Surgical techniques IN IMPLANTOLOGY
Surgical techniques
In surgical time
In two surgical stages
- Introduction
Since Brånemark’s work on osseointegration and its clinical application in 1980, implantology has developed considerably and new surgical techniques have appeared. We will deliberately limit ourselves to the description of a classical approach that has largely proven its effectiveness.
- Material
Standard oral surgery equipment:
Mirror, periodontal probe, scalpels (blade 11 or 15), blunt detachers, retractors, elevators, curettes, claw forceps, needle-holding forceps, suture thread, compresses, suture scissors, suction cannulas.
Specific equipment:
Surgical kit supplied with the implant used, consisting of drills of increasing size, taps if necessary, parallelism rods, special screwdrivers, hand or ratchet tightening keys, implant holder.
Surgical micromotor and contra-angle:
It is necessary to be able to benefit from a sufficiently powerful torque, to avoid problems of bone heating, and an adequate gear ratio range.
Surgical techniques IN IMPLANTOLOGY
- Premedication
Antibiotics:
Given the septic nature of the oral environment, some authors recommend prescribing antibiotics 1 hour before the procedure and continuing for 6 days. However, implant surgery does not justify such a prescription in a healthy subject.
Analgesic:
A level 1 analgesic such as paracetamol is sufficient, to be prescribed one hour before and then every 4 hours for 48 hours.
Anti-inflammatories:
A short course of corticosteroid therapy (3 days) to be started on the morning of the procedure is very effective in preventing the discomfort associated with postoperative edema.
Sedatives:
Depending on the patient’s state of anxiety, hydroxysine may be prescribed one hour before the procedure and possibly the evening before, while monitoring drug interactions.
- Operating protocols
- Two-stage buried technique
- Technique name buried in a single operating time
- The buried technique
- First surgical time
- Anesthesia
The placement of dental implants is most often performed under local anesthesia. The anesthesia protocols will concern soft tissues, bone, on an edentulous site having no sensory innervation of its own (Gaspard 1979). Anesthesia, coupled with a vasoconstrictor, allows intervention on a zone with little blood. The injection must be slow, with a liquid that has been warmed if possible.
Surgical techniques IN IMPLANTOLOGY
- Incisions
Several incision lines have been described. Today the trend is to make a primary incision line on the crest or offset in the keratinized mucosa. This line is possibly continued by secondary vestibular and/or lingual discharge incisions while respecting the marginal gingiva of the adjacent teeth.
The detachment is classic. It will allow full-thickness flaps to be raised, i.e. including the periosteum. It will be carried out using a foam detacher, step by step, and over the entire length of the main incision. A compress placed at the end of the detacher can be usefully used, which ensures hemostasis on the one hand, and protects the flap on the other hand.
- Preparation of the implant site
The drilling technique should be sequential, under abundant irrigation with sterile physiological serum. Bone necrosis may occur in the presence of a temperature above 47 °C for one minute
- The drilling technique
- . Crossing the bony cortex
After placing the surgical guide, the cortex is crossed using a high-speed round burr (1500 to 2000 rpm depending on the authors). - Depth of the implant site or initial drilling
It is achieved with a 2 mm diameter drill bit used at high speed. This drill bit has burial marks corresponding to the different lengths of the selected implant. The preparation axis must be checked in the three planes of space with the surgical guide and a direction indicator or parallelism rod - Intermediate drilling
Allows the preparation to be widened by 2 to 3 mm using a blunt-end drill inserted into the preparation calibrated at 2 mm. The rotation speed is 1000 to 1200 rpm - Terminal drilling . (so-called standard implant of 3.75 or 4 mm in diameter) It calibrates the bone site over its entire height according to the diameter of the implant that we wish to place. A graduated gauge will allow us to check the depth of the drilling. Some manufacturers offer several terminal drills of different diameters depending on the bone density (a wider drill being indicated in denser bone).
- Cervical flaring
If, at the body level, the calibration must be undersized to allow the coils to ensure good primary anchoring of the implant, this is not the case at the cervical level. Indeed, there is generally a smooth neck whose intraosseous insertion requires the creation of cervical flaring using a flaring drill with a blunt end and a flared working part. The rotation speed is reduced: 500 to 800 rpm - Tapping
Most new implants are self-tapping. Tapping will only be indicated in the presence of high bone density. The preparation is carried out at a very slow speed (15 to 20 rpm), hence the need for motors with interesting torques at low speed. The thread will be carried out over all or part of the height of the preparation without exerting pressure and removed, by reverse rotation, without excessive traction. - Implant placement
The implant is positioned in the direction of the preparation. The rotation speed must not exceed 20 to 40 rpm, the insertion being done without constraint. It is buried up to the coronal limit of its body then continued manually using a tightening key to obtain the complete disappearance of the thread in the bone and the correspondence of the cervical flare with the internal bevel. At this stage the implant must be completely immobilized and give a clear sound to axial percussion.
- Installing the cover screw
Intended to protect the internal thread of the implant during the burial period, it is inserted using a screwdriver mounted on a contra-angle (15 to 20 rpm) then manually screwed
- Flap repositioning and sutures
After removing any fibrous and bony debris from the surgical site and then irrigating it abundantly, the flap is gently repositioned. The more carefully it is handled, the less difficult the post-operative period will be. Simple stitches are sufficient to ensure good hermeticity of the flap.
- Second surgical stage
After 6 months of burial in the maxilla and 3 to 4 months in the mandible, the implants are uncovered and “put into operation”. This involves giving the implants an intra-oral emergence by replacing their cover screw with healing screws or with more or less high and flared abutments. The rearrangement of the soft tissues necessary for this intervention can be used to treat other mucogingival problems.
- Noticed
But we will first of all evaluate, clinically and radiologically, the good osteointegration of the implants characterized by:
· Absence of pain
· Lack of mobility
· Production of a clear sound on axial percussion
· Absence of peri-implant radiolucent border
- Implant localization : The surgical guide used for implant
placement is retained and the mucosa is marked with an anesthetic needle, a round burr, or a periodontal probe. Implants can also be localized by X-ray or transparency.
Surgical techniques IN IMPLANTOLOGY
- Operculization :
A full-thickness incision is made on the crest or slightly lingual. A slight detachment is made to allow access to the cover screws, then two small possible relieving incisions on either side of the screw to allow apical displacement of the small detached flap. - The cover screw will then be replaced by the chosen intermediate element, then hermetic sutures will be made. The gingival tissues can also be capped with a circular blade mounted on a contra-angle, which allows the entire attached gingiva to be preserved.
- One-time technique
There is no burial of the implant during the bone healing period. Some researchers have shown that the burial of the implant is not a condition for its osseointegration. Indeed, the placement of implants designed for the submerged technique (Brånemark type) and connected from the first intervention to their transgingival abutments gives success rates similar to those encountered with a classic approach. The non-burial of the implants will allow the patient to avoid a second intervention, certainly less uncomfortable than the first, but which is no less tedious and stressful for him.
- Conclusion
Implantology has been booming for several years. New protocols associated with innovative implant surface conditions are presented with results that appear exceptional in terms of speed and success. These techniques must be reserved for specific indications and require careful “selection” of patients. Our obligation of means encourages us to deviate as little as possible from the conditions defined by Brånemark which guarantee, with a long hindsight, a maximum success rate.
Dental crowns are used to restore the shape and function of a damaged tooth.
Bruxism, or teeth grinding, can cause premature wear and often requires wearing a retainer at night.
Dental abscesses are painful infections that require prompt treatment to avoid complications. Gum grafting is a surgical procedure that can treat gum recession. Dentists use composite materials for fillings because they match the natural color of the teeth.
A diet high in sugar increases the risk of developing tooth decay.
Pediatric dental care is essential to establish good hygiene habits from an early age.