SURGERY FOR TWO STAGE IMPLANT SYSTEM IN ANTERIOR.ppt03.pptx

DR. R. PRIYA DARSHINI
DEPARTMENT OF
PROSTHODONTICS
SURGICAL GUIDELINES FOR
DENTAL IMPLANT PLACEMENT

CONTENTS
 Introduction
 Surgical Requirements
 Surgical Template
 Prophylactic Antibiotics
 Local Anesthesia
 Incision
 Surgical procedures
 Surgical approach – based
 Post operative instructions
 Conclusion
 references

INTRODUCTION
 Successful implant surgery -
dependent upon good treatment planning and
meticulous technique.
 Requires appreciation of the prosthetic or
restorative requirements and visualization of
desired end result of treatment.

SURGICAL
REQUIREMENTS
 Good operating light and high volume suction
 Dental chair adjusted by foot controls or by a third party
 Surgical drilling unit with high (3000 rpm) and low (10
rpm) speed with good control of torque.
 Internal or external irrigating system so as to avoid or
decrease the heat generated while osteotomy
preparation
 Surgical instrumentation
 Sterile drapes gowns, gloves, suction tubing.
Richard Palmer; Basic Implant Surgery, British Dental Journal,
Vol 187, No.8, 1999

 Appropriate number and design of implants
planned
 Surgical stent.
 Complete radiographs including tomographs
 A trained assistant
 A third person to act as runner between sterile
and non-sterile environment.
SURGICAL
REQUIREMENTS
Vol 187, No.8, 1999

DEFINITIONS
 SURGICAL TEMPLATE :
 A thin, transparent form duplicating the tissue
surface of a dental prosthesis and used as a guide
for surgically shaping the alveolar process
 A guide used to assist in proper surgical
placement and angulation of dental implants.
[ GPT – 8 ]

SURGICAL TEMPLATE
 The surgical template dictates to the surgeon
the implant body placement that offers the
best combination of
(1) Support for the repetitive forces of
occlusion
(2) Esthetics
(3) Hygiene requirements
- Carl . E . Misch, Contemporary implant dentistry, 3rd
edition
- Robert Weinkelman; Dental Implants, Fundamentals And
Advanced Laboratory Technology

PURPOSE OF SURGICAL
TEMPLATE
 Provide information regarding implant fixture sites
and desired angulations.
 Provides optimal implant placement.
Carl . E . Misch, Contemporary implant dentistry, 3rd
edition

REQUIREMENTS OF SURGICAL
TEMPLATE
 The template should be stable and rigid when in correct
position. If the arch treated has remaining teeth, the
template should fit over and/or around enough teeth to
stabilize it in position.
 When no remaining teeth are present, the template should
extend onto unreflected soft tissue regions (i.e., the palate
and tuberosities in the maxilla or the retromolar pads in the
mandible). In this way, the template may be used after the
soft tissues have been reflected from the implant site.
- Carl . E . Misch, Contemporary implant dentistry, 3rd
edition
- Robert Weinkelman; Dental Implants, Fundamentals And

 The distance between two points located respectively on
the occlusal surface (central fossa or incisal edge) of the
planned abutment crown and the crest of the ridge
represents about 8 mm. As a result, these two points of
reference can be joined by a line that represents the path
of ideal implant insertion.
 The ideal angulation is perpendicular to the occlusal
plane and parallel to the most anterior abutment (natural
or implant) joined to the implant.
REQUIREMENTS
edition

 Other ideal requirements of the surgical template
include
 size, surgical asepsis, transparency, and the ability to
revise the template as indicated.
 The template should not be bulky and difficult to insert or
obscure surrounding surgical landmarks.
 The surgical template must not contaminate a surgical
field during bone grafts or implant placement.
 It should be transparent. In this way, the bony ridge and
drills can be observed more easily when the template is in
place.
 The surgical template should relate the ideal facial
contour.
REQUIREMENTS
edition

FABRICATION OF
TEMPLATE
 Make two alginate impressions of both upper and lower
dental arches.
 Mount the diagnostic/study casts on a semi-adjustable
articulator .
 Complete a diagnostic wax-up of the prosthetic
restoration according to occlusal condition
 Make a silicone matrix of the diagnostic wax-up and trim
from the most coronal portion to the occlusal surface of
the teeth.
 Remove the teeth, place the silicone matrix, and mark
with pencil the emergence profile and the ideal loading
center
Susanna Annibali; The Role Of Template In Prosthetically Guided
Implantology, Journal Of Prosthodontics, 18 (2009) 177-183

 Place the diagnostic cast on a dental surveyor.
Using a drill, make a hole for each implant site
placed at the center of the tooth profile
 Place a cylindrical marker on the drill rod
inserted in the hole. Stainless steel or titanium
cylinders should be used with a minimum
thickness. They should be suitably shaped and
sized in order to keep the correct inclination of
the drill in the surgical phase, with a diameter
of 0.1/0.2 mm in excess of the pilot drill of the
implant system used and at least 7-mm length.
FABRICATION OF
TEMPLATE

 The cylindrical markers are first fixed with
sticky wax. They are finally blocked-out using
acrylic resin which is also used to construct
extensions on the residual denture and/or
the mucosa.
 The template is trimmed and smoothed. The
occlusion is checked on the semi-adjustable
articulator.
 The template is fitted in the patient’s mouth
to ensure that it is comfortable and stable.
FABRICATION OF
TEMPLATE

RADIOGRAPHIC
TEMPLATE
 Presurgical diagnostic information
 A metal ball bearing is used.
 Actual ball size is compared to the ball size
in the radiograph.
 Size difference between the 2 balls is used
to calculate the ratio which is equivalent to
the distortion factor in the radiograph.
Robert Weinkelman; Dental
Implants, Fundamentals And

BONE MAPPING
 Assessment of the soft tissue width in
edentulous regions.
 The two-dimensional slide-caliper method
(Mainzmodel, modified by Lill)
 The mucosal width is measured by using one
measuring point that can be moved vertically and
two measuring points that are slid horizontally.
 The mucosal width can be read from a millimeter
scale near the handle of the caliper.

 Advantages.
 simple and allow rapid evaluation of the width of
the soft tissues above the proposed implant host
site.
 Disadvantages.
 they require local anesthesia, which can be a strain
on the patient and may distort the measurements
because of expansion of the tissues due to
anesthetic solution.
 In the maxilla, measuring errors can also be due to
the fact that the sharp needles may penetrate the
thin bone (Traxler et al, 1992)

ANTIMICROBIAL
THERAPY
 Prophylactic antibiotics
 Main goal – to prevent infection during initial
healing period from the surgical wound site, thus
decreasing the risk of infectious complications of
soft and hard tissues.
 Antibiotic chosen should for prophylaxis should
encompass the bacteria most known to be
responsible for type of infection found with surgical
procedure.
edition c

ANTIMICROBIAL
THERAPY
 Antibiotics – twice the therapeutic dose and atleast 1 hour
before the surgery. e.g., Amoxicillin –
TD – usual adult dose - 250-500 mg TID maximum
adult dose – 4g/day PD – 2g I hr before surgery.
 If allergic, Cephalexin – 2g 1hr before Clindamycin –
600mg 1hr before
 For sinus involvement procedures Augmentin
(Amoxicillin/Clavulinic acid) -825mg Lavaquin
(Levofloxacin) – 500mg
 NSAIDs - 400 mg 1 hour before surgery.

 0.1% chlorhexidine mouth wash
 Benefits of chlorhexidine as antiseptic in oral
implantology-
 Presurgical rinse : used in aseptic protocol before
surgery for reduction of bacterial load.
 Surface antiseptic : intra and extra oral scrub of
patient, scrubbing of hands before gowns and gloves.
 Post surgical rinse : twice daily untill closure of
incision line.
 Peri – implant maintenance on daily basis
 Treatment of postoperative infections
ANTIMICROBIAL
THERAPY
edition

PREPARATION OF THE PATIENT
 Extraoral scrubbing with iodine, povidine iodine
(betadine) or 0.1% chlorhexidine gluconate – by
scrubbed assistant
 Intraoral – rinsing of chlorhexidine mouthwash
(antimicrobial mouthrinses can be used, as they reduce
bacterial count in the saliva for more than 4 hrs.)
 Patients drapes positioned.
 Surgical gloves – rinsed and wiped with sterile saline to
remove any powder or contaminant that may
inadvertently transmitted on to the implant surface
during subsequent surgery.
edition

ANESTHESIA
 Most implant surgeries can be carried under local
anesthesia
 E.g .,2% lidocaine (1:100000 epinephrine)
maximum dosage of 7mg/kg.
 Short cases like which take < 1hr for placement
or placement of 1-2 implants can be done under
infiltration anesthesia.
Vol 187, No.8, 1999

ANESTHESIA
 Complex cases which take 2-3 hrs it is essential to
use regional block anesthesia and to supplement
this during procedure, local infiltrations are
administered as they improve anesthesia and
control haemorrhage.
 General anesthesia or sedation is recommended
for surgeries of long duration e.g., more than 90
min.
 Analgesics such as ibuprofen or paracetmol,
immediately prior to surgery.

ANESTHESIA
 Infiltrative anesthesia – rather than inferior alveolar nerve block.
 Periosteal tissues anesthetized to provide patient discomfort
during surgery. Endosteal portion of bone doesn’t have sensory
innervation.
 If drill gets close to the neurovascular bundle, the patient will feel
discomfort and can alert surgeon
 Avoids inadvertent trauma and permanent sensory impairment
to the inferior alveolar nerve
 Anesthetic sol is infiltrated lingually, labially, as well as directly
over the alveolar crest.
 LA is placed in a subperiosteal plane to perform a hydropic
dissection of tissues, allowing for bloodless and efficient
reflection of the tissues
1) Colour atlas of dental implant surgery; Michael S. Block
2) Atlas of oral implantology;A. Norman Cranin

INCISIONS
 Irrespective of the applied technique, the surgical access
must provide for –
 Optimal visualization of the surgical area
 Problem free expansion of soft tissue
 Mobilization of the overlying soft tissue to cover the surgical
field
 No placement over bony defects or cavities
 Sufficient vascularisation of soft tissue
 Minimum tissue damage
 Assured wound healing
 Minimum esthetic impairment and good tissue covering
Kleinheinz et al , incision design in implant dentistry based on
vascularization of mucosa; clin. Oral impl. Res. 16, 2005/518-523

MUCOBUCCAL INCISION
 Branemark protocol for implant placement – mucosal
incision to be made in the mucobuccal fold.
 Advantages –
 Epithelial margins kept away from implant.
 Implant completely covered, away from suture line after
implant placement.
 Disadvantages –
 Pain and edema frequently associated with an incision in the
alveolar mucosa
 Buccal tissues are severed from their principal blood supply and
must rely on collateral circulation from palatal and lingual base
of flap.
David R. Scharf ; effect of crestal versus mucobuccal incisions on
the success rate of implant osseointegration, Int J Oral Maxillofac
Implants, 1993, 8, 187-190

CRESTAL INCISION
 Incision made in the keratinized gingiva from the crest of the
soft tissue ridge through to the underlying bone. Buccal and
lingual full thickness flaps are then elevated to expose the
underlying ridge.
 Advantages
 Less edema and discomfort. Alveolar mucosa contains
elastic fibers that contract during healing, creating tension on
the sutures. But, keratinized gingiva contains no elastic fibers.
 No compromise of blood supply to the flaps with a crestal
incision.
 Full thickness incision is faster and simpler to make than a
split thickness dissection in the fold, and suture are simpler
to place and remove.
David R. Scharf ; effect of crestal versus mucobuccal incisions on
the success rate of implant osseointegration, Int J Oral Maxillofac
Implants, 1993, 8, 187-190

CRESTAL INCISION
 Avascular zone in the crestal area of edentulous
alveolar ridge described in 3 main vascularization
characteristics
 Main course of supplying arteries is from posterior to
anterior
 These vessels run parallel to alveolar ridge in the
vestibulum most of the times, only gingival branches
stretch to the alveolar ridge.
 Crestal area of the edentulous alveolar ridge covered by
1-2mm wide avascular zone with no anastomoses
crossing the alveolar ridge.

CRESTAL INCISION
 Mid crestal incision – ideal choice for edentulous
area of the planned implantation.
 Making the cut in the area of avascular zone
prevents the risk of cutting through the
anastomoses or cutting out avascular areas of
the mucosa.

FLAP DESIGN IN AESTHETIC
ZONE
A normal incisor space with a midcrestal
incision. The vertical relieving incisions on
sound bone are flared at their apical extent.
The relieving incisions extend a short
distance into the palatal mucosa to allow
adequate elevation.
An incision on the crest of the
edentulous ridge is extended in the
gingival crevices of the adjacent
teeth to allow adequate exposure of
the ridge.
Implants in Clinical Dentistry; Richard M Palmer

A midcrestal incision leaving papillae in
situ.
The oblique relieving incisions do not
pass over the adjacent root surfaces.
oblique relieving incisions - avoided over
prominent root surfaces because
recession may result if there is an
underlying bony dehiscence.
A broad base to the flap is not necessary
for survival because the blood supply
and nutrient bed for mucosal flaps are
excellent

If augmentation procedures are thought to
be required, it is prudent to base incision
lines more remotely to avoid exposure of
grafted materials.
The relieving incisions have therefore been
made one tooth wide, laterally on each
side, and the crestal incision has been
made towards the palatal side.

OVERLAPPED FLAP
• Cannot be used with thin
tissue or in narrow bands of
attached gingiva.

 This incision line can be used where the tissue is thick in order to
produce overlapped flap margins rather than a simple butt joint.
 This requires incision through epithelium at one point, horizontal
extension of incision in mid-zone of connective tissue and vertical
incision down through periosteum.
 The resulting halving joint may provide more secure coverage in
areas where bone augmentation is planned

• Implants In Clinical Dentistry; Richard M Palmer.
• Langer And Langer, The Overlapped Flap : A Surgical Modification
for implant fixture installation. International journal of periodontics and
restorative dentistry ,1990, vol 10, 3, 209 -215

BASIC PRINCIPLES
 The bone should receive as little trauma as
possible.
 The bone should initially be within 30 to 40 µm
of the implant body, which should be rigidly
fixated and not move during healing.
 The surgical site should remain free of infection.

USE OF SURGICAL
STENT
Introducing Dental Implants - John A. Hobkirk, Roger M. Watson, Lloyd Searson

SURGICAL APPROACH –
BASED ON DENSITY OF BONE
 D1 - Dense cortical
 D2 - Dense to thick porous cortical and coarse
trabecular bone
 D3 - Thin porous cortical and fine trabecular
bone
 D4 - Fine trabecular

DIFFERENT DRILLS USED
FOR OSTEOTOMY SITE
PREPARATION

DENSE CORTICAL BONE -D1
 Anterior mandible with moderate to severe resorption
with greater crown height.
 Threaded implant design provides greater surface area
than a cylinder, esp in shorter lengths and improves
the dissipation of stresses in the crestal cortical region
despite higher moments of forces from greater crown
height, to sustain long term functional stress.
edition

ADVANTAGES
 Composed of dense lamellar, highly mineralized
bone, able to withstand loads
 Bone –implant contact >80%
 Greatest strength
 Less stresses transmitted to apical third of
implants, hence shorter implants can be used
edition

DISADVANTAGES
 Implant height limited to <12 mm in atrophic mandible
and therefore crown-implant ratio >15mm
 Fewer blood vessels, therefore more dependent on
periosteum for nutrition.
 Cortical bone recieves the outer one third of all its
arterial and venous supply from periosteum.
 Bone density is almost all cortical, and the capacity to
regenerate is impaired b’cos of poor blood supply.
 So, delicate and minimal periosteal reflection is
indicated.
edition

IMPLANT OSTEOTOMY
 Most difficult to prepare.
 Implant failure due to
 surgical trauma resulting in overheating of bone.
 Zone of devitalized bone that forms around the
implant is larger in D1 bone and this must be
replaced by vital bone for the interface to be load
bearing.
 So, thermal trauma should be minimized
edition

 Bone is easily overheated, therefore surgical failure
greater
 Cooled irrigation at 50ml/min with sterile saline or 5%
dextrose . No distilled water as rapid cell death may
occur
 Amount of heat produced in the bone is directly
related to amount of bone removed by each drill. E.g.,
3mm drill generates greater heat than 2 mm drill
 Rotational speed is increased to at least 2500 rpm
 No constant pressure – “bone dance” 1sec on bone
and 1-2 sec off bone while cooled irrigant is allowed
to perfuse the site.
IMPLANT OSTEOTOMY
edition

 Pause every 5-10 sec for 1min to allow limited blood
supply access to site, permit dissipation of heat, irrigate
area to reduce bone temperature and to remove debris
from osteotomy site.
 Pressure at the rate of 1mm every 5 sec
 Remove bone chips frequently
 Use new drills with designs like diamond coatings
 Prepare slightly larger in height & width
 Crestal bone drill – last drilling step
IMPLANT OSTEOTOMY
edition

 Implant inserted with slow speed, high torque
hand piece or a hand ratchet.
 Implant should not be tightened with a high
torque pressure (> 75 N-cm) to the full depth of
osteotomy; as this causes it to “bottom out” and
may result in microfractures along the implant
interface
 Hence once the threaded implant is introduced
into osteotomy and in final position, it is often
unthreaded one half turn to ensure that there is
no residual pressure along the bone interface
IMPLANT OSTEOTOMY
edition

HEALING
 Healing time 5 months
 Lamellar bone rather than woven bone at
interface
 Loading can be done at 3-4 months
edition

DENSE TO THICK POROUS
CORTICAL AND COARSE
TRABECULAR BONE – [D2]
 Ant mandible > post mandible > ant maxilla
 Minimum implant height 12 mm
edition

ADVANTAGES
 Excellent implant interface healing.
 Dense to porous cortical bone on the crest or
lateral portions of the implant site provide a
secure initial rigid interface.
 Predictable osseointegration
 Intrabony blood supply allows bleeding during
osteotomy preparation, which helps prevent
overheating during preparation and is most
beneficial for bone implant interface healing
edition

IMPLANT OSTEOTOMY
 Rotations of drill – 2500 rpm (approx)
 Copious cooled saline irrigation
 Cutting surface of drill to contact bone fewerthan
5 every 10 sec
 Pumping up and down motion to prepare
 It also maintains constant drill speed and reduces
friction time against the bone, all of which
reduce heat.
edition

 Drill sequence –
 2.0 mm twist drill
 2.5 mm twist drill
 Final osteotomy preparation determines final drill
used. E.g., 3.75 mm implant body uses a 3.0 mm
drill and a bone tap or a 3.2 mm drill for self
tapping insertion.
edition

IMPLANT OSTEOTOMY
 Crestal bone drill – should be used for most
implant designs in D2 bone.
 Crestal bone drill reduces mechanical trauma to
the bone upon implant insertion, b’cos cortical
bone is present on the crest of the ridgeand the
crest module of implant enlarges
edition

IMPLANT OSTEOTOMY
 Bone tap may be used when implant body engages
lateral or apical cortical bone.
 Hand piece at 30 rpm – direction and advancement
of tap is more precise
 Use of bone tap dependent upon final osteotomy
size, implant body size, depth of thread and shape
of thread.
 E.g., final osteotomy site 3mm and implant body is
3.75mm, a bone tap should be used in D2
 If final osteotomy is 3.2mm and 3.75mm implant
body with apical flutes for bone debris is used,
implant can be inserted with out pretapping
edition

HEALING
 4 months – excellent blood supply and rigid initial
fixation
 Bone – implant percentage is approx 70%
edition

POROUS CORTICAL AND FINE
TRABECULAR D3
 Ant maxilla > post max & mand
 Minimum length of implant 14 mm
 Large diameter implants are more essential in D3
 Porous cortical layer is thinner on the crest and
labial aspect of the maxilla and fine trabecular
pattern is more discrete in wide edentiulous
sites.
edition

ADVANTAGES
 Implant osteotomy time and difficulty – minimal
for each drill size and usually less than 10 sec.
Countersink and bone tap may be eliminated
 Excellent blood supply for initial healing and
intraosseous bleeding helps cool the osteotomy
during preparation
 Highest surgical survival
edition

DISADVANTAGES
 Careful to avoid lateral perforations, enlargement
or elliptical preparation of osteotomy
 During preparation, the drill may be pushed away
by the thick cortical plate and can strip thin plate
 No. of drills may be reduced
 Drill speed < 1500 rpm
 To improve fixation, engage opposing cortical
bone
edition

HEALING
 Approx 6 months
 Actual implant interface develops more rapidly
than D2 bone, however the extended time
permits regional acceleratory phenomenon (RAP)
from implant surgery to stimulate the formation
of more trabecular bone patterns
 Advanced bone mineralisation within the extra
months increase strength before loading.
edition

FINE TRABECULAR BONE D4
 No cortical bone
 Common location is post maxilla
 Min height 16 mm
edition

DISADVANTAGES
 Very porous, initial fixation presents limited
mechanical advantage
 Full size should not be prepared
 Osteotomies should be used
 Implants should self tap
 Bone-implant interface 25%

STAGE II SURGERY
 Permits direct evaluation of healing of implants
 Opportunity to correct poor implant placement,
inadequate crestal healing, soft tissue defects

SOFT TISSUE INCISION
 Full thickness incision 5-10 mm mesial and distal
to the implant
 Elevators not to be levered against implant body

BONE-IMPLANT INTERFACE EVALUATION
CRITERIA FOR SUCCESS
• Rigid fixation
• Absence of crestal bone loss
• Absence of pain
• Adequate zone of keratinized gingiva
• Sulcus depth ≤ 4 mm
• Absence of inflammation
• Proper hard and soft tissue contour
• Prosthetic abutment allows implant loading under
physiologic conditions

BONY DEFECTS
 Causes –
 Premature implant exposure
 Crestal bone trauma during surgery
 Excess torque from implant insertion
 Bone flexure or torsion in posterior mandible
 Incision line opening
 Implant surface contamination
 Patient habits that load the implant during healing

RIGID FIXATION
DETERMINATION
 Remove cover screws
 Flush the internal chamber
 Seat the permucosal extension
 Rigid fixation is tested for resistance to torque
required to place the extension with 10 N-cm

REVERSE TORQUE
TESTING
 2 main advantages-
 its use as a biomechanical measure of initial
stability
 Use as a definitive verification of initial
osseointegration
 Involves placing reverse torque to implant at
level of 10-20 N-cm

REMOVAL OF
IMPLANTS
• The implant may be removed, and if enough
implants remain, the prosthesis may still be
fabricated.
• The prosthesis may be converted from fixed
restoration to removable RP-4 or RP-5
restoration.
• An additional implant may be placed in an
optional location at the same time as the implant
removal.

 The implant may be removed and a larger dia
implant simultaneously inserted with a different
angulation or deeper within the osteotomy.
 The implant may be removed, the site
augmented, and an additional implant placed
months later.

PERMUCOSAL HEALING
ABUTMENT
 4mm permucosal healing cap should extend
atleast 1mm above tissue after suturing to help
prevent tissue overgrowth
 Enlarged permucosal extension may be designed
as part of healing abutment.
 This larger contour helps maintain the apically
positioned tissue in place.

FLAPLESS SURGERY
 Flapless implant surgery is defined as a surgical
procedure used to prepare the implant osteotomy
and to place the implant without elevation of a
mucoperiosteal flap.
 involves accessing the bone by either
 punching out a small amount of soft tissue just
required for osteotomy preparation and implant
placement or
 preparing the osteotomy site by drilling directly
through the soft tissue.

ADVANTAGES
 Minimal pain and postoperative discomfort
 Maintains a better blood supply to the site
 Reduction of intraoperative bleeding,
 Maintains soft tissue architecture and hard tissue
volume
 Decreases surgical time
Flapless surgery and its effect on dental implant
outcomes; Nadine Brodala, Int J Oral Maxillofac Implants
2009;24(suppl):118–125

DISADVANTAGES
 ‘Blind procedure’ . The inability of the surgeon to visualize
anatomical landmarks and vital structures,
 The potential for thermal trauma to the bone due to limited
external irrigation during preparation of the osteotomy with
guided surgery
 An inability to ideally visualize the vertical endpoint of the
implant placement (too shallow/too deep)
 Decreased access to the bony contours for alveoloplasty
 Difficulties in performing an internal sinus lift with a stabilized
template (screw fixated)
 Inability to manipulate the circumferential soft tissues to ensure
the ideal dimensions of keratinized mucosa around implant
2009;24(suppl):118–125

 A MEDLINE search was conducted on studies
published between 1966 and 2008 by Brodala .
For the purpose of this review, only clinical
(human) studies with five or more subjects were
included. Available data on flapless technique
indicate high implant survival overall. The
incidence of intraoperative complications was
3.8% of reported surgical procedures
2009;24(suppl):118–125

REQUIREMENTS
 Attached, keratinized tissue of at least 5 mm
 Bone width of minimum 4.5 mm without
undercuts >15

POST-OPERATIVE PHASE
 Extra-oral ice packs application intermittently for 2 hours on the
first day to minimize oedema,
 oral hygiene instructions including warm 0.2% Chlorhexidine Hcl
mouthwash, as an antiseptic mouthwash twice daily from the day
of implant placement and continued for the whole treatment
period
 Using soft toothbrush
 Gentle cleaning with dental floss,
 To eat soft diet and to avoid biting on the provisional crown
 Continue the use of the pre-operative broad-spectrum antibiotic
and to take the non-steroidal anti-inflammatory analgesic twice
daily for 7-10 days.

PAIN CONTROL
PROTOCOL
DRUG DOSE
PCP 1 Mild pain
expected
Ibuprofen 400mg 1 hr before surgery
PCP 2 Mild to moderate
pain expected
Ibuprofen +
Hydrocodone
(vicodin)
400mg 1hr before surgery + continue 4
times daily for 2 days,
5mg/500 mg as needed
PCP 3 Moderate pain
expected
Ibuprofen +
Hydrocodone
(vicodin ES)
times daily for 2 days, then as needed
7.5mg/750 mg 4 times daily for 2 days,
then as needed
PCP 4 Severe pain
expected
Ibuprofen +
Hydrocodone
(vicodin HP)
times daily for 4 days, then as needed
10mg/660 mg 4 times daily for 2 days,
then as needed

REFERENCES
 Misch CE, Misch CM; Contemporary Implant Dentistry. 2/e,
Elsevier Mosby. St.Louis.
 John A. Hobkirk, Roger M. Watson, Lloyd Searson ;
Introducing Dental Implants .
 Michael S. Block; Colour atlas of dental implant surgery.
 A. Norman Cranin; Atlas of oral implantology.
 Richard M Palmer; Implants in Clinical Dentistry.
 Robert Weinkelman; Dental Implants, Fundamentals And
Advanced Laboratory Technology.
 Scully and Cawson; Medical problems in dentistry

REFERENCES
 Richard Palmer; Basic Implant Surgery, British Dental
Journal, Vol 187, No.8, 1999
 Kleinheinz et al , incision design in implant dentistry
based on vascularization of mucosa; clin. Oral impl.
Res. 16, 2005/518-523
 David R. Scharf ; effect of crestal versus mucobuccal
incisions on the success rate of implant
osseointegration, Int J Oral Maxillofac Implants, 1993,
8, 187-190
 Langer And Langer, The Overlapped Flap : A Surgical
Modification for implant fixture installation.
International journal of periodontics and restorative
dentistry ,1990, vol 10, 3, 209 -215

REFERENCES
 Susanna Annibali; The Role Of Template In
Prosthetically Guided Implantology, Journal Of
Prosthodontics, 18 (2009) 177-183
 Flapless surgery and its effect on dental implant
outcomes; Nadine Brodala, Int J Oral Maxillofac
Implants 2009;24(suppl):118–125
 Handelsman M; Surgical guidelines for
dental implant placement. British Dental
Journal 2006;201:139-152.

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