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2.5 Operation
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All dental implant surgeries can be classified into two types:

  • A single-stage surgical procedure (open protocol). With a one-stage surgery technique, a healing abutment is placed at the time of surgery and protrudes through the gum tissues. Such surgical procedures are performed using a mucotome without a connective tissue graft. One-piece implants are used. The surgery is performed in one step and there is no need for a second surgery to attach a healing abutment.
  • A two-stage surgical procedure (closed protocol). With a two-stage procedure, the implant is placed into the jawbone and covered by gum tissues. Once the implant is healed, a second surgery is performed to attach a healing abutment.

Despite the fact that a two-stage surgery technique is a more complicated procedure (and the patient has to attend you more often), you should start your implant dentistry practice with this protocol. It will enable you to learn by experience how gum tissues correlate with bone volume and will eventually enable you to gain expertise in determining bone volume without relying on computed tomography. A two-stage surgical procedure prevents food particles from getting caught in the peri-implant space due to mucosal hermetic seal.

A surgery, naturally, starts after anesthesia. You are welcome to use any solution in anesthesia (whether Lidocaine or Articaine, or alike) and you are welcome to apply any anesthetic technique you like. It is immensely important that the patient should not feel pain, for only then you will be able to concentrate on the surgery.

INCISION

Later, having gained enough clinical experience, you will be able to perform numerous surgeries and you will certainly have your own ideas concerning surgical incisions. However, I strongly recommend that you should start with the classical midline incision on the alveolar ridge.

Do not be afraid of cutting through the dental papilla. There is a fallacy that dental papilla incisions cause recession.

 
2.5-1 Titanium aspirators are much more convenient than disposable plastic aspirators. They can be used even with minimal mucoperiosteal flap separation, they do not reduce visibility and are effective in removing physiological solution, saliva and blood.
 
2.5-2 A very convenient curette. Apart from its intended purpose it can also serve for removing single-rooted teeth, introducing osteoplastic material into the wound, etc.
 
2.5-3 The CONMET titanium retractor set. The tools are very ergonomic and can be used for almost every purpose.
 

If you perform a neat incision (it goes without saying, that a disposable surgical blade must be used) and a neat surgery, it will heal without leaving a scar. If, trying to save the dental papilla, you make a vertical incision (which almost always leaves a scar) and then unintentionally sever or damage the dental papilla during surgery, there most certainly will be an unattractive scar. The incision is made at the cemento-enamel junction of the tooth adjacent to the defect. Press the scalpel to the tooth without applying excessive force and make a papilla-base incision via the crest of the alveolar ridge on the other side of the defect. The scalpel should be placed at an acute angle to the bone (it is advisable that you should use surgical scalpel blade No 15C, though occasionally No13 can be used 2.5-7A).

MUCOPERIOSTEAL FLAP ELEVATION

If the defect is surrounded by teeth, the separation should be started with the dental papilla with the raspatory placed behind the tooth. Should it be impossible, start in the middle of the flap.

The first solution is more effective when elevating the palatal flap or the tongue flap. Insert the straight raspatory in the incision vertically and slowly turn it so as to place it horizontally, then slowly rotate it on its axis and slightly push it forward. As soon as the working area of the raspatory emerges in the periosteum, slowly pull it upwards leaning on the bone. After that, without changing the raspatory position, make an incision beneath the periosteum, moving medially and distally. Repeat the same for another flap 2.5-7B. Do not haste when elevating a flap. Flap elevation procedure is one of the most laborious and essential surgical procedures (especially important in areas of esthetic concern).

Be very careful when the raspatory emerges in the periosteum. Remember that the cortical bone is always smooth (unless a tooth has been recently extracted).

If instead of seeing bone, you see soft tissue bleeding and flap elevation was complicated, you must have severed the mucous membrane, while the periosteum is still attached to the bone. To make sure, wash the site with cool physiological solution from the physiodispenser.

 
2.5-4 The correct placement of the retractor 1 and the saliva ejector 2.
 
2.5-5 The spherical dental drill is very effective in removing residual connective tissue from the bone.
 
2.5-6 Such scissors are effective in incising the mucous membrane even in hard-to-reach areas. Note that one of the blades of the scissors is serrated, which prevents the scissors from slipping when cutting through the mucosa.
 

If you have managed to separate the periosteum, the bone will not change its colour under the influence of physiological solution. However, if the periosteum has not been separated, the bone will turn milky-white.

Once mucoperiosteal flap elevation is successfully over, your assistant (nurse) places the retractor beneath one of the flaps, and the saliva ejector beneath the other.

Use the Lindemann bur 2.3.8 or the spherical dental drill to create the implant installation axis. Drill point geometry makes it effective for cutting through the bone, bone sampling, smoothing over the alveolar ridge.

Before engaging in bone drilling, turn on the physiodispenser to cool the bur or the drill with some cool physiological solution (1 – 2 sec.).
 
2.5-7A Never press the scalpel with excessive force! Never try to cut beneath the periosteum with a single incision.
 
BONE SURGERY

I have already mentioned that bone drilling must be performed delicately with pauses, the bone must be constantly cooled with cold sterile physiological solution. The flowing of physiological solution must always precede the rotation of the drill. If it is possible from the anatomical point of view (this is hardly possible at the maxillary site), try to make a little puddle of physiological solution at the site of drilling. It is highly advisable that every time before initiating drilling, you should turn on the physiodispenser to cool the bur or the drill with some cool physiological solution (1 – 2 sec.). Only a rotating drill can be inserted into the bone and extracted from it. Never insert the drill into the bone and then start rotating it. It is extremely dangerous. When starting rotation, a drill is bound to twitch and may get trapped in the bone. Should it happen, never try to tug the drill out (never try to go on drilling either, which will be even worse). Nowadays, every physiodispenser has the reverse rotation option.

2.5-7B Try to use the adjacent teeth as raspatory supports when you start the separation. Use the raspatory as a lever.
 

Use the option (do not move your hand with the stuck drill) to let the drill rotate counter-clockwise and get free. Drills usually get stuck when you try to change the inclination. When drilling, the inclination must never be changed. The transition between different diameter drills is another crucial issue (the producers of modern implant systems have elaborated the transition scheme). The smaller the drill, the lower the traumatic impact on the bone. The transition from one diameter drill to another diameter drill should be gradual. It is impermissible to use a 3.5 mm drill immediately after a 2.2 mm drill (the diameter difference is 1.3mm!). You may, probably, make a hole in the bone using the above mentioned combination of drills, but it will be energy consuming and, what is more important, it will inevitably traumatize the bone and consequently result in bone loss or implant rejection.

Having completed every stage of drilling, use the depth probe to see whether the hole needs drilling 2.5-7E.

 
2.5-7C Having separated mucoperiosteal flaps using a straight elevator, use a wider elevator to move further in.
 
2.5-7D Use the Lindemann bur to ensure direction refinement. Hold the handpiece tightly so as to avoid too rapid drill penetration into the bone. Never let the drill tilt, even a slight inclination change may lead to drill breakage.
 
2.5-7E Bone drilling must be careful, discontinuous, with cooling. When starting drilling, use small diameter drills.
 
Carefully control the colour of bone chips! They should always remain light. The brownish colour of bone chips signifies overheating, hence you must use a milder drilling mode and use a cooler physiological solution!

Unpack the implant only after you have perforated a hole of the required depth and diameter (and have threaded the bone, if necessary). It is highly advisable that your assistant should unpack the implant above the operating table lest the implant should fall on the floor (such things can happen).

Insert the implant only after you have washed the bone bed to remove the blood clots and to make the bone bleed again. This way you will ensure a closer blood-implant contact and will consequently secure a greater bone-implant contact.

Use the threading tap to thread the bone and insert the implant using manual tools rather than the handpiece. This will develop the tactile sensation of your fingers and will help you later.

 
2.5-7F When taking a drill of another diameter, use the depth meter to verify the correctness of the procedure.
 

Using a handpiece, you will save no more than a few seconds! The micro engine is very powerful and therefore cannot stop immediately, but it can easily damage the bone thread by overtwisting the implant. The maximum rotation rate used to insert the implant must not exceed 200 rpm. Do not hurry, try to feel and remember the resistance of bone during implant placement.

Before inserting the implant, examine the adjacent tissues. There are often fragments of connective tissue or shreds of periosteum left. Getting in between the bone and the implant, they may continue growing and may hinder bone growth around the implant. Therefore it is highly advisable that you should remove any fragments of connective tissue or shreds of periosteum left. To do it, use the curette or the spherical dental drill.

Carefully rinse the embedded implant (its internal surface) to remove blood residue 2.5-7G and install the cover screw. Attach the cover screw tightly but do not apply excessive force.

 
2.5-7G Remember to rinse the implant bed with sterile physiological solution as often as possible to remove any blood residue or bone chips. To prevent overheating, wash out bone chips.
 

Before applying sutures, wash out residual bone chips, blood residue and fragments of connective tissue from under the mucoperiosteal flaps. If crowns have been recently removed from the adjacent teeth, the mucosal tissue surrounding the dental papilla is black. You’d better take it into consideration.

Start applying sutures at the distal aspect of the incision. The type of suture material is unimportant. Personally, I use Vicryl 2/0 to apply sutures at the lateral aspect of the maxilla and Vicryl 3/0 to apply sutures at the frontal aspect of the maxilla and to apply mandibular sutures 2.5-9.

Do not attempt to join the edges of the wound too tightly. Remember that tissues will inevitably swell. The swelling may be minor, but it is unavoidable. Too tight sutures may sink into the swollen tissue and eventually cut through them, which is especially dangerous in aesthetically relevant sites.

 
2.5-7H Use your hands to screw implants into the bone, it will improve the tactile sensation of your fingers and will enable you to assess bone structure and the degree of implant primary stability.
 
2.5-7I Before inserting the cover screw, clean the internal configuration of the implant to remove any blood residue, mucosal debris, etc.
 
2.5-8 This is the colour of bone chips. These fragments can be used to compensate for minor bone defects. A darker or brownish colour of the bone manifests bone burn, such bones must not be used.
 

 

If mucoperiosteal flaps cannot be sutured to each other, do not panic, apply sutures so as to hold the flaps in place, use Solcoseryl Dental 2.5.12 to cover the open area.

Ask the patient to apply Solcoseryl Dental to the suture site 3 – 4 times a day until the sutures are removed. If you have managed to hermetically seal the wound without causing undue tension at the suture site, apply haemostatic solution to the suture line for 15 – 20 minutes.

Once the wound is sealed, press the mucosa with your finger near the mucobuccal fold to extrude residual blood and move it towards the incision and the suture.

Rinse the oral cavity carefully to remove residual blood left on teeth and interdental spaces.

The surgery is over

 

Provided there are no complications during the postoperative period, remove the sutures after 7 – 8 days.

Once you have mastered the two-stage-surgical procedure, have gained expertise in individual bone anatomy and have sharpened your tactile sensations working with jawbones, you can engage in a one-stage surgical procedure.

 

2.5-9 A type of suture material used in implant dentistry.
 
2.5-10 Ophthalmologic needle holders have proven to be very valuable for the purposes of implant dentistry. The smooth clamp mechanism allows maneuvering a needle (even a needle with a trihedral grinding) through the mucosa.
 
2.5-11 Ligature scissors have proven useful for removing sutures. The notched scissor blade prevents slippage.
 
2.5-12 Apply Solcoseryl Dental to the incision and smooth it out using the patient’s saliva.
 
 
Keep your own diary! It will help you immensely. Spare 5 – 10 minutes after every surgery and shortly describe the procedure and its peculiarities. Speak about your sensations related to bone drilling.
 
Implant type Localization Surgery time Anatomical peculiarities Surgical peculiarities Notes