everything about dental implantology- how to put dental implants

Welcome to the Mini Residency in Oral Implantology

India’s Most Extensive Single Day Implant Course

- Dr Aman Singh, MClinDent, BDS

Welcome to the Odontos Academy for Clinical Dental Studies Mini

Residency in Oral Implantology.

ODONTOS ACADEMY ISO:9001 Certified Only ACADEMY in INDIA which

trains you to Perfection in Dentistry. Started in 2011 We have Trained 1500 Students across the country. 300 being at Zirakpur Center. An Academy aimed at Excellence We believe a B.D.S. is as good as M.D.S. if he or she has

the zeal to learn and work.

ODONTOS ACADEMY Only Academy in North India with Laser and CAD

CAM Sensors for accurate measurement of Cavity cuttings and crown preparation that helps you meet Canadian/Australian Standards.

Supported by 7 Clinics in India, Odontos is fastest emerging Dental Speciality in country.

ODONTOS ACADEMY Awarded Prestigious President’s award for excellence

in Medicine, 2012. Nominated for the Prestigious President’s award for

excellence in Medicine, 2011. Most awarded Clinic in North India. Awards and Nominations include: 1. Excellence Award- CNBC TV18 2. New Idea Award- Lead Medical, Chicago, USA 3. Empanelment with ShareCare, New York, USA

What we will Cover Today Introduction and History Neurovascular Considerations Implant Surfaces How to decide the Implant Length and Diameter Osseointegration and Bioscience of Implant Surface Dental Implant Surface enhancement Implant stability Immediate Loading- Biomechanical Aspects Biological Reactions to Dental Implants. Realistic discussion on Longevity of a Dental Implant.

Introduction History Linkow - “father of modern implantology” Placed Worlds First Dental Implant in 1952 Branemark – Gave the concept of

Osteointegration by placing Titanium Implants in Rabbit Femur. He founded worlds first company in 1978 to manufacture and commercialize Dental Implant.

Today there are 337 Companies manufacturing dental implants.

lengh & diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 2.5mm to 5.5mm

o 3.3mm to 5mm is the preferred and most commonly used

Biomaterials used Cp titanium (commercially pure titanium)

Titanium alloy (titanium-6aluminum-4vanadium)

(Ti-6Al-4V)

Zirconium

Hydroxyapatite (HA), one type of calcium

phosphate ceramic material

Biomaterial used Pure(CP) titanium

lightweight

biocompatible

corrosion resistant (dynamic inert oxide layer)

strong & low-priced

Implant design (root-form) Cylindrical Implant Threaded Implant

Implant surface Increased pitch (number of threads per unit length

)and increased depth between individual threads allows for improved contact area between bone and implant

Moderately rough surfaces with 1.5µm improved contact area between bone and implant surface.

Reactive implant surface by Oxide layer, acid etching or HA coating enhanced osseointegration

How it works Taking a titanium post and inserting it under the gum,

or deep within the jaw bone. The bone accepts and osseointegrates with the

titanium rod, merging into the bone in a similar manner as to how a natural tooth root is enclosed within the bone.

Once the bone has completely fused with the titanium, an artificial tooth can be secured into the rod

As rod is implanted in the gum ,so its impossible to come out ,so secure then other means

Types Endosteal Subperiosteal Transosteal. Endosteal :- During endosteal implants o the gum is opened up, then a hole is drilled within the

bone. o Titanium screws and cylinders are then inserted within the

jawbone. o Once the bone has healed, the teeth can be secured in

place.

Subperiosteal implants A less common screws are placed on top of the bone but under the

gum line. This method is typically only used for patients who

have minimal bone height and are unable or unwilling to wear dentures

Transosteal implants Use even less than subperiosteal implants. drilling completely through the lower jaw, then

bolting a metal plate into the bottom of the mouth. The titanium then goes through the bone

skin under the chin is opened , resulting scarring around the neck area and unnecessary recovery time.

High failure rate

Types of Prosthesis Removable implant prosthesis Fixed implant prosthesis Removable implant :- o Rod itself is not removable, but the tooth that screws into the

rod is. o This form of prosthesis includes an artificial white tooth with a

plastic pink gum to appear realistic. o Tooth snaps into the metal rod, and is typically removed at

night. Advantages • Easy to remove for repairs • Can cover a wider area for

multiple missing teeth for a lower cost

Fixed implant prosthesis o Stays in place all the time, o Either due to permanently being screwed into the

metal rod or because the implant has been cemented in place

Advantages o More secure than removable implants o Can be cleaned and treated like normal teeth.

Procedure o Surgical procedure (for 3-9 months) o First surgery:- insert titanium post in the bone or gum of mouth o Patient sedated gum is cut holes are drilled o titanium cylinder placed cylinder covered by stitched(self dissolving) metal cylinder osseointegrate with bone(2-6 month) o swelling, bruising, pain, and minor bleeding around the

gum area is expected o Pain reliever and antibiotics given for

pain and further infection

During the procedure After the bone gets merged with metal ,second surgery

is done gum is reopened expose previously implanted

metal rod abutment attached who would rather not have two surgeries, the

abutment placed within the gum during the first.(bone is still healing teeth is not placed yet)

Imaging is done before and after dental implants placement to assess bone characteristics at the site of insertion

High resolution CT imaging (0.625 mm slices) Assessment of analytical damage

DATA MEASURED o Bone type o Bone thickness o Density surrounding the tip and parrallel section of

microimplant

Advantages

oFeels and chews like real teeth oDoesn’t alter neighbouring teeth oCompletely secure after healing oBetter for long-term oral health oLooks identical to real teeth oCan be used for one tooth or several oEasy to care oHigh success rate of around 95% o bone stabilization & maintenance

Disadvantages

o Expensive

risk of screw loosening

risk of fixture failure

length of treatment time

need for multiple surgeries

challenging esthetics

What is involved with getting a dental implant? Only patients who need a replacement tooth will be

benefited to correct cosmetic problems, such as having

discoloured or missing teeth. those who have lost teeth due to gingivitis eligible for

dental implants. patients should be of adult age( as children and

teenagers still have their jaw bones growing) NOT FOR CHILDREN &

TEENAGERS

WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT ? Tooth implants cost is quite high ranging from INR 12000 to INR 30000 per implant price depend on certain factors such as where the tooth

is being implanted. if a tooth is being placed in the upper jaw, cost more

than a tooth being placed in the lower jaw. (sinus areas are affected, making the surgery much more complicated)

multiple teeth missing, the price of implants can rise to as much as INR 3 to 5 lakhs

Risk • Infection at or around the implantation area • Injuries to the surrounding teeth • Nerve damage • Pain, numbness, or tingling feeling in the gums,

mouth, chin, or neck area • Sinus problems, especially if the implants are being

placed in the upper jaw.

What can be expected after a dental implant? 95% dental implanting surgeries are successful 5% of failures :- due to the bone failing to fuse with the

metal patients practicing bad habits lead to complications

resulting in a failure smoking. If a patient must smoke, using an electronic cigarette is

encouraged, as this prevents smoke from damaging the implant area.

Avoid chewing hard items such as pens, pencils, ice or hard candy.

What can be expected after dental implants

Patients should visit their dentist every six months

after the surgery to ensure that bone is healthy.

The dentist SHOULD CHECK periodically the healthy

teeth so that they can be preserved.

Patients should be advised to use interdental brush

Who would benefit from dental implant Individuals who have trouble eating or chewing due to

lack of teeth Any adult who is experiencing speech problems due to

missing teeth Individuals missing one or more teeth due to injuries or

tooth decay Adults who are developing premature wrinkles or

sunken cheeks due to missing teeth Patients who would like to have a tooth

added without damaging neighboring teeth

Neuro-Vascular Considerations The anatomy of the intrabony course of the inferior

alveolar nerve (IAN) is very important for dentists, neurologist, radiologists and pathologists to aid in diagnosis, treatment, planning surgery, and the application of local anesthesia (Polland et al., 2001).

Due to increase in number of Implants that are being placed worldwide nowadays, knowledge of course of inferior alveolar nerve becomes of great importance.

Neuro-Vascular Considerations The nerve descends medial to the lateral pterygoid muscle and then, at its lower margin, passes between the sphenomandibular ligament and the mandibular ramus to enter mandibular canal by the mandibular foramen.

Classification of the topography of the IAN. (A = the nerve has a course near the apices of the teeth, B = the main trunk is low down in the body, C = the main trunk is low down in the body of the mandible with several smaller trunks to the molar teeth.

Neuro-Vascular Considerations

Below the lateral pterygoid muscle it is accompanied by the inferior alveolar artery, a branch of maxillary artery. The artery also enters the canal. In the canal the IAN lies downward and forward, usualy below the tip of the teeth until below the first and second premolars, at this point it divides into incicive and mental branches as the terminal branches. It continues forward in the canal or in a plexiform distrubition and giving off branches to the first premolar, canine and incisor teeth, and associated labial gingiva. Just before entering the mandibular canal the IAN gives off mylohyoid branch which pierces the sphenomandibular ligament and occurs a shallow groove on the medial surface of the mandible. It passes below the origin of mylohyoid muscle to lie on the surface of the muscle (Standring et al., 2005;Snell, 2011).

The mandibular foramen placed on midway between the ventral and dorsal magrin of ascending ramus of mandible nearly 1 cm above the occlusal surface of the lower teeth. The small triangular lingula guards the anterior border of the mandibular foramen and provides attachments for he sphenomandibular ligament from which the mandible swings.

In many cases there is a single nerve which runs a few millimeters below the roots of teeth, nearly equal number of the nerve lies much lower in the mandible to continue near the lower border of the bone, or sometimes it is plexiform. The nerve can lie on the lingual or buccal side of the mandible (Standring et al., 2005; Snell, 2011). The MN, a branch of the IAN, when emerges through the mental foramen and then divides into three branches that supply the skin of the chin and mucous membrane of the lower lip and gum. Two of them pass upward and forward nearby the mucosal surface of the lower lip. The third one passes through the intermingled fibers of platysma and depressor anguli oris muscles to harvest the skin of the lower lip and chin. As the MN is one of the two terminal branches of the IAN, it is understandable why one’s chin and lover lip on the affected side lose sensation, as well.(Standring et al., 2005; Snell, 2011)

The MN is significant during surgical procedures of, the chin area such as genioplasty and mandibular anterior segmented osteotomy (Westermark et al.,1998; Seo et al., 2005; Gilbert & Dickerson 1981), and it can also be damaged during dental procedures such as dental implant surgery, orthodontic treatment, and endodontic treatment. Mental neuropathy also may be caused by systemic diseases and tumors (Bodner et al., 1989; Klokkevold et al., 1989; Chand et al., 1997).

A relatively common problem is the use of an inappropriate attachment depth or path during the insertion of dental implant fixtures, which may injure the IAN and MN. The incidence of permanent sensory disturbance to the lower lip after dental implant insertion in the mental foramen region is reportedly 7% to 10%. (Wismeijer et al., 1997; Mardinger et al., 2000). Complications such as loss of lip and chin sensation may result in lip biting, impaired speech, and diminished salivary retention, deficits that have a significant impact on a cases’ activities of daily living (Deeb et al., 2000; Smiler, 1993) .

Nerve Morphology The nerve trunk is surrounded of four connective tissue sheaths. These are the mesoneurium, epineurium, perineurium, and endoneurium from the outside inward (Polland et al., 2001). In 1943, Seddon described a triple classification of mechanical nerve injuries to characterize the morphophysiologic types. Seddon’s classification includes neuropraxia, axonotmesis and neurotmesis and is based on the time course and completeness of sensory recovery (Seddon, 1943).

What to do if the Implant is too Close to the Nerve

65 year-old female patient admitted to Ludhiana Mediways Hospital, Department of Oral and Maxillofacial Surgery, with missing teeth in mandible. As she couldn’t use removable partial denture, we evaluated posterior mandibular area. But mandibular posterior bone height was inadequate for implant placement. A preoperative panoramic radiograph (Fig 2) and computerized tomograhic (CT) scan revealed only 5 mm. of bone between the alveolar crest and the inferior alveolar canal.


Nerve Lateralization or Nerve Repositioning Is the way


The surgical procedure was performed under local anesthesia. A full thickness mucoperiosteal flap was elevated to the inferior border of the mandible. For performing inferior alveolar nerve lateralization, the corticotomy started 4 mm distal to the mental foramen. A small round bur in a straight hand piece with high torque and copious amount of water irrigation was used to prepare the corticotomy site. To remove the trabecular bone and gain access to the neurovascular bundle, only hand instruments (small curettes) were used. The IAN was mobilized from its position. After the nerve was completely released from the canal and before starting to drill, half a rubber piston from a dental anaesthetic cartridge or a piece of membrane was inserted between the nerve bundle and the bone where the drill was expected to reach. At left and right second molar region, we placed 4.75x12 mm Ankylos implant .

Bio Materials as Implant Machined Surface- Branemark- 1969

Bio Materials as Implant Sand blasted Implant

Bio Materials as Implant Acid Etched Implant

Bio Materials as Implant Acid Etched- Sand Blasted Implant

Bio Materials as Implant Anodized Implant

How to Decide Implant Size Sizes of implants have biomechanical and clinical significance. There are two

biomechanical patterns: 1) The longer the implant is the greater integration with bony tissue it features.

This allows heavier functional load on the implant and surrounding osseous tissue.

2) Larger implant's diameter promotes better load distribution in surrounding bone tissue and higher strength.

Thus, size, diameter and length of the implant are to be as great as practicable, from the points of view of both biomechanical and clinical effectiveness.

However, size of the implant is significantly constrained by jaw dimensions, as well as other anatomical structures of maxillo-facial area. In addition, to ensure adequate osseogenesis the implant is to be all round surrounded with bone, which thickness is over 0.75-1.0 mm.

Thus, from biological and clinical points of view the implant dimensions are to be small enough to be all round surrounded with a bone mass, which provides adequate osseogenesis.

How to Decide Implant Size

The distance between the two teeth can be determined by the gap width. Depending on the tooth shape, the gap width is 1.0 mm (2x0, 5 mm) smaller than the distance at the bone level.

Our Implant Cases

SINUS LIFT SURGERY

Clinical Aspects of Surgery

contents 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

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One stage “non-submerged” implant placement Flap designs, incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

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General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

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Patient preparation 1. Explanation of risks and benefits to the patient.

2. Written / Informed consent

3. Local or General Anesthesia depending on patient’s

needs.

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Basic principles of implant therapy 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.

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Surgical site preparation 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.

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Operative requirements 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

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Operative requirements 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.

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One stage VS two stage technique

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One stage technique In the one-stage approach, the

implant or the abutment

emerges through the

mucoperiosteum/gingival

tissue at the time of implant

placement.

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Advantages of one stage Easier Mucogingival management around the implant. Patient management is simplified because a second

stage exposure surgery is not necessary.

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Two stage technique

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.

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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.

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Advantages of 2nd stage surgery 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.

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Two stage “submerged” implant placement 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

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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.

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Two stage “submerged” implant placement 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.

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Incisions

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Implant site preparation 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.

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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.

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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

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Implant site preparation 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.

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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.

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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.

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.

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Round bur/ spiral drill

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2MM twist drill

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Twist drills (To Enlarge the Osteotomy Site to required diameter)

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Pilot drill

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Guide pins

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Depth gauge

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Counter sink drill

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Bone tap

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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.

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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.

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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.

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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.

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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.

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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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Wrench / Ratchet: Fits on top of fixture mount & used to tighten fixture after placement.

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Implant fixtures

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Cover screw

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Flap closure and suturing

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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.

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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.

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Post operative 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. 102

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).

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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.

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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.

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

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Objectives of second stage technique 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.

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Simple circular “punch” incision 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.

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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. 108

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.

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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.

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Post operative care 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.

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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.

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One stage “non-submerged” implant placement

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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).

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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.

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Flap design, incisions, and elevation 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.

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Implant site preparation 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.

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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.

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Post operative 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.

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).

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conclusion 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.

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