PERIO

1. Dental Implants
SURGICAL
ASPECTS

2. • History
• Introduction
• Theory and practice of osseointegration
• Indications to place an implant
• Advantages of implant prosthesis
• Contraindications
Index

3. Index
• Implant selection
– Implant geometry (Macrodesign)
– Implant surface topography (Microdesign)
• General principles of implant surgery
– Patient prepration
– Implant site prepration
– One-stage vs Two-stage implant surgeries

4. • One-staged “ nonsubmerged” implant placement
– Flap design, incisions and elevation
– Implant site prepration
– Flap closure and suturing
– Postoperative care
• Two-stage “Submerged” implant placement
– Flap design, Incisions & Elevation
– Implant site preparation
– Flap closure and suturing
– Postoperative care
– Second-stage exposure surgery

5. • Localized bone augmentation
• Biologic requirements for bone regeneration
• Principles of GBR
• Terminology
• Localized ridge augmentation
• Flap management
• General concepts for flap management
• Particulate bone graft
• Monocortical bone graft
• Complications of localized ridge augmentation
• Delayed vs staged technique

6. • Advanced implant surgical procedures
• Recent advances in implant surgical techniques
• Summary
• References

7. History as it was
The first evidence of the
use of implants dates
back to in the
Mayan population. This
fragment of mandible
illustrates the
implantation of pieces
of shell to replicate
three lower incisor
teeth.

8. The surgical procedures for the placement of
almost all endosseous dental implants
currently used are based on the original work
of
and colleagues in Sweden.

9. This seminar presents general surgical
considerations and outlines the standard
surgical procedures for the placement of
endosseous dental implants.

10. Theory and practice of
Osseointegration
is
defined as a direct bone
anchorage to an
implant body which can
provide a foundation to
support a prosthesis; it
has the ability to
transmit occlusal forces
to the bone

11. OSSEOINTEGRATION
Fibro-osseointegration
(Linkow 1970, James 1975, Weiss
1986)
Osseointegration
(Brånemark 1985)
Meffert et al.,
1987
Adaptive Biointegration

12. • Patients with partially and fully edentulous arches.
• Patients with maxillofacial deformities.
• Patients who are unable to wear removable dentures
and have adequate bone for the placement of implant.
• Good general health.
• Good oral hygiene & patient motivation.
• Patient should be emotionally stable, cooperative and
willing to keep the appointments required for
completion of treatment and maintenance

13. Advantages of implant prosthesis
• Maintained bone
• Teeth positioned for esthetics
• Maintained vertical dimension
• Proper occlusion
• Direct occlusal loads
• Improved success rates
• Increased occlusal forces
• Improved masticatory performance
• Increased stability and retention
• Improved phonetics

14. • Uncontrolled or controlled diabetes.
• Chronic steroid therapy.
• High dose irradiation
• Smoking and alcohol abuse
• Pathologic conditions of the hard and soft
tissues
• Presence of untreated or unsuccessfully treated
periodontal disease.

15. Implant selection and design
considerations
Implant Geometry (Macrodesign)
Root form endosseous dental implants can be
divided into two basic groups:
• Screw shaped with threads
• Cylinderical and Threadless

16. SCREW SHAPED IMPLANT
* Rotated into the bone
recipient 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 .
CYLINDER-SHAPED IMPLANT
* Implants are pushed or tapped
into the a recipient site that is
prepared with a diameter and
shape that is nearly identical to
that of implant. Thus, implant
achieves a tight “Press-fit”.
Vertical stability comes form the
apical end of the implant seating
into the bottom of the osteotomy
site.

17. Why to use threaded implants
than
cylindrical implant
Provide superior initial stability.
Vertical placement of the implant during
placement can be more precisely controlled.
Tapered shape in some implants resemble the
shape of the tooth which prevents apical bone
fenestration, allows for the placement of the
implant into narrower apical area.
Amenable to immediate placement into
anterior extraction sockets.

18. Implant surface Topography (Microdesign)
Surface modifications can be:
- Additive (Macroscopic visible “roughness”)
- Titanium plasma-sprayed (TPS)
- Hydroxyapatite (HA) coated-surface

19. • Subtractive implant
surface modifications
– Blasting
– Acid etching
– Combination of both

20. General principles of Implant surgery
Patient preparation
- Local anesthesia
- Conscious sedation
- Informed consent

21. Implant site preparation
The surgical site should be kept aseptic and the patient
appropriately prepared and draped for an intraoral
procedure.
It is recommended that the patient rinse with
Chlorexidine gluconate for 30 sec immediately before
the procedure.
Every effort should be made to maintain a sterile
surgical field to avoid contamination of the implant
surface.

23. • Before sterilization, wash stainless steel and titanium
instruments separately with a neutral detergent.
• After washing place the instruments into 5 different
beakers
– Beaker 1: Fixture mounts, direction indicators, screw taps
and forceps
– Beaker 2: Cutting drills and counter sink drills
– Beaker 3: Handpiece connector, rotary screw driver, screw
holder, long and short screw driver, open ended wrench
– Beaker 4: Unsterile fixtures if sterile pre-packaged is not
used
– Beaker 5: Unsterile cover screws if sterile pre-packaged is
not used

24. Check the inventory stainless steel instruments after
sterilization, and place into appropriate containers.
Wrap the containers separately with surgical drapes,
steam autoclave for 20 min at 2 p.s.i., 121oC and cool
and dry for additional 20min.

25. Premedication
Patients may be apprehensive the day before the
surgery despite thorough discussions and
consultations. Prescribing 5 to 10 mg Diazepam
may help the patient get a good night’s rest prior to
surgery.
Prior to surgery administer 15-20 mg of Diazepam and
1000mg of antibiotics. Penicillin can be used if the
patient is not allergic, or Erythromycin can be used
for implant surgical procedure.

26. 1. Implant 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 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
micromovement (i.e., undisturbed healing period to allow for
osseointegration) for 2 to 4 and 4 to 6 months in the mandible
and maxilla, respectively.

27. Currently, most threaded endosseous implants
can be placed using one-staged
(nonsubmerged) or a two-staged (submerged)
protocol.

28. One-stage/ Nonsubmerged implant
surgeries Vs Two-staged implant surgeries
One stage
- Implant or the abutment
emerges through the
mucoperiosteum at the time
of implant placement.
- It is valuable in many
patients because of its
simplicity and ability to
provide support to adjacent
gingival tissues.
Two stage
- The top of the implant and
cover screw are completely
covered with the flap
closure.
- In complex cases with poor
quality bone or
simultaneous bone grafting,
this technique allows for the
protection of the implant
during the process of
osseintegration.

29. Advantages of One stage & Two stage
Implant placement
One stage
Easier mucogingival
management around the
implant in many cases.
Patient management is
simplified because two stage
surgery is not necessary.
Two stage
It is advantageous for
situations that require
simultaneous bone
augmentation procedures at
the time of implant
placement.
This also prevents the
movement of the implant by
the patient, who may
inadvertantly chew on it
during the healing period.

30. Procedures for Two-staged implant
placement
Flap management for implant surgery will vary
depending upon the location and objective of the
planned surgery.
Incisions
Flap design
Elevation
Implant placement
in the site
Implant
Operation

31. Local Anesthesia
• Prior to surgery anesthesia is administered in the form
of nerve blocks with 2 % lidocaine with epinephrine
1:50,000.

32. Incisions
Crestal Remote

33. • Crestal or remote incision
• Elevate a full thickness flap bucally or lingually to the
level of the mucogingival junction
• Thorough debribdement
• For a knife-edge alveolar ridge recontour the bone,
but 10 mm of the alveolar bone should be remaining.

34. Implant site preparation
Round Bur/ Spiral drill
 To mark the initial site and for surgical guide.
 Drilled to a depth of 1 to 2 mm
 To break the cortical bone and create a starting point
for the 2 mm twist drill

35. The 2 mm Twist drill
• It is marked to indicate various lengths, is used next
to establish the depth and align the long axis of the
implant recipient site.
• In either cases it is used at a speed of 800 to
1200rpm.
• When multiple implants are placed guide pins are
used to check the parallelism.
• It is used to establish the final depth of the
osteotomy site for each planned implant.

36. Pilot drill
• Following the 2 mm twist drill, a pilot drill with non
cutting 2mm diameter “guide” at the apical end and a
cutting 3 mm diameter midsection is used to enlarge
the osteotomy site, thus facilitating the insertion of
the subsequent drill in the sequence.

37. 3 mm Twist drill
• The final drill preparation of a standard diameter
(4 mm) implant.
• It is used to widen the site along the entire depth of
the osteotomy from 2 to 3 mm.

38. Countersink drill
• When it is desirable to place the cover screw
slightly under the crestal bone aspect of the
osteotomy site. This allows the coronal flare of the
implant and cover screw to fit within the osteotomy
site.

39. Bone tap
• Finally for the placement of the threaded implants
bone tapping may be necessary especially in
moderate to dense bone.
• It is performed at very slow speed of 25-30 rpm.

40. • When placing wide diameter implant, wide diameter
drills are used at a slow speed of 500-600 rpm to
prevent overheating of bone with copious irrigation.
Implant Placement
Inserted at very slow speed of 25 rpm or with the help
of hand held wrench.

41. Suturing
• Once the implant placement us done the surgical site
should be thoroughly irrigated with sterile saline.
• Proper flap management is must be achieved in order
to get a primary closure. The flap should be tension
free.
• One suturing technique that consistently provides the
desired result is the combination of horizontal
mattress and interrupted sutures.
• Further for patient management is appropriate to use
resorbable suture (4-0 chromic gut).

43. Post-operative care
• Usually no antibiotic therapy is required.
• However amoxicllin 500mg tid can be used in case of
extensive surgeries.
• For postoperative swelling – ice pack intermittently
for 20 min over the first 24-48 hrs.
• Adequate pin medication should be prescribes
(Ibuprofen 600-800 mg tid)
• If possible patients should refrain from the use of
tobacco and alcohol for 1-2 weeks postoperatively.

44. Second Stage Exposure surgery
Objectives
• To expose the submerged implant without exposing
the surrounding bone
• To control the thickness of the surrounding tissue
• To preserve and create attached keratinized tissue
around the implant
• To facilitate oral hygiene
• To ensure proper abutment seating

45. The exposure can be achieved in two ways:
Simple circular
“Punch” Incision
Partial Thickness
Repositioned flap

46. One Staged “Non submerged” implant
placement
• In this type of implant placement the healing
abutment protrudes 2 to 3 mm form the bone crest
and the flaps are adapted around the
implant/abutment.

47. Localized bone Augmentation
The use of dental implants in the partially and fully
edentulous patients with deficient jawbones creates a
new demand for bone reconstruction before or during
implant therapy.
Much of what can be achieved with implant surgery and
bone augmentation procedures is directly related to
the achievements and understanding of guided bone
regeneration.

48. Biologic requirements for bone
regeneration
Requirement
• Blood Supply
• Stabilization
• Osteoblasts
• Confined space
• Space maintenance
• Wound coverage
Surgical Procedure
• Cortical perforation
• Fixation screws,
membrane tacks
• Autogenous bone graft
• Barrier membrane
• Tenting screws, Bone
graft materials
• Flap management and
tension free suturing

49. Principle of GBR
The main objective of GBR it to regenerate a single
tissue, namely bone, it is theoretically easier to
accomplish than GTR, which strives to regenerate
multiple tissues in a complex relationship.

50. Terminology
• Osteoconduction: the formation of bone by
osteoblasts from the margins of the defect on the bone
graft material. They serve as a scaffold for bone
growth.
• Osteoinduction: It involves new bone formation
through stimulation of osteoprogenitors from the
defect to differentiate into osteoblasts and being
forming new bone.
• Osteogenesis: It occurs when living osteoblasts are
part of the bone graft, as in autogenous bone
transplantation.

51. Localized ridge augmentation
Patient often present for implant planning after tooth
loss and alveolar ridge resorption.
Depending on the size and morphology of the
defect, various augmentation procedures can be
used. These procedures have been categorized
according to deficient dimensions:
Horizontal
Vertical
These methods employ the use of Particulate and
Monocortical block grafts.

52. Flap management
The design and management of mucoperiosteal flap
must consider the increased dimensions of the ridge
after augmentation as well as esthetics and
approximation of wound margins.
Usually a remote incision is used but crestal incision in
case of large defects.

53. General concepts for flap management
• Make remote incisions to placement of barrier
membranes
• Full mucoperiosteal flap elevation 5mm from the
bone defect
• The use of vertical incisions must be minimized
• Periosteal releasing inisions must be used in order to
give elasticity to the flap
• Avoid post operative trauma by avoiding insertion of
any prosthesis for at least 2 weeks

54. Particulate bone graft
INDICATIONS
• In defects with multiple osseous walls that will
contain the graft
• In dehiscence and fenestration defects when implants
are placed during bone augmentation procedures
• If any of the above is mot present barrier membrane
can be used.

55. ADVANTAGES
• Smaller pieces of bone demonstrate more rapid
revascularization
• Larger osteoconduction surface
• More exposure to osteoconductive growth factors
• Easier biologic remodelling compared with bone
block

56. Monocortical block graft
• Can be used to reconstruct horizontal alveolar
deficiencies
• Taken from remote areas (intraoral/extraoral) and
fixated to prepare recipient site with the help of
screws
• The main disadvantage is that of revascularization, so
the block needs to have a high number of osteogenic
cells.

57. Complication of localized ridge
augmentation
• Keratinized tissues which have been advanced to
cover an increased amount of bone end up with non-
load-bearing mucogingival discrepancies.
• Exposure of bone transplants obtained form various
sites.
• Increased exposure rate is associated with increased
loss of transplanted tissue.
• High risk of membrane exposure.
• Bleeding, postoperative infection, bone fracture,
nerve dysfunction, perforation of mucosa, loss of
portion of bone graft.

58. Delayed Vs Staged technique
Depending on the quality, quantity and support of the
existing bone, as well as the preference of the
clinician and the patient, the placement of the implant
after tooth extraction can be immediate or delayed.

59. Immediate implant placement
• Reduced healing time
• Normal bone healing which
occurs in sockets occurs
around implants, it may
increase bone to implant
contact.
Disadvantages
• Need of subsequent
mucogingival surgeries
Delayed implant placement
• Extraction site preservation
• Allows time for soft tissue
healing.
• Reduce length of treatment
• May facilitate more
osteogenesis around the
implant.
• Mucogingival flap
advancement is not
necessary, hence no
additional surgeries.

60. Advanced implant surgical procedures
Here we will be dealing with the advanced surgical
procedures used to treat the most challenging patient-
related factors, a deficiency in vertical height.
- Maxillary sinus elevation & bone augmentation
- Vertical bone augmentation & distraction
osteogenesis

61. Maxillary sinus Elevation and Bone
Augmentation
Rehabilitation of the edentulous posterior maxilla with
endosseous dental implants often represents a clinical
challenge because of the insufficient bone volume
resulting from pneumatization of the maxillary sinus
along with resorption of the alveolar crestal bone.
Boyne and James (1980) First to describe the
procedure to graft the maxillary sinus – “Caldwell-
Luc Procedure”

62. Indications
• Alveolar bone height in the posterior maxilla less
than 10 mm.
Contraindications
• Local factors
– Tumors or pathologic growth in the sinus
– Maxillary sinus infection
– Severe chronic sinusitis
– Dental infection involving or in proximity to sinus
– Severe allergic rhinitis/ sinusitis
– Chronic topical steroid use

63. • Systemic factors
– Radiation therapy involving the maxillary sinus
– Metabolic diseases (e.g. uncontrolled diabetes mellitus)
– Excessive tobacco use
– Drug/alcohol abuse
– Physiologic / Mental impairment

64. Surgical procedure
Specifically four different locations have been
described:
- Superior lateral wall, Caldwell-Luc opening located
just anterior to the zygomatic arch
- Middle lateral wall opening, which is located midway
between the alveolar ridge and the zygomatic arch
- Middle lateral wall opening which is located at the
level of the alveolar ridge.
- Crestal approach with the osteotomes through the
alveolar bone crest superiorly to the floor of the sinus.

65. Pre-surgical evaluation
– Radiographic evaluation
• CT scan
• Cone-beam computed tomography

66. Bone graft materials
Autogenous bone graft- because of
osteoconductive, osteoinductive and osteogenic porperties.
Other bone substitutes commonly used are
Autogenous bone grafts form iliac crest or oral cavity
Bone substitutes
Freeze-dried mineralized bone
Resorbable/Nonresorbable hydroxyapatite
Xenografts
ALL THESE MATERIAL HAVE BEEN SHOWN TO BE
OSTEOCONDUCTIVE, ONLY DFDBA ALLOGRAFT HAS PROVEN TO
HAVE GOOD OSTEOINDUCTIVE PROPERTIES BUT HAS NOT
PROVEN TO BE ADVANTAGEOUS IN MAXILLARY SINUS BONE
AUGMENTATION.

67. Osteotome Technique
Indicated when the available bone in the posterior
maxilla is less than 10 mm and more than 7 mm. The
osteotomes are used from crestal approaches.
Compression of the alveolar bone from inside of the
socket causing “inward fracture” of the sinus floor
along with the schneiderian membrane.

68. Osteotomy Procedure
Osteotomy Instruments
A) Straight osteotomes
B) Offset osteotomes

69. Procedure
Initially site is prepared with a series of drills to a depth 2 to
3 mm from the floor of maxillary sinus.
Osteotomes are used to increase compressive forces against
the floor of the sinus.
Once the sinus membrane is elevated with bone graft
material to desired height the implant osteotomy can be
prepared with the final drill and the implant can be
inserted.
Published Reports – Gain of 2 to 7 mm (avg. of 3.8mm)
For increasing height more than 4 mm lateral wall approach
is more useful.

70. Contraindicated for
Sinuses with acutely sloped floor or septa in
location of the planned osteotomy.
Presence of Septa making it virtually impossible
for fracturing the floor of the sinus.

71. Lateral window technique
• Most effective and efficient

72. Risks and complications
• Tearing or perforation of the Schneiderian membrane
(60%)
• Intraoperative or postoperative bleeding
• Posoperative infection
• Loss of bone graft or implant

73. Supracrestal vertical bone
augmentation
It presents greatest challenge in terms of regenerating
bone and placing implants.
Unsuccessful attempts have been made with the use of
- Onlay block graft
- Particulate hydroxyapatite
Distraction Osteogenesis A NEW TECHNIQUE

74. Under the proper circumstance most cells in the bone
can differentiate into osteogenic or chondrogenic
cells needed for repair.
Ilizarov introduced the process of generating new bone
by “stretching” referred to as distraction osteogenesis.
Advantages
- No secondary surgical site needed
- The newly created bone has native bone at the crest
which is thought to withstand forces better than fully
regenerated bone.

75. Recent advance in implant surgical
technology
• Computer imaging software to “simulate”
preoperatively the implant position(s) into a virtual
patient that is three-dimensional computer image of
the patients jaw created for the CT scan data.
• Computer-generated surgical guides with drill
holes based on the presurgical “virtual” implant
positioning
• Computer – assisted implant surgery (CAIS)
through simultaneous tracking and “guidance” of the
implant instrumentation

76. CAIS
Advantage
– Precision
– Facilitate presurgical planning and guide the
surgical placement of implants
– Allows precise positioning of implants while
avoiding injury to the important anatomic
structures

77. Sequence of steps
• Data acquisition
• Identification
• Registration
• Navigation
• Accuracy
• Feedback

78. The goal of modern dentistry is to return patients to oral
health in a predictable fashion.
The partial and complete edentulous patient may be unable to
recover normal function, esthetics, comfort or speech with
traditional prosthetic measures.
The patients functioning may be reduced by 60% that formerly
experienced with natural dentition.
The esthetics of the edentulous patient are also affected as a
result of bone atrophy. Continued resorption leads to
irreversible facial changes.
Soft tissues of the edentulous patients are tender from the
effect of thinning mucosa, decreased salivary flow, unstable or
unretentive prosthesis.

79. All these symptoms can be easily managed by the use of
implants or implant supported prosthesis. It may
Return the function to near normal limits
Stimulate the bone and maintain its dimension in a
manner similar to healthy natural teeth. As a result the
facial features are not compromised by lack of
support.
The implant-retained restoration does not require soft
tissue support and improves the oral health.
And it is stable and retentive without the efforts of
musculature.

80. • Carranza’s Clinical Periodontology 10th edition
• Clinical periodontology and implant dentistry
Jan Lindhe
• Osseointegration and occlusal rehablitation
Hobo
• Contemporary Implant dentistry
Carl E. Misch
References

81. Thank You