Basic dental implant surgery/ cosmetic dentistry training

Basic implant surgery
Basic implant
surgery
INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

CONTENTS
 Introduction
 Preoperative measures
 Operative requirements
 Sterile technique
 Surgical techniques for implant instillation
 Surgery for abutment connection
 Recent advances
 Conclusion
 References

INTRODUCTION
Successful implant surgery is largely dependent upon good
planning and meticulous technique.
The planning requires an appreciation of the restorative
requirements and visualization of the desired end result
of treatment.
The meticulous technique requires adequate surgical
training and experience of the selected implant system.

The essential pre-requisites before proceeding to
implant surgery are:
The patient should be medically fit to undergo the
surgery. Placement of one or two implants is equivalent
to relatively minor oral surgery whereas placement of
five or six implants increases the magnitude significantly.

DENTIST PATIENT INTERACTION

INFORMING THE PATIENT

INFORMATION AIDS

INFORMED CONSENT
1. The patient should understand the procedure and be
warned of any complications.
2. They should have agreed the treatment plan, treatment
schedule, costings, and given their consent.

 The diagnostic set-up surgical stent and relevant
radiographs should be available.
 The surgeon should have a clear idea of the number,
size and planned location of the implants. They should
be trained in the procedure and able to cope with any
unforeseen circumstances.

GENERAL MEDICAL CONTRAINDICATIONS
1. Age
2. Current medications
3. Metabolic disorders
4. Hematologic disorders
5. Cardiac and circulatory disorders
6. Osseous metabolic disorders
7. Pregnancy
8. Heart valve prosthesis or bacterial endocarditis

INTRAORAL CONTRAINDICATIONS
1. Unfavorable bone quality and quantity
2. Problematic occlusal and functional relationship
3. Pathologic conditions in alveolar bone
4. Radiation therapy in jaw region
5. Pathologic alteration of oral mucosa
6. Xerostomia
7. Poor oral hygiene

PSYCHOLOGICAL CONTRAINDICATIONS
1. Poor patient compliance
2. Alcohal and smoking
3. Neurosis and psychosis
4. Problem patients

ANAESTHESIA
Most implant surgery can be carried out under local
anaesthesia, although some patients will require
sedation or general anaesthesia.
For extremely anxious patients benzodiazepine 5-
20 mg 1 hour before operation.

STERILE TECHNIQUE
 Every effort should be
made to conduct implant
surgery under sterile
operating conditions.
 Chlorhexidine 0.2% is
used as a pre-operative
mouthwash and skin
preparation circumorally
using broad spectrum
microbicide ex: betadine.

BASIC INSTRUMENTARIUM

SURGICAL DRAPE KIT

IMPLANT PACKAGING

STERILE PHYSIOLOGIC SALINE SOLUTION

Reduction gear angled handpiece
system uses both internal and external irrigation

Operatory: sterilized, ventilated

Disposable plastic sleeve for motor and cord. Avoids
repeated autoclaving

High speed hand piece to run at high torque with a speed
of 1500 to 2000 RPMs, and the slow speed hand piece at
high torque with speed of approximately 15 to 20 RPMs

Drills used for bone preparation include: guide drill, 2 mm
twist drill, pilot drill, the 3 mm twist drill, and countersink

Irrigation unit is used to deliver an even, steady flow of
sterile water to the surgical site at all times during high and
low speed preparation

Surgical guide stent is placed in the area to project the
future position of the fixture

FLAP DESIGN
 There are many different flap designs for implant
surgery. practically in all situations a mid-crestal incision
can be employed.
 Access and elevation of the flaps can usually be
improved by the additional use of vertical relieving
incisions

IncIsIons

CRESTAL INCISION

EXTENDED CRESTAL INCISION

Arcuate vestibular primary incision

Crestal incision with buccal reflection

Vestibular incision with lingual reflection

Primary incisions – maxilla
crestal incision in edentulous maxilla

Palatal primary incision with buccally reflected
mucoperiosteal flaps

Buccal primary incision with palatal reflection of
mucoperiosteal flaps

Partially edentulous maxilla – palatal incision

Single tooth implant – periodontal surgery type
incision technique

Single tooth implant – maxillofacial surgery type incision
technique

Stage I Surgery is the procedure for installing implants
into bone. This procedure demands exacting, non-
traumatic preparation of the recipient site and a specific
insertion protocol. Variations in this procedure mainly
depends on the quality and quantity of bone and also on
the load demands on the final prosthesis

Guide drill is the first drill used in the bone preparation
process. It is designed to penetrate the cortical layer of the
bone

Initial penetration using surgical guide stent, is initiated
using high speed guide drill at 1500 RPM. Copious saline
irrigation used at all times

2 mm twist drill is used second in the sequence to prepare
the site to 2mm in diameter

Site is progressively enlarged to 2mm with a 2mm twist drill
at 1500 RPM

Pilot drill is used next. Inferior portion of the drill is to
engage the 2mm prepared site and superior portion begins
the enlargement of the site

Final orientation and inclination of the implant is done by
using the pilot drill at high speed, high torque. It has an
2mm non-cutting edge and a 3mm cutting edge

3 mm twist drill is fourth drill in bone preparation. Its used to
prepare bone to its final destination

Implant site is prepared to final length and width utilizing a
3mm twist drill operating at high speed

Countersink is the final drill used in the high speed drilling
process. It is used to create a shelf in the prepared bony
site

Crestal bone carefully prepared using countersink. Allows
superior aspect of implant to be placed crestally or sub-
crestally.

Bone tap is the first in the series of slow speed bone
preparation. Made of titanium and used to thread the bone
prior to implant placement

Receptor site is tapped utilizing a titanium tap operating at
15 to 20 RPMs along with copious irrigation

Implants are composed of commercially pure titanium and
range in length from 7 to 20 mm and width of range 3.75
and 4.0 mm

Fixture mount is connected to the implant

Connection to handpiece is used to connect the fixture
mount to the handpiece

Implant is connected to the handpiece, and inserted to the
pre-tapped site at 15 to 20 RPMs

implant is in position

Cylinder wrench used for final tightening of implant

Open end wrench to stabilize the implant during removal of
fixture mount

Subcrestal position of the implant

Screwdriver, either hexagonal or slotted used to place
cover screw into implant

Cover screws are available either a hexagonal or slotted
configuration

Coverscrew picked up in slow handpiece and placed into
the implant

Appearance of implant after insertion of cover screw

Sutures placed

Stage II surgery
Uncovering of implants
may be after 3 to 4
months of healing in
mandible and 5 to 6
months in case of
maxillae

Repositioned flaps

Connective tissue transplant

Free gingival graft

Electrosurgery

Excessive bone formation

STAGE II
SURGERY
PROCEDURE

Cover screw is exposed after removal of overlying bone or
soft tissue

Hexagon cover screw driver used to remove cover screw
from implant

After 4 months of healing, cover screw removed

Selection of proper sized abutment for transmucosal
connection

Abutment placed into implant and secured with abutment
screw

Small or large healing caps used to prevent debris
collection in threaded portion of abutment screw

Surgical dressing during healing phase

Tissue response after two weeks

Hex abutment screwdriver to screw abutment into implant

Abutment placed with help from screwdriver

Abutment clamp used to prevent transfer of torque to
implant while connecting abutment screw

Abutment clamp in use

Post-operative care
After implant surgery, patients should be warned to
expect:
1. Some swelling and possibly bruising
2. Some discomfort which can usually be controlled with
oral analgesics
3. Some transitory disturbance in sensation if surgery has
been close to a nerve.

They should be advised:
1. In most circumstances, not to wear dentures over the
surgical area for at least 1 week (possibly 2 weeks) to
avoid loading the implants and the possibility of
disrupting the sutures
2. To use analgesics and ice packs to reduce swelling and
pain
3. To keep the area clean by using chlorhexidine
mouthwash 0.2% for 1 minute twice daily
4. Not to smoke.

ANTIBIOTIC COVER
The original protocols recommended an antibiotic such
as amoxicillin 250 mg 8 hourly for 5 to 7 days, unless the
patient is allergic where a suitable alternative should be
prescribed.

Recent advances :
Computer Guided Implant Surgery
Computer Guided Implant Surgery SIM/Plant is the
recent advance in implant treatment planning. It is an
interactive 3D computer imaging system that guides us
in implant surgery.
With SIM/Plant we can visualize the placement of
simulated implants and it gives us detailed knowledge of
the anatomy of the jaw in all three dimensions. It helps
us locate important internal structures and also helps us
measure bone quality directly from images.

Wand's computer controlled local anesthetic injection
system:
• It doesn't feel like a syringe. We know that some patients
get more nervous than others at the mere site of a
needle and syringe.
• That's why this performs injection with a revolutionary
system called the Wand, a computer controlled local
anesthetic injection system.
• The microprocessor inside the Wand automatically
ensures a steady flow rate regardless of tissue density.
The flow of anesthetic into your tissue is the source of
discomfort for most injections-not the needle.

Conclusion
Implant surgery is highly technique sensitive and
requires adequate training and an understanding of the
restorative requirements of the proposed treatment.
However, control of these factors can produce a highly
predictable, aesthetic and long-lasting result.

References
1. Atlas of oral implantology – A.Norman Cranin
2. Contemporary implant dentistry – Carl.E.misch
3. Implants in clinical dentistry – Richard.M.Palmer
4. Color atlas of dental implantology – Hubertius
spiekermann
5. Implant prosthodontics – Stevens Friedrickson

6. Atlas of tooth and implant supported prosthodontics –
Lawrence.A.Weinberg
7. Principles and Practice of Implant Dentistry: Adam Weiss and
Charles M.Weiss
8. Richard palmer, paul palmer and peter Floyd. Basic implant
surgery. British dental journal 1999, vol 187, no 8, page 415.
9. Effect of surgical techniques on primary implant stability and
periimplant bone. J Oral Maxillofacial Surgery 2007, 65, 2487.
10. A surgical guide for dental implant placement . J Prosthet
Dent 2006; 96; 129.

Thank you
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Basic dental implant surgery/ cosmetic dentistry training

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