Part 3 Surgical Phase 26/11/2015 LIMU Dr. Rafik M. Alkowafi 109 - PDF document

5/20/2016 Part 3 Surgical Phase 26/11/2015 LIMU Dr. Rafik M. Alkowafi 109 Basic factors in implant surgery • After planning, the surgical execution of implant placement is the next critical procedure in attaining successful osseointegrated implants. The most important factors to control in implant surgery are as follows: 1. A sterile technique avoiding contamination of the implant surface. 2. Avoiding damage to the bone by thermal injury during the drilling process. 3. Carefully preparing the bone site so that the implant is stable at placement (Primary stability). 4. Placing the implant in an aesthetically and functionally acceptable position. 5. Avoiding excessive loading in the healing period. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 110 1

5/20/2016 Basic factors in implant surgery • Poor control of these factors can lead to failure of osseointegration, which may be manifested subsequently as: 1. Infection at the implant site. 2. Implant mobility or the implant may be rotated when attempting to detach or attach a component. 3. Pain from inflammation in the bone surrounding the implant. 4. A radiolucent space surrounding the implant, which is consistent with fibrous encapsulation. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 111 Basic factors in implant surgery • Avoiding damage to the bone by thermal injury during the drilling process. This is avoided by: 1. careful cooling of the bone and drills with copious sterile saline (internal or/and external). 2. Use of sharp drills. 3. Control of the cutting speed. 4. Periodic withdrawal of the drill to allow bone cuttings to be cleared from the drill flutes. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 112 2

5/20/2016 Basic factors in implant surgery • Ensuring good initial stability (Primary stability) of the implant. This can be judged by: 1. Simple clinical evaluation (dependent on operator experience). 2. Torque insertion forces — these can be set on the drilling unit and are usually between 10 and 50 Ncm. Some units record the torque and provide a print out. 3. Periotest values — the mobility can be measured with an electronic instrument that was originally designed to measure tooth mobility. 4. Resonance frequency analysis — this device measures the stiffness of the implant within the bone through electronic vibration and recording. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 113 Basic factors in implant surgery • Initial stability of the implant depends on the following: 1. Length of the implant. 2. Diameter of the implant. 3. Design of the implant. 4. Surface configuration of the implant. 5. Thickness of the bone cortex and how many cortices the implant engages. 6. Density of the medullary bone trabeculation. 7. Dimensions of the preparation site compared with that of the implant. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 114 3

5/20/2016 Basic factors in implant surgery • Preoperative care, anaesthesia and analgesia: 1. Antiseptic rinsing of the oral cavity. Chlorhexidine gluconate (2% or 1.2% proprietary rinses for 1 minute) is recommended. 2. Administration of analgesics. Oral analgesics (ibuprofen 200 mg or 400 mg or paracetamol 1 g) are usually sufficient. Control of pain is more effective if analgesics are given prior to surgery . 3. Administration of antibiotics (e.g., multiple implants where bone is exposed for long periods or grafting is carried out), the clinician could use a standard protocol (e.g., amoxicillin 0.5 to 1 g preoperatively followed by a 5-day course). 26/11/2015 LIMU Dr. Rafik M. Alkowafi 115 Basic factors in implant surgery • Basic postoperative care: 1. Patients should be prescribed appropriate analgesics, antibiotics if indicated, and a chlorhexidine mouthrinse. 2. They should be advised to use ice packs to reduce swelling and bruising. 3. Pain should not be severe. Pain should not arise from the bone because this would indicate poor technique and damage possibly leading to failure. 4. Surgery close to the inferior dental nerve may result in transient altered sensation and the patient should be made aware of this possibility. 5. In many cases patients are advised not to wear their removable dentures for one to two weeks to avoid pressure on the wound and implants. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 116 4

5/20/2016 Surgical techniques (Basic) • Surgical Armamentarium 1. Anesthesia: syringes and cartridges of anesthetic 2. Retractors: for cheeks, tongue, and soft tissue 3. Incision: scalpels and blades 4. Exodontia: peritomes, elevators, and forceps 5. Bone modification: rongeurs, burs, bone files, chisels, and mallet 6. Osteotomy development: implant drills, motors, handpieces, and osteotomes 7. Soft tissue manipulation: scissors and tissue forceps 8. Suturing: sutures, needle holders, scissors, and tissue forceps 9. Irrigation: syringes and solution 10. Suction: Suction tips 11. Miscellaneous: bowls, mouth props, gauze, tile clips 26/11/2015 LIMU Dr. Rafik M. Alkowafi 117 Surgical preparation • Preparation for implant surgery requires a thorough review of the patient’s chart including: – Medical and dental histories, operatory notes, radiographs, anticipated implant sizes and locations, surgical guides, surgical sequencing and strategy, possible complications. • Once the patient has been draped in a sterile fashion and the surgical team has been gloved and gowned, the patient is anesthetized. • In many cases, the implants can be placed using local anesthetic block or infiltration techniques. However, in more complex and lengthy procedures, some type of sedation or general anesthesia may be preferred 26/11/2015 LIMU Dr. Rafik M. Alkowafi 118 5

5/20/2016 Implant site exposure • Exposure of the implant site can be accomplished in several ways, including: 1. Flapless surgery. 2. Tissue elevation (flap) that may include. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 119 Implant site exposure 1. Flapless surgery: • Indicated when there is adequate keratinized tissue over an ideal ridge form. • flapless surgery, the implant and the healing or provisional restoration are placed in a single stage. • • Advantages: Disadvantages: 1. Minimal incision and less 1. Lack of surgical visibility especially trauma near vital structures. 2. Patient comfort 2. Greater learning curve. 3. Less bone resorption 3. Limited irrigation to osteotomy. 4. Allows for immediate loading 4. Limited hard/soft tissue manipulation. 5. Improved esthetics 6. Decreased surgical time 7. Patient perception of “minimally invasive surgery 26/11/2015 LIMU Dr. Rafik M. Alkowafi 120 6

5/20/2016 Flapless surgery Flapless surgery. A, Preoperative view. B, Tissue is excised in the exact diameter of the implant to be placed using a tissue punch. C, Tissue removed. D, Implant placement 26/11/2015 LIMU Dr. Rafik M. Alkowafi 121 Implant site exposure 2. Tissue elevation (flap): – The flap should be designed to allow convenient retraction of soft tissue for unimpeded access for implant placement. This is usually necessary when better access and visualization of the underlying bone is necessary and when additional procedures such as bone or soft tissue grafting are done at the time of implant placement. – Types: a. Sulcular incision. b. Mid-crestal incision c. Vertical-releasing incisions ( two sided or 3 sided flap). 26/11/2015 LIMU Dr. Rafik M. Alkowafi 122 7

5/20/2016 Implant site exposure A and B, Papilla-sparing, mid-crestal incision, conservative release. C, Incision with more generous anterior releasing incision . D, Mesial- and distal-releasing incision providing more generous exposure 26/11/2015 LIMU Dr. Rafik M. Alkowafi 123 Implant site exposure • Mid-crestal incision: The incision should be made through the keratinized tissue, In areas with a narrow zone of keratinized tissue, • If sulcular incisions are necessary, great care is taken to follow the contour of the sulcus so as not to damage the soft tissue architecture. • Vertical-releasing incision: Using a sharp #15 blade, a curvilinear, papilla sparring incision should be made to reduce or eliminate incision scarring. • It must be ensured that the vertical-releasing incision is extended apically enough to allow complete release of the flap. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 124 8

5/20/2016 Implant placement 1. Flap reflection. 2. Flap retraction , When the buccal flap has been reflected completely, a retractor can be positioned against the bone inside the flap. This allows good visualization of the operative site while protecting the integrity of the flap. 3. Preparing the osteotomy, The surgeon must confirm that the handpiece and motor are functioning properly: the speed setting on the motor should be checked; it must be confirmed that the drill is spinning in the forward mode. The torque is about 15 Ncm and the speed should be set at 800 to 1200 revolutions per minute (rpm) for the precision and pilot drills. All drills, including osteotomy drills, should be copiously irrigated , internally, externally, or both, when preparing the bone. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 125 Implant placement A and B, Initial marking or preparation of the implant site with a round bur. C and D, Use of a 2-mm twist drill to establish depth and align the implant. 26/11/2015 LIMU Dr. Rafik M. Alkowafi 126 9