Surgical Procedure

The pre-surgical checklist is to aid the surgeon and staff in preparation of the implant surgery. It should facilitate the procedure to be performed in an orderly, smooth, and safe manner.

  • Radiographs/Computerized images
  • Mounted study cast
  • Surgical stents
  • Medical clearance/Health history review
  • Consent form signed
  • Treatment plan/Agreement among all Team Members
  • Alternate treatment plans
  • Financial arrangements
  • Medications
  • Pre- and Post- operative instructions
  • Implants ordered and received
  • Communication with the patient about the procedure
  • Follow-up appointment for suture removal

SURGICAL STENT GUIDE

The surgical stent is recommended to aid the surgeon in proper implant placement. Surgical stents with teeth forms with their cemento-enamel junctions defined by the template are recommended as a positional guide for implant placement so ideal mesio-distal, bucco-lingual and long axis orientation of the implant(s) can be determined. These stents are important for the best emergence profile and proper axial directed loading forces. The surgical stent (template) is also used to determine the need for grafting for better implant placement.

In the event a lack of available bone and/or anatomical structures that may prevent ideal placement, secondary sites may be chosen, or implants may be placed in other locations predetermined to achieve the alternate treatment plan. Guided by the surgical stent, the surgeon may determine the required number, location or axial orientation of the implants to successfully complete the prosthetic reconstruction dictated by the treatment plan(s) and may elect to place no implants. To fabricate the surgical stent, the implant laboratory may assist the surgical and the restorative dentist as well as providing suggestions.

POST-OPERATIVE CARE

  • Educate patients on post-operative care
  • Review with patient the healing time required based upon the procedure
  • Be available for post-operative care
  • Prescribe the needed post-operative medications
  • Schedule post-operative visits for suture removal and evaluation

Instruct the patient to follow a post-surgery regimen including cold packs for the initial 24 hours. An antibiotic of choice may be prescribed. Sutures may be removed after ten days. In cases where a prosthetic appliance is to be worn during the healing phase, the prosthesis is relieved and relined with a soft liner to prevent premature loading and micro movement of the implants. Patients should be recalled in ten days to evaluate soft tissue health, to review the condition of the reline materials, and to confirm that the implants are not being loaded by the prosthesis.

Hand outs for Patient Care

Pre-Operative Instructions
Post-Operative Instructions

Buccal view of missing mandibular right 2nd premolar area.

Mid-crestal incision with full mucoperiosteal flap reflection exposing the alveolar crestal bone. Smooth the bone ridge crest as needed.

At the predetermined implant site, use a number eight round bur to notch the cortical bone.

Place the 2mm pilot drill into the notched area of bone and drill to the predetermined depth.

After selecting the proper diameter and length of the implant drill, complete the osteotomy to the predetermined depth.

Thread-tap the recipient implant site with the corresponding thread former, if needed.

Remove healing cap from implant carrier with .050 hex wrench and set aside. Insert the implant into the recipient site with the pre-loaded implant carrier and tighten with hand pressure.

Remove the implant carrier and insert the implant driver to take the implant to the final depth. The implant is seated when the apical portion of the implant neck is flush with the crestal bone.

The nut must be unlocked to set flush with the top of the implant. Note: when healing cap is in locked position it will not seat. Turn healing cap 1-2 turns counterclockwise with .050 hex wrench to unlock.

Place the cap into the top of the implant until the healing cap is level with the top of the implant. Tighten the cap with hand pressure.

Suture the gingival tissue around the implant neck with 4-0 plain gut suture. The top of the implant should be flush with the gingival tissue. The implant may also be completely submerged below the soft tissue if desired. It is the clinician's choice.
Adjust provisional prostheses as needed and provide the necessary post-op instructions and medications.

Surgical Procedure

  1. Site identification with surgical stent and administer anesthetic.
  2. Isolate and clean the surgical area.
  3. Mid-crestal incision with full mucoperiosteal flap reflection exposing the alveolar crestal bone; smooth the bone ridge crest as needed. (Locate and note vital structures e.g. nerves, sinus, etc.)(Figures 1 & 2)
  4. At the predetermined implant site, use a number eight round bur to notch the cortical bone. (Figure 3)
  5. Place the 2mm pilot drill into the notched area of bone and drill to the determined depth. (Figure 4)
  6. Place color coded spacing pins to verify proper implant diameter, location and distance between the implants and teeth. Adjust the implant location and size as needed (1 1/2 mm of bone is needed between tooth and implant; 3mm between implant and implant; and 2mm of bone on buccal and lingual areas.)
  7. After determining the proper diameter and length of the implant drill, complete the osteotomy with the implant drill to the predetermined depth. (Figure 5)
  8. Thread-tap the recipient implant site with the corresponding bone tap, if needed. (Figure 6)
  9. Insert the implant into the recipient site with the pre-loaded implant carrier and tighten with hand pressure. (Figure 7)
  10. Remove the implant carrier and insert the implant driver to take the implant to the final depth. The implant is seated until the apical rim of the implant neck is flush with the crestal bone. (Figure 8)
  11. Insert the healing cap into the top of the implant until it is level with the top of the implant. Tighten the healing cap with hand pressure. NOTE: When the healing cap is in the locked position it will not seat. Turn healing cap 1-2 turns counterclockwise with the .050 hex wrench to unlock. (Figures 9 & 10)
  12. Suture the gingival tissue around the implant neck with 4-0 plain gut suture. The top of the implant should be flush with the gingival tissue. If needed, a gingival-plasty procedure may be required to remove teh excess gingival tissue. The implant may also be completely submerged below the soft tissue if using a 2-stage procedure. it is the clinician's choice. (Figure 11)
  13. Adjust provisional prosthesis as needed to prevent premature loading and tissue trauma during healing.
  14. Provide written post-op instructions and the necessary post operative medications.
PRINT VIEW

Drilling Techniques
The internally irrigated tooling requires a specific technique to prevent the irrigation holes from becoming plugged with bone. When drilling with the rosette drill, pilot drills, and depth drills, use an in-and-out motion. Drill in the bone, then move the drill up and out of the bone, without stopping the handpiece motor, to allow the irrigation to wash away bone chips. Proceed with this method until the desired depth reference line is reached. Should a drill become plugged, remove the drill from the handpiece and clear the irrigation hole utilizing A 22-gauge needle. Maximum recommended drill speed varies, depending on bone density. Thread tap the bone at a maximum speed of 50 rpm.

1. 8 Round Bur
Notch the crest of the bone with an 8 round bur at the implant site. Copious external irrigation should be used during this procedure. The 8 round bur is especially helpful when drilling in dense bone.

2. 2 mm Diameter Pilot Drill
Drill to the appropriate depth reference line with the 2 mm diameter pilot drill. Check orientation of the osteotomy using a parallel pin. When placing more than one implant, place a parallel pin into the completed pilot hole and proceed to the next implant site. Align the pilot drill parallel to the previous pin when available bone permits and drill the next hole. A radiograph may be taken with the pilot drill in place to analyze the location of the drill relative to available bone.

3. Implant Drill for Osteotomy
Select appropriate drill diameter and length to enlarge implant site.

4. Thread Former Drill
Place the tip of the thread former into the drilled implant site. Apply firm pressure and begin rotating the thread former slowly (50 rpm maximum). When the threads engage, allow the thread former to feed without pressure. Thread the osteotomy to the desired depth reference line. Irrigate the site with sterile water or sterile saline and suction to remove any tissue and bone debris that may be left from the drilling procedure. Switch the handpiece to the reverse mode and back the thread former out. Do not pull on the thread former. If desired, the implant site may be threaded by hand by attaching the ratchet assembly to the thread former. If larger implants are to placed, perform the same drilling procedure with the proper implant diameter.

Implant Placement
Remove the implant and carrier from the sterile package. Be careful not to touch the implant. Screw the implant into the prepared site using the implant carrier until the threads engage the bone on the implant. If the implant does not seat to the desired level, remove the implant, place it in a sterile ceramic dish, drill, and thread form to the desired depth by repeating steps 3 and 4 above. Reinsert the implant into the osteotomy. Place the neck portion of the PerioSeal Implant at bone crest. Proper placement of the implant relative to the soft tissue crest will ensure better esthetics and simplicity for restorative procedures.

Healing Cap
Empty the healing cap from the carrier onto a sterile field. Suction implant area to remove any blood left inside the implant. Insert the .050 hex driver into the socket of the healing cap and lock it into place in the implant. To minimize the potential for infection, the clinician may elect to dip the healing screw threads into antibiotic ointment prior to placing it into the implant.

Closure
Close and suture the tissue flap using desired technique. A radiographic check of implant position should be taken at this time for a base line.

In spite of the pre-plan desired result prior to Stage I surgery, treatment-planning options must be reassessed after implant integration or at 2nd Stage surgery and prior to the restorative phase. Proper soft tissue management often dictates the success of the restoration and the final esthetic result. Surgical procedures utilizing guided soft tissue healing (repositioned flap, gingival grafts, gingival augmentation and gingival contouring) must be considered after implant integration. Following the integration period, uncover the implant healing cap, if the cap has not self exposed. The location can be determined by palpation of the soft tissue or sounding with a periodontal probe. To surgically expose the healing cap, use either a tissue punch or a scalpel, taking care to preserve an adequate amount of attached keratinized gingiva. Remove the healing cap.

Note: It is absolutely imperative that all bone and soft tissue be removed from the coronal aspect of the implant body to guarantee complete seating of the abutments. The presence of soft tissue, bone fragments, or debris between the implant and abutment can lead to incomplete abutment seating. During the surgical uncovering, do not use a bur or drilling instruments, as they may compromise the implant-abutment junction. To verify proper abutment seating, a periapical x-ray should be taken to evaluate the abutment-implant interface. Any noticeable gap is indicative of improper seating and the abutment should be removed. The entrapped tissue or debris is removed, if present, and the abutment connection repeated and confirmed with a new radiograph. Suturing may be required to adapt the soft tissue around the abutment or the implant neck. The prosthetic margin on the neck of the implant should be 1-2mm apical to the soft tissue level. A provisional restoration may be placed at the second stage appointment. A tissue retraction abutment may also be utilized to prevent the soft tissue covering the top of the implant during the prosthetic construction. The final restoration may placed after soft tissues have matured (6-8 weeks).

  • Educate patients on post-operative care
  • Review with patient the healing time required based upon the procedure
  • Be available for post-operative care
  • Prescribe the needed post-operative medications
  • Schedule post-operative visits for suture removal and evaluation

Instruct the patient to follow a post-surgery regimen including cold packs for the initial 24 hours. An antibiotic of choice may be prescribed. Sutures may be removed after ten days. In cases where a prosthetic appliance is to be worn during the healing phase, the prosthesis is relieved and relined with a soft liner to prevent premature loading and micro movement of the implants. Patients should be recalled in ten days to evaluate soft tissue health, to review the condition of the reline materials, and to confirm that the implants are not being loaded by the prosthesis.

Hand outs for Patient Care

Pre-Operative Instructions
Post-Operative Instructions

Suggested Armamentarium

Personal Attire
Caps
Masks
Scrub Suit
Shoe covers

Room Equipment
Dental chair or operating table
Mayo stand
Instrument table
Suction equipment
Overhead or surgical head light
Oxygen and nasal cannula
Patient monitoring equipment

Supplies Necessary in Operatory
Implant installation (kit)
Drilling equipment (handpiece)
Instruments for flap dissection
Antiseptic solution
Anesthesia carpules
Sterile water
Suture material
Selection of implants
IV supplies (if needed)

Surgical Pack or Supplies
Table cover
Mayo stand cover
Flat sheet
Adhesive towels
Split sheet to drape patient
Head drape
Surgical gowns and hand towels Surgical gloves
Cassette cover
Pack 1” steri strips
Suction tubings
Suction tips
4 x 4’s
#15 Scalpel blades

Instruments
Scalpel holders
Dental mirrors
Explorer
Probe
Narrow periosteal elevators
Wide periosteal elevators
Variety of lip and check retractors
Bone curette - small
Small bone rasp
Tissue forceps with teeth
Tissue forceps without teeth
Suture scissors
Dissecting scissors
Dental syringe
Surgical marker
Bone burs

Miscellaneous
Necessary x-rays
Study models (mounted)
Surgical stent
mm ruler
Periodontal dressing
Bone grafting materials
Membrane barriers