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DENTAL IMPLANTOLOGY
– CHAPTER THREE –
Basic Implant Surgical Procedures
Dr. Haydar Munir Salih Alnamer
BDS, PhD (Board Certified)

Surgical procedures always start with detailed
surgical preparation. Preparation for implant
surgery requires a thorough review of:
•The patient's chart, including medical and
dental histories, operatory notes, radiographs,
•Anticipated implant sizes and locations,
surgical guides, surgical sequencing and
strategy,
•possible complications, patient management,
anesthesia, operating time, instrumentation,
postoperative management, and restorative
plan.

Prophylactic antibiotic
• 2 g amoxicillin I hour
preoperatively
• Ampicillin 2 g
intramuscularly or
intravenously 1 hour before
• Alternative medications
include 600 mg of
clindamycin orally or
intravenously
• No postoperative antibiotic
administration is necessary.

The surgical site should be kept aseptic

Change in bone height around the implant
After initial bone remodeling in the first year
( l to l .5 mm of resorption described as
"normal remodeling around an externally hexed
implant"), the bone level around healthy
functioning implants remains stable for many
years afterward. The average annual crestal
bone loss after the first year in function is
expected to be 0.1 mm or less

One-Stage vs Two-Stage
Implant Placement Surgery
Two stage
Dr. Haydar Munir Salih

One Stage

Implant Site Exposure
1. Flapless surgery
2. Flap with tissue elevation that may include
sulcular, midcrestal, and vertical releasing
incisions.

Flapless surgery

Flap with tissue elevation
(mid Cristal incision)

Vertical releasing 3 sided flap

Flap reflection
Dr. Haydar Munir SalihDr. Haydar Munir SalihDr. Haydar Munir Salih

Flap reflection

Preparing the Osteotomy
• A low-speed (800-1500 rpm)
• High-torque hand piece
• Intermittent drilling technique → allow the irrigant to
reach the depth of the preparation and allow the bone
chips to be removed and to prevent the heat buildup
• Sharp drills
• Copious saline irrigation (external, internal, manual )

•Heat production during bone preparation is
a critical factor, a maximum temperature
of 47 C for 1 minute is commonly quoted
as a threshold temperature

Low speed high torque headpiece

• The depth indicator markings on the precision and pilot
drills should always be reviewed.
• The entry point and its ideal angulation should be
determined with the precision drill. The proper
angulation should be verified from different vantage
points. A surgical guide is usually used to facilitate
orientation.

Dr. Haydar Munir Salih Dr. Haydar Munir Salih

Implant insertion
• The implant is opened and placed on the driver that has
been inserted into the hand piece.
• The tip of the implant is inserted into the osteotomy,
and the position and angulation are verified again. The
implant is driven into position by keeping light pressure
in an apical direction until the implant is almost
completely seated or until the motor torques out
(approximately I to 2 mm short of complete seating).
• the surgeon continues to seat the implant, using the
torque lever of the wrench to quantify the amount of
torque present.

Implant insertion

Suturing Flap

Postoperative Management
• A radiograph should be taken postoperatively to
evaluate the position of the implant in relation to
adjacent structures
• Analgesia + Antibiotic
• Patient may also be instructed to use 0.12%
chlorhexidine gluconate rinse for 2 weeks after
surgery
• The patient is evaluated weekly until soft tissue
wound healing is complete (approximately 2 to 3
weeks).

If the patient wears a tissue-borne denture over the area of
implant placement, the denture can be relined with a soft liner
after l week

Uncovering
• The healing time or the length of time necessary
to achieve osseointegration varies from site to
site and from patient to patient Typical healing
times are 4 to 6 months.
• In a two-stage system, the implant must be
surgically uncovered and a healing abutment
placed. The goals of surgical uncovering are to
attach the healing abutment to the implant,
preserve keratinized tissue, and modify the form
or thickness of tissue

Uncovering

Implant Stability
Initial implant stability is one of the most
important predictors of long-term implant success.
This depends on:
1. the depth and density of bone,
2. implant size
3. precision of the surgical technique.

A. Intraoperative Complications:
•Poor primary stability (loose implant)
•Positioning error
•Excessive soft tissue trauma
•Poor attention to detail in preparation of
the osteotomy
•Invasion of critical anatomic structures

B. Postoperative complications:
• Incision line opening
• Pain,
• Swelling.
• Reactionary or secondary hemorrhage
• Infection
• Expose or loose cover screw

C. Late complications:
•mucosal recession
•bone resorption
•mobility
•implant fracture

Treatment Protocols
• A. Delayed Placement : in which delay
placement until an extraction site was
completely filled with bone (6 month or longer).
• A covered non loaded healing phase requiring a
stress-free OI period of approximately 4 months
guarantees a high degree of safety if the classic
surgical protocol is followed.
• 3 - 6 months non-loaded phase for dental
implants is generally accepted for safe bone
apposition to implant interface

Delayed Placement

Treatment Protocols
B. Immediate Placement  placing the implant
at the same time as tooth extraction.
The Advantages:
• preserve more residual alveolar bone result in
improved esthetic and better emergence profile
• the time between extraction and implant
placement will be significantly reduced.

B. Immediate Placement
Contraindications:
1. Bony or soft tissue infection
2. Inadequate bone apical to extraction site for
implant stabilization
3. Inability to provide occlusion from oral
contamination
4. Chronic problems such as granuloma or radicular
cyst

Immediate Placement

Treatment Protocols
C. Semi-immediate Placement  placement of
implant is delayed until the mucosa has
regenerated over the socket, allowing a more
predictable soft-tissue covering over the implant
site
this require 2 months of epithelial healing and
maturation.

Criteria for implant success
• have been proposed in the literature but have not
been used consistently. The problem is that a
universally accepted definition of implant success
has not been established. In the classic
definition, Albrektsson and colleagues defined
• Success as an implant with no pain ,no mobility,
no radiolucent peri-implant areas, and less than
0.2 mm of bone loss annually after the first year
of loading.

Criteria for implant success
Implant success is suggested for a span of:
•1-3 years → early implant success
•3-7 years → intermediate implant success
•More than 7 years → long-term implant
success

Assessment of failure according to the
time when occurred:
(1) Early failures or failures during the
osseointegration period (usually within the first
year after an implant insertion, during the healing
period and initial loading), and
(2) Late failures or failures after the
osseointegration period (usually about a year after
implant insertion, when an osseointegration
process is complete and implant function is
established).
•

Causes of early implant failures:
1. Poor quality and quantity of bone and soft tissue
2. Patient medical condition
3. Unfavorable patient habits (bruxism, heavy long-
term smoking, poor oral hygiene, others)
4. Inadequate surgical analysis and technique
5. Inadequate prosthetic analysis and technique
6. Suboptimal implant design and surface
characteristics
7. Implant position or location (functional implant
zones)
8. Unknown factors

Misch Criteria of Success
Depend on PEMB
P = pain
E = exudate
M = mobility
B = bone loss > 2 mm

I. Success (optimum health)
a) No pain or tenderness upon function
b) 0 mobility
c) <2 mm radiographic bone loss from initial
surgery
d) No exudates history

II. Satisfactory survival
a) No pain on function
b) 0 mobility
c) 2–4 mm radiographic bone loss
d) No exudates history

III. Compromised survival
a) May have sensitivity on function
b) No mobility
c) Radiographic bone loss > 4 mm (less than 1/2 of
implant body)
d) Probing depth > 7 mm
e) May have exudates history

IV. Failure (clinical or absolute failure)
a) pain on function
b) mobility
c) radiographic bone loss > ½ length of implant
d) uncontrolled exudate
e) No longer in mouth

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