Welcome to the Mini Residency in Oral Implantology

Indiarsquos 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 ISO9001 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 BDS is as good as MDS 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 CanadianAustralian Standards

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

ODONTOS ACADEMY Awarded Prestigious Presidentrsquos award for excellence

in Medicine 2012 Nominated for the Prestigious Presidentrsquos 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 - ldquofather of modern implantologyrdquo Placed Worlds First Dental Implant in 1952 Branemark ndash 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 amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Welcome to the Odontos Academy for Clinical Dental Studies Mini

Residency in Oral Implantology

ODONTOS ACADEMY ISO9001 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 BDS is as good as MDS 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 CanadianAustralian Standards

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

ODONTOS ACADEMY Awarded Prestigious Presidentrsquos award for excellence

in Medicine 2012 Nominated for the Prestigious Presidentrsquos 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 - ldquofather of modern implantologyrdquo Placed Worlds First Dental Implant in 1952 Branemark ndash 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 amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

ODONTOS ACADEMY ISO9001 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 BDS is as good as MDS 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 CanadianAustralian Standards

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

ODONTOS ACADEMY Awarded Prestigious Presidentrsquos award for excellence

in Medicine 2012 Nominated for the Prestigious Presidentrsquos 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 - ldquofather of modern implantologyrdquo Placed Worlds First Dental Implant in 1952 Branemark ndash 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 amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 CanadianAustralian Standards

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

ODONTOS ACADEMY Awarded Prestigious Presidentrsquos award for excellence

in Medicine 2012 Nominated for the Prestigious Presidentrsquos 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 - ldquofather of modern implantologyrdquo Placed Worlds First Dental Implant in 1952 Branemark ndash 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 amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

ODONTOS ACADEMY Awarded Prestigious Presidentrsquos award for excellence

in Medicine 2012 Nominated for the Prestigious Presidentrsquos 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 - ldquofather of modern implantologyrdquo Placed Worlds First Dental Implant in 1952 Branemark ndash 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 amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 - ldquofather of modern implantologyrdquo Placed Worlds First Dental Implant in 1952 Branemark ndash 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 amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Introduction History Linkow - ldquofather of modern implantologyrdquo Placed Worlds First Dental Implant in 1952 Branemark ndash 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 amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

lengh amp diameter Lengh

Varies between 6 to 45mm

Depends on bone characterstics in the insertion location

Diameter

o Varies between 25mm to 55mm

o 33mm 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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Biomaterial used Pure(CP) titanium

lightweight

biocompatible

corrosion resistant (dynamic inert oxide layer)

strong amp 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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 15microm 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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 bull Easy to remove for repairs bull 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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 characterstics at the site of insertion

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

High resolution CT imaging (0625 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 oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Advantages

oFeels and chews like real teeth oDoesnrsquot 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 amp 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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 amp

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

mouth chin or neck area bull 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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 2005Snell 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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 onersquos 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 al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

The MN is significant during surgical procedures of the chin area such as genioplasty and mandibular anterior segmented osteotomy (Westermark et al1998 Seo et al 2005 Gilbert amp 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 casesrsquo 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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 Seddonrsquos 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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 couldnrsquot 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

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

Nerve Lateralization or Nerve Repositioning Is the way

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

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 475x12 mm Ankylos implant

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

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 475x12 mm Ankylos implant

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Bio Materials as Implant Acid Etched Implant

Bio Materials as Implant Acid Etched- Sand Blasted Implant

Bio Materials as Implant Anodized 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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Bio Materials as Implant Acid Etched- Sand Blasted Implant

Bio Materials as Implant Anodized 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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Bio Materials as Implant Anodized 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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 implants 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 075-10 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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

The distance between the two teeth can be determined by the gap width Depending on the tooth shape the gap width is 10 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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Clinical Aspects of Surgery

contents General principles of implant surgery

Patient preparation Implant site preparation One stage versus two stage implant surgeries

Two stage ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Clinical Aspects of Surgery

contents General principles of implant surgery

Patient preparation Implant site preparation One stage versus two stage implant surgeries

Two stage ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

contents General principles of implant surgery

Patient preparation Implant site preparation One stage versus two stage implant surgeries

Two stage ldquosubmergedrdquo implant placement Flap designs incisions and reflection Implant site preparation Flap closure and suturing Post operative care Second stage exposure surgery

57

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

One stage ldquonon-submergedrdquo implant placement Flap designs incisions and elevation Implant site preparation Flap closure and suturing Postoperative care

Conclusion

58

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

General principles of implant surgery

Patient preparation

Implant site preparation

One stage Vs two stage implant surgery

59

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Patient preparation 1 Explanation of risks and benefits to the patient

2 Written Informed consent

3 Local or General Anesthesia depending on patientrsquos

needs

60

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Basic principles of implant therapy 1 Implants must be sterile and made of a biocompatible material (eg 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 (ie

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

61

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

62

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

63

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

64

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

One stage VS two stage technique

65

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

One stage technique In the one-stage approach the

implant or the abutment

emerges through the

mucoperiosteumgingival

tissue at the time of implant

placement

66

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

stage exposure surgery is not necessary

67

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

68

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 (ie 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 implantabutment 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

69

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

70

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Two stage ldquosubmergedrdquo implant placement The first stage ends by

Suturing So the implant remains submerged and isolated from the oral

cavity Mandible implants ndash 2 to 4 months Maxillary implants ndash 4 to 6 months

Longer periods ndash

less dense bone Less initial implant stability

Shorter periods ndash More dense bone Altered surface microtopography

71

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

72

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Two stage ldquosubmergedrdquo 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

73

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Incisions

74

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

75

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Once the flaps are reflected and the bone is prepared (ie 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

76

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

77

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 reducedcontoured 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

78

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Implant site preparation Sequence of drills used for standard-diameter (40-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

79

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

80

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

81

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Round bur spiral drill

82

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

2MM twist drill

83

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

84

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Pilot drill

85

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Guide pins

86

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Depth gauge

87

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Counter sink drill

88

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Bone tap

89

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

90

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

It is better to allow the threaded implant to ldquocutrdquo

its own path into the osteotomy site

Bone tapping and implant insertion are both done

at very slow speeds (eg 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

91

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

92

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

When wide-diameter drills are used for implant site

preparation it is advisable to reduce the drilling speed

according to the manufacturers 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

93

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Implant site preparation (osteotomy ) for a 40-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

94

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

95

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

96

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

97

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement

98

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Implant fixtures

99

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Cover screw

100

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Flap closure and suturing

101

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

102

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

103

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Post operative care Simple implant surgery in a healthy patient usually

does not require antibiotic therapy

However patients can be premedicated with

antibiotics (eg 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 104

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 (eg

ibuprofen 600 to 800 mg tid)

105

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

106

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Second stage exposure surgery For implants placed using a two-stage ldquosubmergedrdquo

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

107

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

108

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Simple circular ldquopunchrdquo incision In areas with sufficient zones of keratinized tissue the

gingiva covering the head of the implant can be exposed

with a circular or ldquopunchrdquo 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

109

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Clinical view of stage two implant exposure surgery in a case with adequate keratinized tissue A Simple circular ldquopunchrdquo 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 110

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

111

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

112

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

113

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

114

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

One stage ldquonon-submergedrdquo implant placement

115

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 (ie 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 andor minimal implant support they may be allowed to heal for periods of 4 to 6 months or more)

116

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 implantabutment

117

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

118

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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 implantimplant abutment

119

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

Flap closure and suturing The keratinized edges of the flap are sutured with

single interrupted sutures around the implant Depending on the clinicians 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

120

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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)

121

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion

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

122

• Slide Number 1
• Welcome to the Mini Residency in Oral Implantology
• Slide Number 3
• Slide Number 4
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• ODONTOS ACADEMY
• What we will Cover Today
• Introduction History
• lengh amp diameter
• Biomaterials used
• Biomaterial used
• Implant design (root-form)
• Implant surface
• How it works
• Types
• Subperiosteal implants
• Transosteal implants
• Types of Prosthesis
• Fixed implant prosthesis
• Procedure
• During the procedure
• Slide Number 23
• Advantages
• Disadvantages
• What is involved with getting a dental implant
• WHAT IS INVOLVED WITH GETTING A DENTAL IMPLANT
• Risk
• What can be expected after a dental implant
• What can be expected after dental implants
• Who would benefit from dental implant
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Neuro-Vascular Considerations
• Slide Number 35
• Slide Number 36
• Nerve Morphology
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• What to do if the Implant is too Close to the Nerve
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• Bio Materials as Implant
• How to Decide Implant Size
• How to Decide Implant Size
• Slide Number 52
• Our Implant Cases
• SINUS LIFT SURGERY
• Slide Number 55
• Clinical Aspects of Surgery
• contents
• Slide Number 58
• General principles of implant surgery
• Patient preparation
• Basic principles of implant therapy
• Surgical site preparation
• Operative requirements
• Operative requirements
• One stage VS two stage technique
• One stage technique
• Advantages of one stage
• Two stage technique
• Slide Number 69
• Advantages of 2nd stage surgery
• Two stage ldquosubmergedrdquo implant placement
• Slide Number 72
• Two stage ldquosubmergedrdquo implant placement
• Incisions
• Implant site preparation
• Slide Number 76
• Slide Number 77
• Slide Number 78
• Implant site preparation
• Slide Number 80
• Round bur
• Round bur spiral drill
• 2MM twist drill
• Twist drills (To Enlarge the Osteotomy Site to required diameter)
• Pilot drill
• Guide pins
• Depth gauge
• Counter sink drill
• Bone tap
• Slide Number 90
• Slide Number 91
• Slide Number 92
• Slide Number 93
• Slide Number 94
• Slide Number 95
• Slide Number 96
• Slide Number 97
• Wrench Ratchet Fits on top of fixture mount amp used to tighten fixture after placement
• Implant fixtures
• Cover screw
• Flap closure and suturing
• Slide Number 102
• Slide Number 103
• Post operative care
• Slide Number 105
• Slide Number 106
• Second stage exposure surgery
• Objectives of second stage technique
• Simple circular ldquopunchrdquo incision
• Slide Number 110
• Slide Number 111
• Slide Number 112
• Post operative care
• Slide Number 114
• One stage ldquonon-submergedrdquo implant placement
• Slide Number 116
• Slide Number 117
• Flap design incisions and elevation
• Implant site preparation
• Flap closure and suturing
• Post operative care
• conclusion