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One stage “non-submerged” implant
placement
Flap designs, incisions and elevation
Implant site preparation
Flap closure and suturing
Postoperative care
Conclusion
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Patient preparation
Implant site
preparation
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1. Explanation of risks and benefits to the
patient.
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1. Implants must be sterile and made of a biocompatible material
(e.g., titanium).
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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.
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1. Good operating light
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
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9. The surgical stent
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In the one-stage approach,
the implant or the
abutment emerges
through the
mucoperiosteum/gingival
tissue at the time of
implant placement.
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Easier Mucogingival management around
the implant.
Patient management is simplified because
a second stage exposure surgery is not
necessary.
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In the two-stage approach, the top of the
implant and cover screw are completely
covered with the flap closure.
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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.
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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.
Longer periods –
less dense bone
Less initial implant stability
Shorter periods –
More dense bone
Altered surface microtopography
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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.
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Flap design, incisions, and elevation
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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.
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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.
D, Tissue approximation to
achieve primary flap closure
without tension
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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.
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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.
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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.
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As the final step in preparing the osteotomy site
in dense cortical bone, a tapping procedure may
be necessary.
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In partially edentulous cases, limited jaw opening or proximity
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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.
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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.
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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
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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.
Once the periosteum is released, the flap becomes very elastic and
is able to be stretched over the implant(s) without tension.
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One suturing technique that consistently provides the
desired result is a combination of alternating
horizontal mattress and interrupted sutures.
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Simple implant surgery in a healthy patient usually
does not require antibiotic therapy.
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This is particularly true when the periosteum has been
incised (released).
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For implants placed using a two-stage
“submerged” protocol, a second-stage
exposure surgery is necessary after the
prescribed healing period.
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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.
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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.
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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. 55
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.
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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.
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If a minimal zone of keratinized tissue exists
at the implant site, a partial-thickness flap
technique can be used to fulfill the objective
of the second-stage surgery (exposing the
implant) while increasing the width of
keratinized tissue.
A partial-thickness flap is then raised in such
a manner that a nonmobile, firm periosteum
remains attached to the underlying bone. The
flap, containing a narrow band of keratinized
tissue, is then repositioned to the facial side
of the emerging head of the implant and
sutured to the periosteum with a fine needle
and resorbable suture such as a 5.0 gut
suture
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A partial-thickness flap is apically
displaced and sutured to the periosteum
without exposing the alveolar bone.
A free gingival graft may be harvested
from the palate and sutured to the
periosteum on the labial surface of the
implants to increase the zone of
keratinized tissue.
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A, Partial-thickness f lap is created from the lingual aspect of the
crest toward the labial surf ace in order to preserve the keratinized
tissue on the crest (over the implant). note: This tissue might be
excised in a simple implant exposure.
Finally , the remaining connectiv e tissue over the cover screw (B) is
excised with a sharp blade to expose the implant. Care should be
taken to avoid removing keratinized tissue from the lingual aspect of
the implant.
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After the flap is repositioned and secured
with periosteal sutures, the excess tissue
coronal to the cover screw is excised, usually
with a surgical blade.
When the excess tissue over the cover screw
is removed or displaced, the outline of the
cover screw is visible.
A sharp blade is used to eliminate all tissues
coronal to the cover screw.
The cover screw is then removed, the head of
the implant is thoroughly cleaned of any soft
or hard tissue overgrowth, and the healing
abutments or standard abutments are placed
on the implant
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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.
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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.
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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).
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Inthe 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.
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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.
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Theprimary 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.
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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.
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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).
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Itis 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.
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Newman, Takei, Klokkevold, Carranza.
Carranza’s Clinical Periodontology, 10th
Edition and 11th Edition
Lindhe, Lang, Karring. Clinical
Periodontology & Implant Dentistry, 5th
Edition.
Carle E. Misch. Contemporary Implant
Dentistry. 3rd edition.
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