadless (see Figure 76-1). The screw-shaped, threaded implants are rotated into the bone recipient site like a screw with a handpiece or handheld wrench after preparing an osteotomy site that is slightly smaller in diameter than the implant threads. Thus the threads engage the walls of the prepared osteotomy site and provide vertical stabilization. The cylinder-shaped, threadless implants are pushed or tapped into a recipient site that is prepared with a diameter and shape that is nearly identical to that of the implant. Thus the implant achieves a tight “press-fit”. Vertical stability comes from the apical end of the implant seating into the bottom of the osteotomy site. The most common implant design being used today is the screw-shaped or threaded cylindrical implant (Figure 68-4, A). A threaded implant design is preferred because it engages bone well and is able to achieve good primary stabilization. Even systems that started with cylindrical press-fit (nonthreaded) designs progressively evolved to a threaded geometry. The (longitudinal) shape of implants may be parallel or tapered (Figure 68-4, B). Although a vast majority of all implants have been parallel walled, the use of a tapered implant design has recently been advocated because it requires less space in the apical region (i.e., better for placement between roots or in narrow anatomic areas with labial concavities). Tapered implants have also been advocated for use in extraction sockets (Figure 68-5).
- Additive: hydroxyapatite coat or Ti oxide Roughness…..etching/TI oxide blasting/sand blasting
- GENERAL PRINCIPLES OF IMPLANT SURGERY Patient Preparation Most implant surgical procedures can be done in the office using local anesthesia. For some patients, depending on individual preferences and complexity of the case, conscious sedation (oral or intravenous) may be indicated. The risks and benefits of implant surgery specific to the patient’s needs should be thoroughly explained at an appointment before the day of surgery. Once the patient understands the proposed treatment and has questions answered, a written informed consent should be obtained for the procedure Implant Site Preparation The surgical site should be kept aseptic, Rinsing or swabbing the mouth with chlorhexidine gluconate for 1 to 2 minutes immediately before the procedure will aid in reducing the bacterial load present around the surgical site and to avoid contamination of the implant surface. Implant sites should be prepared using gentle, atraumatic surgical techniques with a continuous effort to avoid overheating the bone. H- incsion flap design “papillae sparing inscision
- Nasal cavity +maxillary sinus Alveolar bone contour Implant into the nerve………..neuropathy….compression or damage to nerve….pain-impared sensation- parathesia
- Compact bone: more bone-implant contact Dense cortical bone: Dec. blood supply Loose trabecular :loss of support and integration Post maxilla…..lower success rates Ant. Mand……highest success rate
- Incision contouring Reflection Implant replacing Suturing
- Flap Design, Incisions, and Elevation Flap management for implant surgery varies slightly, depending on the location and objective of the planned surgery. Two types of incisions, crestal or remote, can be used. The remote incision is made some distance from the planned osteotomy site. A periosteal elevator is then used to reflect a mucoperiosteal (full-thickness) flap. For the crestal flap design, the incision is made along the crest of the ridge, bisecting the existing zone of keratinized mucosa (see Figure 71-2, A, and Figure 71-4, B). A remote incision with a layered suturing technique may be used to minimize the incidence of bone graft exposure when extensive bone augmentation is planned. The crestal incision, however, is preferred in most cases because closure is easier to manage and typically results in less bleeding, less edema, and faster healing.[10] Sutures placed over the implant generally do not interfere with healing. A full-thickness flap is raised (buccal and lingual) up to or slightly beyond the level of the mucogingival junction, exposing the alveolar ridge of the implant surgical sites (see Figure 71-2, B, and Figure 71-4, C). 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. For a “knife-edge” alveolar process with sufficient alveolar bone height and distance from vital structures (e.g., inferior alveolar nerve), a large round bur is used to recontour or flatten the bone to provide a wider, level surface for the implant site preparation (see Figure 71-2, B). However, if the vertical height of the alveolar bone is limited (e.g., <10 mm), the knife-edge alveolar bone height should be preserved. Bone augmentation procedures can be used to increase the ridge width while preserving alveolar bone height (see Chapter 72).
- 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 (Figure 71-5).
- Implant Site Preparation A surgical guide or stent is inserted…. checked for proper positioning, and to direct the proper implant placement. Guided Surgery Guided Surgery involves the placing of dental implants in a case that has first been planned on a computer. A CT scan is taken of the jaw bones then loaded onto the computer in 3D. The dentist then plans where the implants are going to go using cutting edge software. This information is then sent to a specialized laboratory who make a guide (stent) that fits over the patients gums. This guide is used to drill the holes where the implants are placed giving very accurate implant placement. This is particularly useful for patients who want a complete set of fixed teeth very quickly (under an hour) or for patients with very little bone. Surgical stent …used to orient and position the implant . Round Bur 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 (see Figure 69-9). 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 - 2 mm with a round drill, breaking through the cortical bone and creating a starting point for the 2-mm twist drill. The 2-mm Twist Drill A small twist drill, usually 2 mm in diameter and marked to indicate various lengths (i.e., corresponding to the implant sizes), is used next to establish the depth and align the long axis of the implant recipient site (see Figure 71-3, B). This drill may be externally or internally irrigated. In either case, the twist drill is used at a speed of approximately 800 to 1500 rpm, with copious irrigation to prevent overheating of the bone. Additionally, drills should be intermittently and repeatedly “pumped” or pulled out of the osteotomy site while drilling to expose them to the water coolant and to facilitate clearing bone debris from the cutting surfaces. In other words, in an effort to reduce heat generation and the resistance of drills while in bone, clinicians should pump the drill (up and down) intermittently and avoid preparing the bone with a unidirectional “push” of the drill in the apical direction only. When multiple implants are being placed next to one another, a guide pin should be placed in the prepared sites to check alignment, parallelism, and proper prosthetic spacing throughout the preparation process (see Figure 71-3, C). The relationship to neighboring vital structures (e.g., nerve and tooth roots) can be determined by taking a periapical radiograph with a guide pin(s) or radiographic marker(s) in the osteotomy site(s) (see Figure 70-13). Implants should be positioned with approximately 3 mm between one another to ensure sufficient space for interimplant bone and soft tissue health and to facilitate oral hygiene procedures. Therefore the initial marks should be separated by at least 7 mm (center to center) for 4 mm standard-diameter implants. Incrementally more space is needed for wide-diameter implants (see Figure 69-9). The 2-mm twist drill is used to establish the final depth of the osteotomy site corresponding to the length of each planned implant. The clinician should also evaluate the bone quality (density) with this drill while preparing the osteotomy to assess the need for modification of subsequent drills used (Box 71- 2). If the vertical height of the bone was reduced during the initial ridge preparation, this must be taken into account when preparing the site for a predetermined implant length. For example, if it appears that the implant will be too close to a vital structure, such as the inferior alveolar nerve canal, the depth of the implant osteotomy site and length of the implant may need to be reduced.
- Bone Tap (Optional) As the final step in preparing the osteotomy site in dense cortical bone, a tapping procedure may be necessary (not shown). 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 Implant Placement Implants are inserted with a handpiece rotating at slow speeds (e.g., 25 rpm) or by hand with a wrench. Insertion of the implant must follow the same path or line as the osteotomy site. When multiple implants are being placed, it is helpful to use guide pins in the other sites to have a visual guide for the path of insertion.
- Flap Closure and Suturing Once the implants are inserted and the cover screws secured (Figure 71-4, G), 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 (Figure 71-3, H). This is achieved by incising the periosteum (innermost layer of full-thickness flap), which is nonelastic. 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 (Figure 71-4, H). 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. The clinician should choose an appropriate suture for the given patient and procedure. For patient management, it is sometimes simpler to use a resorbable suture that does not require removal during the postoperative visit (e.g., 4-0 chromic gut suture). However, when moderate-to-severe postoperative swelling is anticipated, a nonresorbable suture is recommended to maintain a longer closure period (e.g., 4-0 monofilament suture). These sutures require removal at a postoperative visit.
- Sequence of drillls used for standered diameter 4 mm implant: round bur- 2mm twist- pilot drill- 3mm twist- counter sink –bone tap -implant
- Postoperative Care 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 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). 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
- A:simple circular(punch )incision used to exposed implant when sufficient k. tissue is present B.Implant exposure c:healing abutment attached D: final restoration in place ,achieve an esthetic results with a good zone of k. gingiva. Second-Stage Exposure Surgery For implants placed using a two-stage “submerged” protocol, a second-stage exposure surgery is necessary after the prescribed healing period. Box 71- 3 lists the objectives for second-stage implant exposure surgery. Thin soft tissue with an adequate amount of k. attached gingiva, along with Good OH, ensures healthier periimplant soft tissues and better clinical results. The need for periimplant keratinized tissue is somewhat controversial, depending on the type of implant prosthesis and location of the implant. However, one long-term study indicated that, at least in the posterior mandible and in partially edentulous patients, the presence of keratinized tissue is strongly correlated with soft and hard tissue health.[2]
- Flap Design, Incisions, and Elevation The flap design for the one-stage surgical approach is always a crestal incision bisecting the existing keratinized tissue (see Figure 71-9). Vertical incisions may be needed at one or both ends to facilitate access to the bone/osteotomy site. 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. Full-thickness flaps are elevated facially and lingually. Implant Site Preparation Implant site preparation for the one-stage approach is identical in principle to the two-stage implant surgical approach. 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. Flap Closure and Suturing 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. Postoperative Care 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(s). 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). When removable prosthetic appliances are used, they should be adequately relieved and a soft tissue liner should be applied
- A one-stage surgical Is more simple and easily handling as there is no need for 2nd surgery The two-stage, submerged approach is advantageous for situations that require bone augmentation procedures at the time of implant placement because membranes can be covered by primary flap closure, which will minimize postoperative exposure. also prevents movement of the implant by the patient,. Mucogingival tissues can be augmented if desired. However, without the second-stage surgical opportunity, mucogingival augmentation must be managed at the initial surgery or an additional, separate surgery.
- Observe signs of inflammation or swelling ,palpate any edema tenderness and exudate or suppuration 1-1.5mm bone loss in the 1st year after replacement and less or equal than 0.1mm after the 1st year (normal remodeling)
- Periotest….if ossotingration is maintained or not …..noninvasive tech. ,measure reaction of periodontuim to impact loads applied to tooth(sensitive to horizontal movements) Resonance frequency analysis……non invasive tech….steady state signals applied through transducer and response is measured ,…measure movements in all direction not in horizontal only (better) Mobility means failed implant Periapical x ray is the best ……..bone level around the implant (the problem in the standardization of x-ray from baseline till the end)