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The implant procedures  
There are different techniques that can be used for the surgical placement of dental implant. It depends on the particular conditions of the case, doctor’s preferences, and dental implant system used. First let's take a look on a classical 2 step implant surgery, which is the most common technique used for dental implant placement.
 
Classical 2 step implant surgery  d_implant_1.jpg                                                         Edentulous area to be restored by implants
Stage 1
 - Surgical placement of implant
1. When you come for the surgery, you will be given a surgical consent form, describing the procedure and possible complications. It is a good time to address any questions and concerns. After you sign the consent form, you will be anesthetized and surgery will soon begin.




2. Doctor will make a cut in you gum along the crest of the bone and push it to the sides to access the bone.


                                                                                                                                                                 X-ray showing surgically placed dental implants

3. Using different sizes of special drills, doctor will drill inside the bone to make a path for an implant.

dental_implant_2.jpg

Doctor will start with thin drills, gradually moving to thicker ones. The diameter of last drill will be slight smaller than the diameter of the selected implant. Surgical drills have a canal inside its body to allow constant water irrigation, which is necessary to cool down the bone, preventing it from overheating.
4. Implant is screwed inside the bone. Necessary x-rays can be taken during the procedure


5. A surgical cover screw is inserted into the top if the implant to prevent bone and tissue to grow inside the implant. 6. Gum is placed back and sutures are used.

Doctor will give you all necessary prescriptions and instructions. In 7-10 days, you come back for suture removal and follow up. There will be several other follow-up visits to monitor the healing process until such time that the implant is ready to be restored with a prosthetic. 

Stage 2 –Uncovering the implant                                                                                                   Left dental implant with healing collar


 What happens after dental implant is osseointegrated? den_im_3.jpg
 
After the doctor has concluded that implant integration is complete, the dental implant has to be uncovered:
  1. Local anesthesia is administered.
  2. A small incision is done in the gum, allowing doctor to unscrew the surgical cover screw.
  3. Healing cover placed instead of the surgical screw, projects above the gum preventing it from closing over the implant. Sutures  are placed to hold the gum back in place.
  4. One week later doctor will remove stitches, and after few more days of healing implant is ready for restoration.


Implants with restoration abutments (posts)

den_imp_4.jpg

Immediate Placement Of implant  ( Implant Placement into fresh extracted site )

When the tooth has to be extracted, and the implant is a choice of treatment for substitution of removed tooth, immediate placement of implant into extracted site could be done. There are a lot of advantages to this technique. In aslassical 2 stage technique described above, after the extraction is done, we would wait for about 6 month for the bone to build up, and then proceed with the implant surgery. The immediate placement of implants eliminates this 6 month waitng period, no second surgery required, healing process of implant (osseointegration) runs as natural process (your body buids up the new bone in the extracted site where the implant placed). There are some limitations though, when this procedure can be done (severe infection, cortical bone lose). Your doctor will advise you if the immediate placement of implant is the right procedure for you.

The next implant case presentation describes surgical placement of two implants, one of them is classical two stage technique, another is the extraction and immediate placement of implant.

Implants case presentation
X-ray showes decay under the crown # 18
existing_bridge.jpg

53 years old female presented in the office for  the exam. Intaraoral and X-ray examination revealed severe decay under the crown supporting the bridge. The decay was so extensive, that the could not be saved. Since the other teeth uder the bridge did not require any urgent treatment, it was decided to cut the bridge, leaving antertior crowns intact (## 20, 21), extract back tooth #18, and place two implants # 18, as an immediate placement implant, and # 19, where the tooth has been missing for a while.  4.7 mm diameter and 13 mm length internal hex Zimmer implants were planned to be placed. Patient was explained  the nature of the surgery and possible complications. All her questions were answered. To prevent possible secondary infection, patient was placed on antibiotic regimen 4 days before the scheduled surgery, also she was prescribed and instructed to use PeridexR as mouth rince solution.

                                                                                                                                             Intraoral picture of existing bridge
Existing_bridge1.jpg


Patient arrived at the surgery at her scheduled time. It was verified that she was taking prior prescribed medications. All her questiones were answered once more, she was anesthetized, and the bridge was cut between crown # 20 and pontic 19. Back part of the bridge was removed.



Bridge was cut

Bridge_was_cut.jpg

Demolished # 18 ( after bridge removal)

demolished_tooth.jpg

 Incision was made along the crest of the bone between demolished # 18 and tooth #20. Periosteal flap reflected using periosteal elevators. The remaining roots of the # 18 carefully extracted with luxators to preserve integrity of the bone.

Periosteal Flap opened

flap.jpg

Tooth # 18 is removed

tooth_extraction_site.jpg

Osteotomy was performed in the area of planned implant sites. Drills of increasing sizes were used. The widest drill 4.4 mm was used to make a 13 mm path for the implant.

Osteotomy.jpg
Each tooth implants is placed in corresponding sites. Hand ratchet is used to screw the implant (with implant driver) into the place. Control X-ray is taken.

Implant with implant driver placed in the bone
tooth_implant_with_implant_driver.jpg
Same picture from a different angle
tooth_implant_with_implant_driver.jpg

X-ray showing implants in place

implant_xray.jpg

Implant drivers removed and position of each tooth implant was verified.

Implant driver removed
implant_placed.jpg

 Surgical cover screw placed into the tooth implant


Gum placed in its place and silk sutures placed to hold the gum. Patient is given instructions and due back in the office in one week for removal of sutures.

Sutures placed
impl12.jpg
One week later sutures were removed and patient is scheduled in two weeks for the follow up visit.

Sutures removed
sutureremoval.jpg

One Step Implant Placement Procedure

Depending on the particular situation 1 step surgical implant placement technique may be used. Instead of making a line incision and opening the flap doctor will use the special round knife("tissue puncher")  to cut off a round piece of the gum in the area of projected implant(punch technique). Ostoetomy performed thru this opening, and the implant screwed directly in. Instead of puting the surgical cover, doctor will place righty away the implant healing color, having it exposed above the gum line and preventing the gum from closure. Implant remain exposed and there is no need for the second surgical stage -openning of the implant. This technique is used more and more. Besides the fact that there is no need for second surgery, the postsurgical discomfort and pain much less than in a 2 stage technique procedure.
 

Immediate Load implants

Immediate load implants are the implants which are being restored the same visit as their surgical placement. More and more implant manufactures advertize some of their implants as an immediate load. Immediate loading is posssible in the areas of the mouth and in patients with "strong" bone. If possible to use immediate load implants has some advantages. I will dedicate the separate page for immediate load implants soon



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