India's Most Extensive Single Day Implant Course

Welcome to the Mini Residency in
Oral Implantology
India’s Most Extensive Single Day Implant Course
- Dr Aman Singh, MClinDent, BDS

Welcome to the Odontos
Academy for Clinical
Dental Studies Mini
Residency in Oral
Implantology.

ODONTOS ACADEMY
 ISO:9001 Certified Only ACADEMY in INDIA which
trains you to Perfection in Dentistry.
 Started in 2011
 We have Trained 1500 Students across the country.
300 being at Zirakpur Center.
 An Academy aimed at Excellence
 We believe a B.D.S. is as good as M.D.S. if he or she has
the zeal to learn and work.

ODONTOS ACADEMY
 Only Academy in North India with Laser and CAD
CAM Sensors for accurate measurement of Cavity
cuttings and crown preparation that helps you meet
Canadian/Australian Standards.
 Supported by 7 Clinics in India, Odontos is fastest
emerging Dental Speciality in country.

ODONTOS ACADEMY
 Awarded Prestigious President’s award for excellence
in Medicine, 2012.
 Nominated for the Prestigious President’s award for
excellence in Medicine, 2011.
 Most awarded Clinic in North India.
 Awards and Nominations include:
1. Excellence Award- CNBC TV18
2. New Idea Award- Lead Medical, Chicago, USA
3. Empanelment with ShareCare, New York, USA

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

Introduction History
 Linkow - “father of modern implantology”
Placed Worlds First Dental Implant in 1952
 Branemark – Gave the concept of
Osteointegration by placing Titanium
Implants in Rabbit Femur. He founded
worlds first company in 1978 to
manufacture and commercialize Dental
Implant.
 Today there are 337 Companies
manufacturing dental implants.

lengh & diameter
Lengh
 Varies between 6 to 45mm
 Depends on bone characterstics in the insertion location
Diameter
o Varies between 2.5mm to 5.5mm
o 3.3mm to 5mm is the preferred and most commonly used

Biomaterials used
 Cp titanium (commercially pure titanium)
 Titanium alloy (titanium-6aluminum-4vanadium)
(Ti-6Al-4V)
 Zirconium
 Hydroxyapatite (HA), one type of calcium
phosphate ceramic material

Biomaterial used
Pure(CP) titanium
 lightweight
 biocompatible
 corrosion resistant (dynamic inert oxide layer)
 strong & low-priced

Implant design (root-form)
Cylindrical Implant Threaded Implant

Implant surface
 Increased pitch (number of threads per unit length
)and increased depth between individual threads
allows for improved contact area between bone and
implant
 Moderately rough surfaces with 1.5µm improved
contact area between bone and implant surface.
 Reactive implant surface by Oxide layer, acid etching
or HA coating enhanced osseointegration

How it works
 Taking a titanium post and inserting it under the gum,
or deep within the jaw bone.
 The bone accepts and osseointegrates with the
titanium rod, merging into the bone in a similar
manner as to how a natural tooth root is enclosed
within the bone.
 Once the bone has completely fused with
the titanium, an artificial tooth can be secured
into the rod
 As rod is implanted in the gum ,so its impossible to
come out ,so secure then other means

Types
 Endosteal
 Subperiosteal
 Transosteal.
Endosteal :- During endosteal implants
o the gum is opened up, then a hole is drilled within the
bone.
o Titanium screws and cylinders are then inserted within the
jawbone.
o Once the bone has healed, the teeth can be secured in
place.

Subperiosteal implants
A less common
 screws are placed on top of the bone but under the
gum line.
 This method is typically only used for patients who
have minimal bone height and are unable or unwilling
to wear dentures

Transosteal implants
 Use even less than subperiosteal implants.
 drilling completely through the lower jaw, then
bolting a metal plate into the bottom of the
mouth. The titanium then goes through the bone
 skin under the chin is opened , resulting scarring
around the neck area and unnecessary recovery time.
 High failure rate

Types of Prosthesis
 Removable implant prosthesis
 Fixed implant prosthesis
Removable implant :-
o Rod itself is not removable, but the tooth that screws into the
rod is.
o This form of prosthesis includes an artificial white tooth with a
plastic pink gum to appear realistic.
o Tooth snaps into the metal rod, and is typically removed at
night.
Advantages
• Easy to remove for repairs
• Can cover a wider area for
multiple missing teeth for a lower
cost

Fixed implant prosthesis
o Stays in place all the time,
o Either due to permanently being screwed into the
metal rod or because the implant has been
cemented in place
Advantages
o More secure than removable implants
o Can be cleaned and treated like normal teeth.

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

During the procedure
 After the bone gets merged with metal ,second surgery
is done
 gum is reopened expose previously implanted
metal rod abutment attached
 who would rather not have two surgeries, the
abutment placed within the gum during the
first.(bone is still healing teeth is not placed yet)

 Imaging is done before and after dental
implants placement to assess bone characteristics
at the site of insertion
 High resolution CT imaging (0.625 mm slices)
 Assessment of analytical damage
DATA MEASURED
o Bone type
o Bone thickness
o Density
surrounding the tip and parrallel section of
microimplant

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

Disadvantages
o Expensive
 risk of screw loosening
 risk of fixture failure
 length of treatment time
 need for multiple surgeries
 challenging esthetics

What is involved with getting a dental implant?
 Only patients who need a replacement tooth will be
benefited
 to correct cosmetic problems, such as having
discoloured or missing teeth.
 those who have lost teeth due to gingivitis eligible for
dental implants.
 patients should be of adult age( as children and
teenagers still have their jaw bones growing)
NOT FOR CHILDREN &
TEENAGERS

WHAT IS INVOLVED WITH GETTING A
DENTAL IMPLANT ?
 Tooth implants cost is quite high
 ranging from INR 12000 to INR 30000 per implant
 price depend on certain factors such as where the tooth
is being implanted.
 if a tooth is being placed in the upper jaw, cost more
than a tooth being placed in the lower jaw. (sinus areas
are affected, making the surgery much more
complicated)
 multiple teeth missing, the price of
implants can rise to as much
as INR 3 to 5 lakhs

Risk
• Infection at or around the implantation area
• Injuries to the surrounding teeth
• Nerve damage
• Pain, numbness, or tingling feeling in the gums,
mouth, chin, or neck area
• Sinus problems, especially if the implants are being
placed in the upper jaw.

What can be expected after a dental
implant?
 95% dental implanting surgeries are successful
 5% of failures :- due to the bone failing to fuse with the
metal
 patients practicing bad habits lead to complications
resulting in a failure
 smoking.
 If a patient must smoke, using an electronic cigarette is
encouraged, as this prevents smoke from damaging the
implant area.
 Avoid chewing hard items such as pens, pencils, ice or
hard candy.

What can be expected after dental implants
 Patients should visit their dentist every six months
after the surgery to ensure that bone is healthy.
 The dentist SHOULD CHECK periodically the healthy
teeth so that they can be preserved.
 Patients should be advised to use interdental brush

Who would benefit from dental implant
 Individuals who have trouble eating or chewing due to
lack of teeth
 Any adult who is experiencing speech problems due to
missing teeth
 Individuals missing one or more teeth due to injuries or
tooth decay
 Adults who are developing premature wrinkles or
sunken cheeks due to missing teeth
 Patients who would like to have a tooth
added without damaging neighboring
teeth

Neuro-Vascular Considerations
 The anatomy of the intrabony course of the inferior
alveolar nerve (IAN) is very important for dentists,
neurologist, radiologists and pathologists to aid in
diagnosis, treatment, planning surgery, and the
application of local anesthesia (Polland et al., 2001).
 Due to increase in number of Implants that are being
placed worldwide nowadays, knowledge of course of
inferior alveolar nerve becomes of great importance.

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.

Below the lateral pterygoid muscle it is accompanied by the inferior alveolar artery, a
branch of maxillary artery. The artery also enters the canal. In the canal the IAN lies
downward and forward, usualy below the tip of the teeth until below the first and
second premolars, at this point it divides into incicive and mental branches as the
terminal branches. It continues forward in the canal or in a plexiform distrubition and
giving off branches to the first premolar, canine and incisor teeth, and associated labial
gingiva. Just before entering the mandibular canal the IAN gives off mylohyoid branch
which pierces the sphenomandibular ligament and occurs a shallow groove on the
medial surface of the mandible. It passes below the origin of mylohyoid muscle to lie on
the surface of the muscle (Standring et al., 2005;Snell, 2011).
The mandibular foramen placed on midway between the ventral and dorsal magrin of
ascending ramus of mandible nearly 1 cm above the occlusal surface of the lower teeth.
The small triangular lingula guards the anterior border of the mandibular foramen and
provides attachments for he sphenomandibular ligament from which the mandible
swings.

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

 The MN is significant during surgical procedures of, the chin
area such as genioplasty and mandibular anterior segmented
osteotomy (Westermark et al.,1998; Seo et al., 2005; Gilbert &
Dickerson 1981), and it can also be damaged during dental
procedures such as dental implant surgery, orthodontic
treatment, and endodontic treatment. Mental neuropathy also
may be caused by systemic diseases and tumors (Bodner et al.,
1989; Klokkevold et al., 1989; Chand et al., 1997).
 A relatively common problem is the use of an inappropriate
attachment depth or path during the insertion of dental implant
fixtures, which may injure the IAN and MN. The incidence of
permanent sensory disturbance to the lower lip after dental
implant insertion in the mental foramen region is reportedly 7%
to 10%. (Wismeijer et al., 1997; Mardinger et al., 2000).
Complications such as loss of lip and chin sensation may result
in lip biting, impaired speech, and diminished salivary retention,
deficits that have a significant impact on a cases’ activities of
daily living (Deeb et al., 2000; Smiler, 1993) .

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

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

Nerve

Nerve
Nerve Lateralization or Nerve Repositioning
Is the way

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
4.75x12 mm Ankylos implant .

Bio Materials as Implant
 Machined Surface- Branemark- 1969

 Sand blasted Implant

 Acid Etched Implant

 Acid Etched- Sand Blasted Implant

 Anodized Implant

How to Decide Implant Size
Sizes of implants have biomechanical and clinical significance. There are two
biomechanical patterns:
1) The longer the implant is the greater integration with bony tissue it features.
This allows heavier functional load on the implant and surrounding osseous
tissue.
2) Larger implant's diameter promotes better load distribution in surrounding
bone tissue and higher strength.
Thus, size, diameter and length of the implant are to be as great as practicable,
from the points of view of both biomechanical and clinical effectiveness.
However, size of the implant is significantly constrained by jaw dimensions, as
well as other anatomical structures of maxillo-facial area. In addition, to
ensure adequate osseogenesis the implant is to be all round surrounded with
bone, which thickness is over 0.75-1.0 mm.
Thus, from biological and clinical points of view the implant dimensions are to
be small enough to be all round surrounded with a bone mass, which provides
adequate osseogenesis.

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

contents
 General principles of implant surgery
 Patient preparation
 Implant site preparation
 One stage versus two stage implant surgeries
 Two stage “submerged” implant placement
 Flap designs, incisions and reflection
 Flap closure and suturing
 Post operative care
 Second stage exposure surgery
55

 One stage “non-submerged” implant placement
 Flap designs, incisions and elevation
 Flap closure and suturing
 Postoperative care
 Conclusion
56

General principles of implant
surgery
Patient preparation
Implant site
preparation
One stage Vs two
stage implant surgery
57

Patient preparation
1. Explanation of risks and benefits to the patient.
2. Written / Informed consent
3. Local or General Anesthesia depending on patient’s
needs.
58

Basic principles of implant therapy
1. Implants must be sterile and made of a biocompatible material (e.g., titanium).
2. Implant site preparation should be performed under sterile conditions.
3. Implant site preparation should be completed with an atraumatic surgical technique
that avoids overheating of the bone during preparation of the recipient site.
4. Implants should be placed with good initial stability.
5. Implants should be allowed to heal without loading or micro-movement (i.e.,
undisturbed healing period to allow for osseointegration) for 2 to 4 or 4 to 6 months,
depending on the bone density, bone maturation, and implant stability.
59

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.
60

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
61

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.
62

One stage VS two stage technique
63

One stage technique
In the one-stage approach, the
implant or the abutment
emerges through the
mucoperiosteum/gingival
tissue at the time of implant
placement.
64

Advantages of one stage
 Easier Mucogingival management around the implant.
 Patient management is simplified because a second
stage exposure surgery is not necessary.
65

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.
66

 In areas with dense cortical bone and good initial implant support, the
implants are left to heal undisturbed for a period of 2 to 4 months,
whereas in areas of loose trabecular bone, grafted sites, and sites with
lesser implant stability, implants may be allowed to heal for periods of 4
to 6 months or more.
 Longer healing periods are indicated for implants placed in less dense
bone or when there is less initial implant stability (i.e., slight looseness
caused by limited bone-to-implant contact), regardless of jaw or specific
anatomic location.
 In the second-stage (exposure) surgery, the implant is uncovered and a
healing abutment is connected to allow emergence of the
implant/abutment through the soft tissues, thus facilitating access to the
implant from the oral cavity.
 The restorative dentist then proceeds with the prosthodontic aspects of
the implant therapy (impressions and fabrication of prosthesis) after soft
tissue healing.
67

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.
68

Two stage “submerged” implant
placement
 The first stage ends by
 Suturing
 So the implant remains submerged and isolated from the oral
cavity.
 Mandible implants – 2 to 4 months
 Maxillary implants – 4 to 6 months
 Longer periods –
 less dense bone
 Less initial implant stability
 Shorter periods –
 More dense bone
 Altered surface microtopography
69

 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.
70

Two stage “submerged” implant
placement
 Flap design, incisions, and elevation
 Vary slightly depending on the location and objective of the
planned surgery.
 Crestal
 The incision is made from along the crest of the ridge, bisecting the
existing zone of keratinized mucosa
 Adv. Easy to manage, results in less bleeding, less edema, faster
healing.
 Suturing placed generally do not interfere with the healing.
 Remote
 The incision is made some distance from the planned osteotomy
site.
 Layer suturing is indicated to minimize the bone graft exposure.
71

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. 73

 Once the flaps are reflected and the bone is prepared (i.e., all
granulation tissue removed and knife-edge ridges flattened), the
implant osteotomy site can be prepared.
 A series of drills are used to prepare the osteotomy site precisely
and incrementally for an implant.
 A surgical guide or stent is inserted, checked for proper
positioning, and used throughout the procedure to direct the
proper implant placement.
74

Tissue management f or a two-stage implant
placement.
A, Crestal incision made along the crest of the
ridge,
bisecting the existing zone of keratinized mucosa.
B, Full-thickness flap is raised buccally and
lingually to the level of
the mucogingival junction.
A narrow, sharp ridge can be
surgically reduced/contoured to
provide a reasonably f lat bed f or the implant.
C, Implant is placed in the prepared osteotomy
site.
D, Tissue approximation to
achieve primary flap closure
without tension
76

Sequence of drills used
for standard-diameter (4.0-
mm) implant site osteotomy
preparation:
round,
2-mm twist,
pilot,
3-mm twist, and
countersink.
Bone tap (not shown here)
is an optional drill that is
sometimes used in dense
bone
before implant placement.
77

 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.
78

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.
79

Twist drills (To Enlarge the
Osteotomy Site to required
diameter)
82

 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.
88

 It is better to allow the threaded implant to “cut”
its own path into the osteotomy site.
 Bone tapping and implant insertion are both done
at very slow speeds (e.g., 20 to 40 rpm). All other
drills in the sequence are used at higher speeds
(800 to 1500 rpm).
 It is important to create a recipient site that is very
accurate in size and angulation.
89

 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.
90

 When wide-diameter drills are used for implant site
preparation, it is advisable to reduce the drilling speed,
according to the manufacturer's guidelines, to prevent
overheating the bone.
 Copious external irrigation is critical. In the case of wide
diameter implants, a specific pilot drill is often indicated as
a transition between each of the subsequent wider drills.
91

Implant site preparation (osteotomy ) for a 4.0-mm diameter, 10 mm length
screw-type, threaded (external hex) implant in a subcrestal position.
A, Initial marking or preparation of the implant site with a round bur. B, Use of
a 2-mm twist drill to establish depth and align the implant. C, Guide pin is
placed in the osteotomy site to confirm position and angulation.
D, Pilot drill is used to increase the diameter of the coronal aspect of the
osteotomy site.
92

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
93

Wrench / Ratchet: Fits on top of fixture mount & used
to tighten fixture after placement.
96

 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.
100

 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.
101

Post operative care
 Simple implant surgery in a healthy patient usually
does not require antibiotic therapy.
 However, patients can be premedicated with
antibiotics (e.g., amoxicillin, 500 mg three times a
day [tid]) starting 1 hour before the surgery and
continuing for 1 week postoperatively if the surgery
is extensive, if it requires bone augmentation, or if
the patient is medically compromised.
 Postoperative swelling is likely after flap surgery.
102

 This is particularly true when the periosteum has been incised
(released).
 As a preventive measure, patients should apply an ice pack to the
area intermittently for 20 minutes (on and off) over the first 24
to 48 hours.
 Chlorhexidine gluconate oral rinses can be prescribed to
facilitate plaque control, especially in the days after surgery when
oral hygiene is typically poorer. Adequate pain medication
should be prescribed (e.g., ibuprofen, 600 to 800 mg tid).
103

 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.
104

Second stage exposure surgery
 For implants placed using a two-stage “submerged”
protocol, a second-stage exposure surgery is necessary
after the prescribed healing period.
 Thin soft tissue with an adequate amount of
keratinized attached gingiva, along with good oral
hygiene, ensures healthier peri-implant soft tissues
and better clinical results
105

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.
106

Simple circular “punch” incision
 In areas with sufficient zones of keratinized tissue, the
gingiva covering the head of the implant can be exposed
with a circular or “punch” incision
 Alternatively, a crestal incision through the middle of the
keratinized tissue and full-thickness flap reflection can be
used to expose implants.
 This latter approach may be necessary when bone has
grown over the implant and needs to be removed.
107

Clinical view of stage two, implant exposure surgery in a case with adequate
keratinized tissue.
A, Simple circular “punch” incision used to expose implant when
sufficient keratinized tissue is present around the implant(s).
B, Implant exposed.
C, Healing abutment attached.
D, Final restoration in place, achieving an esthetic result with a good
zone of keratinized tissue. 108

Clinical v iew of stage two implant exposure surgery in a case with inadequate
keratinized tissue.
A, Two endosseous implants were placed 4 months previously and are ready to be
exposed.
B, Two vertical incisions are connected by crestal incision.
C, Buccal partial thickness flap is sutured to the periosteum apical to the emerging
implants.
D, Gingival tissue coronal to the cover screws is excised using the
gingivectomy technique.
E, Cover screws are removed, and heads of the implants are cleared.
F, Abutments are placed. Visual inspection ensures intimate contact between the
abutments and the implants.
109

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.
110

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.
111

 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.
112

One stage “non-submerged”
implant placement
113

 In the one-stage implant surgical approach, a second
implant exposure surgery is not needed because the
implant is exposed (per gingival) from the time of
implant placement
 In the standard (classic) implant protocol, the
implants are left unloaded and undisturbed for a
period similar to that for implants placed in the two-
stage approach
 (i.e., in areas with dense cortical bone and good initial
implant support, the implants are left to heal
undisturbed for a period of 2 to 4 months,
 whereas in areas of loose trabecular bone, grafted sites,
and/or minimal implant support, they may be allowed
to heal for periods of 4 to 6 months or more).
114

 In the one-stage surgical approach, the implant or the
healing abutment protrudes about 2 to 3 mm from the
bone crest, and the flaps are adapted around the
implant/abutment.
115

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.
116

 The primary difference is that the coronal aspect of the
implant or the healing abutment (two-stage implant)
is placed about 2 to 3 mm above the bone crest and the
soft tissues are approximated around the
implant/implant abutment.
117

Flap closure and suturing
 The keratinized edges of the flap are sutured with
single interrupted sutures around the implant.
 Depending on the clinician's preference, the wound
may be sutured with resorbable or nonresorbable
sutures.
 When keratinized tissue is abundant, scalloping
around the implant(s) provides better flap adaptation.
 However, if minimal keratinized tissue exists in an
area, tissues should remain thick and soft tissue
augmentation may be indicated.
118

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).
119

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.
120

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