SURGICAL MANUAL OF IMPLANT DENTISTRY: STEP-BY-STEP PROCEDURES (2007) pptx

Editor: Bryn Goates Design and production: Dawn Hartman Printed in Canada Table of Contents Preface… vii 1 Basic Surgical Principles… 1 2 Indications for Each Implant Type… 17 3 Surgical

SURGICAL MANUAL OF IMPLANT DENTISTRY:

STEP-BY-STEP PROCEDURES (2007)

Front Matter

Title Page

Daniel Buser DDS, Dr med dent

Professor and Chairman

Department of Oral Surgery and Stomatology

School of Dental Medicine

Baylor College of Dentistry

Texas A & M University System Health Science Center

Dallas, Texas

Alvin B.K Yeo BDS, MSc

Periodontics Unit

Department of Restorative Dentistry

National Dental Centre

Republic of Singapore

Quintessence Publishing Co, Inc

Chicago, Berlin, Tokyo, London, Paris, Milan, Barcelona, Istanbul, Sao Paulo, Mumbai, Moscow, Prague, and

Warsaw

Copyright Page

Library of Congress Cataloging-in-Publication Data

Buser, Daniel

Surgical manual of implant dentistry : step-by-step procedures /

Daniel Buser, Jun Y Cho, Alvin Yeo

p ; cm

ISBN-13: 978-0-86715-379-8

1 Dental implants Handbooks, manuals, etc 2 Dental implants

Atlases I Cho, Jun Y II Yeo, Alvin III Title

[DNLM: 1 Dental Implantation methods Atlases 2 Dental

© 2007 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

4350 Chandler Drive

Hanover Park, Illinois 60133

www.quintpub.com

All rights reserved This book or any part thereof may not be reproduced, stored in a retrieval system, or

transmitted in any form or by any means, electronic, mechanical, photocopying, or otherwise, without prior

written permission of the publisher

Editor: Bryn Goates

Design and production: Dawn Hartman

Printed in Canada

Table of Contents

Preface… vii

1 Basic Surgical Principles… 1

2 Indications for Each Implant Type… 17

3 Surgical Procedures in Standard Nonesthetic Sites… 23

4 Surgical Procedures in Standard Esthetic Sites… 39

5 Surgical Procedures for Implant Placement with Simultaneous Guided Bone Regeneration… 61

6 Surgical Procedures for Implant Placement with Simultaneous Sinus Floor Elevation… 77

7 Clinical Cases… 93

Suggested Reading… 123

Preface

Based on the concept of osseointegration first described by Branemark and Schroeder, implant dentistry has

evolved tremendously over the past 15 years, and today it plays an integral role in dental rehabilitation

Though it was developed primarily to rehabilitate fully edentulous patients, since the late 1980s the treatment

focus has gradually shifted to partially edentulous patients Today, single-tooth replacement is the number one

indication for implant therapy

Implant dentistry also has benefited from the significant progress made in associated treatment protocols

Development of bone augmentation procedures allows clinicians to correct alveolar bone deficiencies, while

guided bone regeneration with barrier membranes and sinus floor elevation have become standards of care to

correct bone defects in other parts of the oral cavity In addition, improved osteophilic microtextured titanium

implant surfaces help to accelerate healing, significantly reducing treatment time Together, these advances

make implant therapy more predictable and more attractive to patients, and the result has been a rapid

expansion of implant dentistry in daily practice and more clinicians placing dental implants

This book is the culmination of many years' effort to standardize surgical technique in implant dentistry It is

designed for postdoctoral students and practitioners who wish to perform surgical implant procedures in daily

practice with a high predictability for success and a low risk for complications Basic surgical principles and

detailed explanations and hand-drawn illustrations The final chapter of the book presents 14 comprehensive

clinical case reports, several documenting long-term follow-ups over a period of 10 years

The publication of this book coincides with the production of a DVD featuring live surgery of the same surgical

techniques in seven clinical cases The surgery was recorded during master courses in implant dentistry offered

by the University of Bern

The authors wish to thank the staff of Quintessence Publishing for their excellent support during the

preparation and production of this book

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Chapter 1 Basic Surgical Principles

Introduction

This chapter presents the basic surgical principles related to the placement of Straumann implants in partially

edentulous patients To achieve successful osseointegration, a precise and low-trauma surgical technique is

required Surgeons must take important measures preoperatively to prevent postsurgical infection, handle

surgical instruments expertly to preserve soft tissues, and carefully accomplish adequate implant site

preparation without overheating the bone Precise surgical protocol includes the following precautions:

• Preoperative mouthwash with 0.1% chlorhexidine

• Perioral skin disinfection with alcohol solution

• Antibiotic prophylaxis 2 hours prior to surgery (eg, 2 g amoxicillin intraorally)

• Low-speed drilling (between 500 and 600 rpm)

• Cooling spray during drilling with chilled sterile saline

• Intermittent drilling technique

• Use of sharp drills

It is important to perform a surgical procedure systematically, always applying the same surgical principles

Fig 1-1 Smoothing the alveolar crest following flap elevation.

Fig 1-1a Once the implant surgical site has been exposed, a large round bur is used to smooth and level the

crest of the alveolar ridge

Fig 1-1b All sharp edges and irregularities are removed by running the round bur across the alveolar ridge.

Fig 1-1c In this cross section, the irregular, narrow crest is smoothed to produce a flat, wide ridge, which is

favorable for implant site preparation

Fig 1-2 Sequence of site preparation for a standard implant.

Fig 1-2a A no 1 round bur is used to mark the position of the implant site.

Fig 1-2b Access is widened with a no 2 round bur This step makes it possible to correctly position the next

drill

Fig 1-2c The initial implant site preparation is made with a 2.2-mm-diameter pilot drill.

Fig 1-2d A 2.2-mm-diameter guide pin is inserted into the initial preparation to check its position and axis.

Fig 1-2e The crest of the osteotomy is enlarged with a no 3 round bur.

Fig 1-2f A 2.8-mm-diameter spiral drill is easily inserted for preparing the depth of the site.

Fig 1-2g A profile drill is used to further increase the surgical access for the next, larger-size drill.

Fig 1-2h Preparation of the implant site continues with the 3.5-mm-diameter spiral drill.

Fig 1-2i Occasionally, when the bone structure is uniformly dense, bone tapping is performed prior to implant

placement

Fig 1-2j A standard implant is placed in the site, with the rough surface positioned at the level of the alveolar

ridge crest This allows the implant shoulder to be located at the gingival level

Fig 1-3 Correction of the position and axis of the implant site

preparation.

position of the implant site.

Figs 1-3b and 1-3c Any required changes to the marking made with the first round bur can be accomplished

with the no 2 round bur, as shown in this occlusal view These initial steps for the preparation of the implant

site ensure the correct implant position orofacially and mesiodistally

Fig 1-3d After the use of the first pilot drill (A), a 2.2-mm-diameter guide pin is used to check the axis and

depth of the implant preparation (B) Any incorrect axis orientation can be adjusted with the same

2.2-mm-diameter pilot drill (C and D) and then followed with the 2.8-mm-2.2-mm-diameter spiral drill (E).

Fig 1-4 Pretapping of implant sites with bone of varying

density.

Fig 1-4a Tapping of the bone in the implant site is performed when the bone structure is uniformly dense (ie,

type 1 bone) This is done through the entire depth of the implant bed

Fig 1-4b If the alveolar ridge is partially dense (ie, type 2), tapping of the implant site to one third of the

predetermined depth is done within the crestal area

Fig 1-4c When the alveolar ridge is predominantly cancellous bone (ie, types 3 and 4), no tapping of the bone

is required prior to implant placement

Fig 1-5a The 3.5-mm-diameter depth gauge is inserted so that the middle of the 12-mm mark is aligned with

the bone crest (left) When the standard implant is inserted, this allows the rough border to be aligned exactly

at the crest (right).

Fig 1-5b If the implant site is prepared with the 12-mm mark slightly below the crest, the rough border of the

inserted implant will be positioned approximately 0.5 mm below the crest This approach is most often used in

posterior implant sites for a nonsubmerged implant healing

Fig 1-5c The implant site is prepared to the 14-mm mark, and the profile drill is used to flare the coronal

portion of the crest A 12-mm-long standard implant can be inserted more deeply to partially submerge the

machined collar This approach is normally used in esthetic implant sites for a submerged implant healing

Fig 1-6 Overview of implant site preparation and implant

placement.

Fig 1-6a The implant site is prepared to a diameter of 2.8 mm to receive a narrow neck or a reduced-diameter

implant Pretapping, as shown in Fig 1-4, is rarely used with these implants

Fig 1-6b When a standard implant is used, the implant site is prepared to a diameter of 3.5 mm Pretapping,

as shown in Fig 1-4, is rarely used

Fig 1-6c The implant site is prepared to a diameter of 4.2 mm, and a wide body or wide neck implant is

inserted Pretapping, as shown in Fig 1-4, is used more often due to larger implant diameter

Fig 1-7 Selection of implant length in the posterior mandible.

Fig 1-7a In regions restricted by anatomic limitations, shorter implants are frequently used In this long-span

mandibular distal extension situation, two implants are placed to support a three-unit fixed partial denture An

8-mm short implant (right) is used to avoid the mandibular canal.

Fig 1-7b In a short-span mandibular distal extension situation, two short implants with lengths of 6 and/or 8

mm may be indicated They are used here to avoid the mandibular canal These short implants are often

restored with splinted crowns

Fig 1-8 Selection of implant length in the posterior maxilla.

Fig 1-8 In the maxillary posterior distal extension situation, the maxillary sinus can be avoided with the use of

shorter implants Here, two implants (12 and 8 mm) are inserted in the second premolar and first molar sites,

respectively, in close proximity to the sinus

Fig 1-9 Minimum width of alveolar crest for implants of varying

diameter.

Fig 1-9a In the premolar site, a crest width of at least 6 mm is recommended for a standard implant.

Fig 1-9b In the molar site, a wide body or wide neck implant requires a minimum crest width of 7 mm.

Fig 1-9c In the anterior region, where a narrow neck implant is often indicated for the replacement of lateral

incisors, a minimum alveolar crest width of 5 mm is required

Fig 1-10 Minimum space of single-tooth gaps for various

implant types.

Figs 1-10a and 1-10b Occlusal (a) and lateral (b) views of regular neck implants A space of at least 7 mm is

required for the 4.8-mm-diameter implant shoulder shown here

Figs 1-10c and 1-10d Occlusal (c) and lateral (d) views of wide neck implants The 6.5-mm-diameter

implant shoulder requires a single-tooth gap of at least 9 mm

Figs 1-10e and 1-10f Occlusal (e) and lateral (f) views of narrow neck implants In sites that require narrow

neck implants, a minimum of 5.5 mm is needed to accommodate the 3.5-mm-diameter implant shoulder

Fig 1-10g A minimum interocclusal distance of 5.5 mm from the implant shoulder to the opposing dentition is

necessary to allow the placement of the abutment and crown

Fig 1-11 Spacing between implants or between implants and

teeth.

Figs 1-11a and 1-11b Occlusal (a) and lateral (b) views of a regular neck implant placed next to a tooth A

distance of approximately 4 to 5 mm is required between the central axis of the implant and the root surface of

the tooth at the alveolar crest

Figs 1-11c and 1-11d Occlusal (c) and lateral (d) views of a wide neck implant placed next to a second

premolar The wide neck implant is positioned approximately 5 to 6 mm from the tooth

Figs 1-11e and 1-11f Occlusal (e) and lateral (f) views of regular neck implants When two regular neck

implants are placed side by side in a posterior distal extension situation, the first implant should be positioned

4 to 5 mm from the tooth and the second implant should be positioned 7 to 8 mm from the anterior implant

Figs 1-11g and 1-11h Occlusal (g) and lateral (h) views of regular neck and wide neck implants When a

regular neck implant and a wide neck implant are indicated to replace a missing second premolar and molar,

the regular neck implant should be placed 4 to 5 mm from the tooth and the wide neck implant placed

Figs 1-11i and 1-11j Occlusal (i) and lateral (j) views of implants positioned in the first premolar and first

molar sites In this extended posterior distal extension situation, a regular neck implant and a wide neck

implant are indicated as abutments for a three-unit fixed partial denture The regular neck implant is positioned

4 to 5 mm from the tooth The wide neck implant is inserted about 16 mm from the anterior implant

Figs 1-11k and 1-11l Occlusal (k) and lateral (l) views of a short distal extension situation A regular neck

implant is indicated to restore the missing first molar and serve as a distal abutment to a combined tooth- and

implant-supported three-unit fixed partial denture The implant is positioned 11 to 12 mm from the tooth

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Chapter 2 Indications for Each Implant Type

Introduction

Modern implant systems, such as the Straumann Dental Implant System, offer a variety of different implant

types for the various clinical indications of implant therapy More than 25 years ago, most implant systems

offered just one implant type, primarily to treat fully edentulous patients with implant-borne restorations; the

standard implant dates back to 1986 Due to the expansion of implant therapy for partially edentulous patients

in the late 1980s, the application of implants has steadily increased In recent years, the single-tooth gap and

the distal extension situation have become the two most important indications for implant therapy

Today, screw-type implants are generally preferred in implant dentistry Therefore, the diameter of the main

implant body with its thread must be differentiated from the diameter of the implant shoulder (other implant

systems call it a platform) The Straumann Dental Implant System includes three diameters for implant

shoulders (ie, regular neck, wide neck, and narrow neck) and three diameters for implant threads (ie, standard,

wide body, reduced diameter, and tapered effect)

This chapter presents the author's preferences where these implant types are primarily used

Fig 2-1 Standard implant.

Fig 2-1a Two standard implants are restored with a three-unit fixed partial denture in a mandibular distal

extension situation The implants provide adequate support and function against the opposing dentition

Fig 2-1b For this single-tooth gap, a 12-mm-long standard implant is indicated to replace a missing

mandibular second premolar

Fig 2-2 Standard plus implant.

Fig 2-2a In an esthetic restoration involving a single-tooth gap in the anterior region, a standard plus implant

is indicated to replace a missing central incisor

Fig 2-2b A standard plus implant can also be used to replace a maxillary canine in the esthetic zone.

Fig 2-3 Wide body implant.

Fig 2-3a Shorter and wider implants are indicated in the posterior maxilla to avoid the maxillary sinus A

standard implant is indicated in the second premolar site, and a wide body implant is indicated in the first

molar site

Fig 2-3b Shorter and wider implants are also indicated in the posterior mandible to avoid the mandibular

canal Two wide body implants can be placed in the first and second molar sites These implants are restored

and, in cases of short 6-mm implants, routinely splinted

Fig 2-4 Wide neck implant.

Fig 2-4a A wide neck implant is ideal for a single-tooth gap in the first molar position.

Fig 2-4b In a posterior distal extension situation, a standard implant and a wide neck implant are ideal

replacements for a missing second premolar and first molar, respectively

Fig 2-5 Narrow neck implant.

Fig 2-5a A narrow neck implant is indicated to replace a missing lateral incisor where the single-tooth gap

offers limited space

Fig 2-5b Another indication for a narrow neck implant is to replace missing mandibular incisors where

available tooth space is likewise restricted

Fig 2-6 Reduced-diameter implant.

Fig 2-6 For situations in which the posterior distal extension has inadequate alveolar ridge width,

reduced-diameter implants can be used in premolar sites, whereas a standard implant can be placed in the first molar

position Splinting of the crowns is recommended when implants of reduced diameter are used

Fig 2-7 Tapered effect implant.

Fig 2-7a For a single-tooth gap following an extraction in the anterior maxilla, a tapered effect implant is

indicated to replace a missing central incisor

Fig 2-7b In the extraction socket of a first premolar, a tapered effect implant can also be indicated for early

implant placement

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Author:

Daniel Buser DDS, Dr med dent

Jun-Young Cho DDSAlvin B.K Yeo BDS, MSc

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Chapter 3 Surgical Procedures in Standard Nonesthetic

Sites

Introduction

The majority of surgical implant procedures are performed in nonesthetic sites, most often for implant

placement in premolar and molar sites in the mandible and maxilla The primary objective of therapy in these

sites is to reestablish masticatory function with a fixed restoration

This chapter deals with implant surgery in standard sites without bone deficiencies The clinical situations

represent a simple, straightforward level of difficulty Details of flap elevation, implant site preparation,

implant insertion, and soft tissue suturing using a nonsubmerged approach are presented The surgical steps

illustrate the most important indication in posterior sites, the distal extension situation

Fig 3-1 Flap elevation in a mandibular distal extension

situation.

Fig 3-1a Long-span distal extension situation in the posterior mandible in which the canine is the most distal

tooth A three-unit, implant-supported fixed partial denture is planned Note the presence of the mental

foramen and mandibular canal

Fig 3-1b The surgery begins with a midcrestal incision made with a no 15c blade The intention is to maintain

an adequate band of keratinized mucosa on the buccal and lingual wound margins

Fig 3-1c A no 12b blade is used to extend the incision through the sulcus of the adjacent canine.

Fig 3-1d If indicated, a vertical releasing incision is made on the mesial line angle of the canine on the facial

aspect Releasing incisions are also positioned in the second molar region

Fig 3-1e A full-thickness mucoperiosteal flap is elevated using a fine tissue elevator to expose the alveolar

ridge

Fig 3-1f Retraction mattress sutures are attached to the buccal and lingual flaps to allow sufficient access to

the implant sites

Fig 3-1g The retraction sutures are attached to hemostats to keep the flaps opened and in place.

Fig 3-2 Implant site preparation in a mandibular distal

extension situation.

Fig 3-2a A large round bur is used in a counterclockwise rotation to smooth any irregularities and level the

alveolar crest

Fig 3-2b A diagnostic T caliper is used to determine the distance of the anterior implant from the canine.

Because a standard implant is used here, a distance of 4 to 5 mm is required from the canine's distal root

surface to the central axis of the implant

Fig 3-2c The position of the anterior implant is marked with a small round bur.

Fig 3-2d The first spiral drill (2.2-mm diameter) is easily positioned, and the site is prepared to a depth of 12

mm

Fig 3-2e A 2.2-mm depth gauge with a 5-mm platform ring is inserted to check the correct distance from the

adjacent canine

Fig 3-2f A pair of calipers is used to locate the position of the posterior implant by measuring a distance of 14

mm from the anterior implant

Fig 3-2g The same small round bur is used to mark the second implant site.

Fig 3-2h The 2.2-mm-diameter spiral drill prepares the site to a depth of 8 mm to avoid the mandibular canal.

Fig 3-2i The 2.2-mm guide pins are inserted into the site preparations to check their positions and the

parallelism of their axes

Fig 3-2j The openings of the implant site preparations are enlarged using a larger round bur.

Fig 3-2k The 2.8-mm-diameter spiral drill is inserted to the predetermined depth at each implant site.

Fig 3-2l The sink depths and parallel axes for the implant preparations are examined with the

2.8-mm-diameter depth gauges in situ

Fig 3-2m The initial profile drills are now used to prepare the coronal aspect of the implant site preparations.

Fig 3-2n Drilling continues with the use of the 3.5-mm-diameter spiral drills prepared to the correct depths.

Fig 3-2o The sink depths and parallel axes of the preparation sites are again examined with the 3.5-mm depth

gauges

Fig 3-2p Only the posterior implant site is enlarged with the second profile drill.

Fig 3-2q The preceding steps allow the final 4.2-mm spiral drill to be inserted easily and the posterior implant

site to be prepared to the correct sink depth

Fig 3-2r Final verification of the implant sites is performed with the 3.5- and 4.2-mm-diameter depth gauges

in the anterior and posterior implant sites, respectively

Fig 3-2s For implant sites with a type 1 bone density, pretapping is required to allow easy insertion of the

implant Here, the implant sites are prepared with 3.5- and 4.2-mm-diameter tapping instruments, respectively

Pretapping is rarely necessary in the posterior mandible

Fig 3-3 Implant placement in a mandibular distal extension

situation.

Fig 3-3a A standard implant is inserted in the anterior site and a wide body implant is inserted in the posterior

site The insertion device can be attached to a low-speed contra-angle handpiece (15 rpm) (left) or to a hand

ratchet device (right).

Fig 3-3b The insertion device is removed in a counterclockwise direction using a fixation key.

Fig 3-3c Final positions of the standard (left) and wide body (right) implants.

Fig 3-3d Healing caps for the mesial implant (3 mm) and the distal implant (1.5 mm) are attached to cover the

implants

Fig 3-3e To preserve the available band of keratinized mucosa, gingivectomy is avoided Instead, the flaps of

the surgical site are closed with interrupted single sutures

Fig 3-3f Complete closure following suturing In standard posterior sites without bone deficiency, a

nonsubmerged healing modality is routinely used Soft tissue healing requires a period of 10 to 14 days.

Fig 3-4 Soft tissue suturing of a mandibular distal extension

situation with one implant.

Fig 3-4a Occlusal view following placement of a wide neck implant in the mandibular first molar site Closure

of the flaps begins with the mesial papilla

Fig 3-4b Once the mesial papilla is secured, relieving incisions are made approximately 3 mm distal to the

implant to ensure a tension-free closure and obtain an adequate band of keratinized mucosa surrounding the

implant

Fig 3-4c The buccal and lingual wound margins are rotated in slightly and sutured.

Fig 3-4d The remaining surgical site is closed with interrupted single sutures The slight exposure of the bone

distal to the implant site will heal by granulation

Fig 3-5 Soft tissue suturing of two implants with adequate

keratinized mucosa.

Fig 3-5a In sites with adequate keratinized mucosa surrounding two adjacent implants, a modified procedure

is used to achieve flap closure The mesial papilla is closed first with an interrupted single suture Two Palacci

incisions are made into the keratinized wound margin with a new no 15c blade

Fig 3-5b The newly created Palacci flaps are rotated in to provide a more favorable proximal soft tissue

adaptation and closure

Fig 3-5c The flaps are approximated and closed with several interrupted single sutures.

Fig 3-6 Alternative method for soft tissue suturing of two

implants with adequate keratinized mucosa.

Fig 3-6a In situations with an adequate band of keratinized mucosa, a modified Palacci incision can also be

used Incisions are made into both the buccal and lingual wound margins

Fig 3-6b The small flaps, from the buccal and lingual aspects, are rotated in proximally for a close,

tension-free adaptation

Fig 3-6c Final closure is achieved with several interrupted single sutures.

Fig 3-7 Soft tissue suturing of two implants with inadequate

keratinized mucosa in the mandible.

Fig 3-7a For cases in which minimal keratinized mucosa surrounds two adjacent implants, adjunctive grafting

procedures may be necessary for better management of the soft tissues