Surgical Manual Of Implant Dentistry Step By Step Procedures Daniel Buser, JunYoung Cho, Alvin B. K. Yeo

Dựa trên khái niệm về sự tích hợp răng được Brånemark và Schroeder mô tả lần đầu tiên, nha khoa cấy ghép implant đã phát triển vượt bậc trong 15 năm qua, và ngày nay nó đóng một vai trò không thể thiếu trong việc phục hồi răng. Mặc dù nó được phát triển chủ yếu để phục hồi chức năng cho những bệnh nhân phù hợp hoàn toàn, từ cuối những năm 1980, trọng tâm điều trị đã dần chuyển sang những bệnh nhân phù hợp một phần. Ngày nay, thay thế một chiếc răng là chỉ định số một cho liệu pháp cấy ghép implant. Nha khoa cấy ghép cũng đã được hưởng lợi từ những tiến bộ đáng kể đạt được trong các phác đồ điều trị liên quan. Sự phát triển của các thủ thuật nâng xương cho phép các bác sĩ lâm sàng điều chỉnh các thiếu hụt xương ổ răng, đồng thời tái tạo xương có hướng dẫn bằng màng ngăn và nâng cao sàn xoang đã trở thành các tiêu chuẩn chăm sóc để chỉnh sửa các khiếm khuyết xương ở các bộ phận khác của khoang miệng. Ngoài ra, bề mặt cấy ghép titan vi cấu trúc xốp xương được cải tiến giúp đẩy nhanh quá trình lành thương, giảm đáng kể thời gian điều trị. Cùng với nhau, những quảng cáo này làm cho liệu pháp cấy ghép dễ dự đoán hơn và hấp dẫn hơn đối với bệnh nhân, và kết quả là sự mở rộng nhanh chóng của nha khoa cấy ghép trong thực tế hàng ngày và ngày càng có nhiều bác sĩ lâm sàng đặt cấy ghép răng hơn. Cuốn sách này là đỉnh cao của nỗ lực trong nhiều năm nhằm tiêu chuẩn hóa kỹ thuật phẫu thuật trong nha khoa cấy ghép. Nó được thiết kế cho các sinh viên và học viên sau tiến sĩ muốn thực hiện các thủ thuật cấy ghép phẫu thuật trong thực tế hàng ngày với khả năng thành công cao và nguy cơ biến chứng thấp. Các nguyên tắc và quy trình phẫu thuật cơ bản để đặt cây im ở cả vị trí tiêu chuẩn và vị trí có khuyết tật cục bộ được trình bày bằng cách sử dụng giải thích chi tiết và minh họa vẽ tay. Chương cuối của cuốn sách trình bày 14 báo cáo trường hợp lâm sàng toàn diện, một số tài liệu ghi lại quá trình theo dõi dài hạn trong khoảng thời gian 10 năm. Việc xuất bản cuốn sách này đồng thời với việc sản xuất một đĩa DVD trình chiếu trực tiếp các kỹ thuật phẫu thuật tương tự trong bảy trường hợp lâm sàng. Ca phẫu thuật đã được ghi lại trong các khóa học thạc sĩ về nha khoa cấy ghép do Đại học Bern cung cấp. Các tác giả muốn gửi lời cảm ơn đến các nhân viên của Nhà xuất bản Tinh hoa đã hỗ trợ hết mình trong quá trình chuẩn bị và sản xuất cuốn sách này.

Step-By-Step Procedures

Daniel Buser, DDS, Dr med dent

Professor and ChairmanDepartment of Oral Surgery and Stomatology

School of Dental MedicineUniversity of BernBern, Switzerland

Jun-Young Cho,DDS

Associate ProfessorDepartment of PeriodonticsBaylor College of DentistryTexas A & M University System Health Science Center

Dallas, Texas

Alvin B K Yeo, BDS, MSc

Periodontics UnitDepartment of Restorative DentistryNational Dental CentreRepublic of Singapore

Quintessence Publishing Co, Inc

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

Implantation methods Case Reports WU 600.7 B977s 2007]

RK667.I45S874 2007

617.6'93 dc22

2006033380

© 2007 Quintessence Publishing Co, Inc

Quintessence Publishing Co, Inc

Editor: Bryn Goates

Design and production: Dawn Hartman

1 Basic Surgical Principles 1

Indications for Each Implant Type 17

Surgical Procedures in Standard Nonesthetic Sites 23

Surgical Procedures in Standard Esthetic Sites 39

Surgical Procedures for Implant Placement with 61

Simultaneous Guided Bone Regeneration

Surgical Procedures for Implant Placement with 77

Simultaneous Sinus Floor Elevation

Based on the concept of osseointegration firstdescribed by Brånemark and Schroeder, implant

dentistry has evolved tremendously over the past 15

years, and today it plays an integral role in dental

rehabili-tation Though it was developed primarily to rehabilitate

fully edentulous patients, since the late 1980s the

treat-ment 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

signifi-cant progress made in associated treatment protocols

Development of bone augmentation procedures allows

clinicians to correct alveolar bone deficiencies, while

guid-ed 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 ad vances make implant

therapy more predictable and more attractive to patients,

and the result has been a rapid expansion of implant

den-tistry in daily practice and more clinicians placing dental

implants

This book is the culmination of many years’ effort tostandardize surgical technique in implant dentistry It isdesigned for postdoctoral students and practitioners whowish to perform surgical implant procedures in daily prac-tice with a high predictability for success and a low riskfor complications Basic surgical principles and proceduresfor placing im plants both in standard sites and in siteswith local defects are presented using detailed explana-tions and hand-drawn illustrations The final chapter of thebook presents 14 comprehensive clinical case reports, sev-eral documenting long-term follow-ups over a period of

10 years

The publication of this book coincides with the tion of a DVD featuring live surgery of the same surgicaltechniques in seven clinical cases The surgery was record-

produc-ed during master courses in implant dentistry offerproduc-ed bythe University of Bern

The authors wish to thank the staff of QuintessencePublishing for their excellent support during the prepara-tion and production of this book

Basic Surgical Principles

1

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

pre-operatively 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

surgi-cal principles

Fig 1-1 Smoothing the alveolar crest following flap elevation

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, narrowcrest is smoothed to produce a flat, wide ridge,which is favorable for implant site preparation

Fig 1-1a Once the implant surgical site has beenexposed, a large round bur is used to smooth andlevel the crest of the alveolar ridge

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 1-2d A 2.2-mm-diameter guide

pin is inserted into the initial

prepara-tion to check its posiprepara-tion 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 spiraldrill is easily inserted for preparingthe depth of the site

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

Ñ

Fig 1-2g A profile drill is used to ther increase the surgical access forthe next, larger-size drill

fur-Fig 1-2h Preparation of the implant sitecontinues with the 3.5-mm-diameter spi-ral drill

Fig 1-2i Occasionally, when thebone structure is uniformly dense,bone tapping is performed prior toimplant placement

Fig 1-2j A standard implant is placed in the site, withthe rough surface positioned at the level of the alveo-lar ridge crest This allows the implant shoulder to belocated at the gingival level

Fig 1-3a The

prepara-tion of the implant site

begins with the use of

the nos 1 and 2 round

burs to mark the position

of the implant site

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-diameter spiral drill (E).

Figs 1-3b and 1-3c Any required changes to the marking made with the first roundbur can be accomplished with the no 2 round bur, as shown in this occlusal view Theseinitial steps for the preparation of the implant site ensure the correct implant positionorofacially and mesiodistally

Fig 1-4a Tapping of the bone in the implant site is performedwhen 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), ping of the implant site to one third of the predetermineddepth is done within the crestal area

tap-Fig 1-4c When the alveolar ridge is predominantly cellous bone (ie, types 3 and 4), no tapping of the bone isrequired prior to implant placement

can-Fig 1-4 Pretapping of implant sites with bone of varying density.

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

col-lar This approach is normally used in esthetic implant sites for a submerged implant healing

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-mmmark slightly below the crest, the rough border of theinserted implant will be positioned approximately 0.5 mmbelow the crest This approach is most often used in pos-terior implant sites for a nonsubmerged 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 areduced-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 1-7a 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

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

Fig 1-8 In the maxillary posterior distal extension

situa-tion, 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

≥6

m

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 neckimplant 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

≥7 m m

≥

5 mm

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

≥ 7 mm

≥ 9 mm

Ñ

Figs 1-10e and 1-10f Occlusal (e) and lateral (f) views of

narrow neck implants In sites that require narrow neckimplants, a minimum of 5.5 mm is needed to accommodatethe 3.5-mm-diameter implant shoulder

Figs 1-10g A minimum interocclusal distance of 5.5

mm from the implant shoulder to the opposing

den-tition is necessary to allow the placement of the

abut-ment and crown

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

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

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

Ñ

4–5 mm 9 mm

4 5 m m

9 m m

e

4 5 m

7 8 m

f

4–5 mm 7–8 mm

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

Ñ

g

h

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

11–12 mm

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

posi-tioned 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

Indications for Each Implant Type

2

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

dif-ferent implant types for the various clinical indications of implant therapy More than 25years ago, most implant systems offered just one implant type, primarily to treat fully eden-tulous 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

applica-tion of implants has steadily increased In recent years, the single-tooth gap and the distal

exten-sion 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

func-tion against the opposing dentifunc-tion

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

Fig 2-3a Shorter and wider implants are indicated in the

poste-rior 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 2-3 Wide body implant.

Fig 2-3b Shorter and wider implants are also indicated in theposterior mandible to avoid the mandibular canal Two widebody implants can be placed in the first and second molarsites These implants are restored and, in cases of short 6-mm

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 2-5 Narrow neck implant.

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 standardimplant and a wide neck implant are ideal replacements for amissing second premolar and first molar, respectively

Fig 2-7 Tapered effect implant.

Fig 2-6 For situations in which the posterior distal

exten-sion 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 2-7a 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 taperedeffect implant can also be indicated for early implant placement

Surgical Procedures in

Standard Nonesthetic Sites

3

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

objec-tive 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 uation in the posterior mandible in whichthe canine is the most distal tooth Athree-unit, implant-supported fixed par-tial denture is planned Note the pres-ence of the mental foramen andmandibular canal

sit-Fig 3-1b The surgerybegins with a midcrestalincision made with a no

15c blade The intention

is to maintain an quate band of kera-tinized mucosa onthe buccal and lin-gual woundmargins

ade-Fig 3-1c A no 12b blade

is used to extend the sion through the sulcus

inci-of the adjacent canine

Fig 3-1f Retraction mattress sutures are

attached to the buccal and lingual flaps to

allow sufficient access to the implant sites

Fig 3-1d If indicated, a vertical

releasing incision is made on

the mesial line angle of the

canine on the facial

aspect Releasing

inci-sions are also

posi-tioned in the

sec-ond molar

region

Fig 3-1e A full-thicknessmucoperiosteal flap is ele-vated using a fine tissueelevator to expose thealveolar ridge

Fig 3-1g The retraction sutures are attached

to hemostats to keep the flaps opened and inplace

Fig 3-2 Implant site preparation in a mandibular distal extension situation.

Fig 3-2b A diagnostic Tcaliper is used to deter-mine the distance of theanterior implant from thecanine Because a stan-dard implant is usedhere, a distance of 4 to 5

mm is required from thecanine’s distal root sur-face to the central axis ofthe 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 adepth of 12 mm

Fig 3-2e A 2.2-mm depth gaugewith a 5-mm platform ring isinserted to check the correct dis-tance from the adjacent canine

Fig 3-2a A large round

bur is used in a

counter-clockwise rotation to

smooth any

irregu-larities and level

the alveolar

crest

Fig 3-2f A pair of calipers is used

to locate the position of the

pos-terior implant by measuring a

dis-tance of 14 mm from the anterior

implant

Fig 3-2g The same small roundbur is used to mark the secondimplant site

Fig 3-2h The 2.2-mm-diameterspiral drill prepares the site to adepth of 8 mm to avoid themandibular canal

Fig 3-2i The 2.2-mm guide pins

are inserted into the site

prepara-tions to check their posiprepara-tions and

the parallelism of their axes

Fig 3-2j The openings of theimplant site preparations areenlarged using a larger round bur

Fig 3-2k The 2.8-mm-diameterspiral drill is inserted to the prede-termined depth at each implantsite

Ñ

Fig 3-2n Drilling continues with the use

of the 3.5-mm-diameter spiral drills pared to the correct depths

pre-Fig 3-2o The sink depths and parallelaxes of the preparation sites are againexamined with the 3.5-mm depth gauges

Fig 3-2m The initial profile drills are nowused to prepare the coronal aspect of theimplant site preparations

Fig 3-2l The sink depths and parallelaxes for the implant preparations areexamined with the 2.8-mm-diameterdepth gauges in situ

Fig 3-2r Final verification of the implant

sites is performed with the 3.5- and

4.2-mm-diameter depth gauges in the

anteri-or and posterianteri-or implant sites, respectively

Fig 3-2s For implant sites with a type 1 bone density,pretapping is required to allow easy insertion of theimplant 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 3-2q The preceding steps allow thefinal 4.2-mm spiral drill to be inserted eas-ily and the posterior implant site to beprepared to the correct sink depth

Fig 3-2p Only the posterior implant site

is enlarged with the second profile drill

Fig 3-3 Implant placement in a mandibular distal extension situation.

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

coun-terclockwise direction using a fixation key

Fig 3-3c Final positions of the

stan-dard (left) and wide body (right)

implants

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

Fig 3-3f Complete closure following suturing

In standard posterior sites without bone ciency, a nonsubmerged healing modality isroutinely used Soft tissue healing requires aperiod of 10 to 14 days

defi-Fig 3-3e To preserve the

available band of

kera-tinized mucosa,

gin-givectomy is avoided

Instead, the flaps of

the surgical site are

closed with

inter-rupted single

sutures