TRADITIONAL SURGERY
The type of surgical guide if any in
conjunction with the bone quality,
volume and type of final restoration (cementable, screwretained,
overdenture, hybrid,
PIB). will drive the surgical
procedure. Any surgical guides are either tissue or teeth borne.
Assuming adequate bone is available the patient is anesthetized and
the tissue sectioned along the edentulous crest. Releasing incisions are
made to create a buccal and a lingual flap. If the papilla to the adjacent
teeth is still intact the releasing incisions will be 1mm to 1.5mm distally
and mesialy respectively from the preserved papilla's. In case there is no
papilla present, the releasing incision line will be made right next to the
existing teeth. The tissue is carefully released away from the underling bone structure
with curettes. Tissue flaps can be tied back with sutures to allow unimpeded
access. Underlying bone structures are visually evaluated to confirm adequate
bone width and length. Sometimes it is necessary to flatten the bony crest
to create a more favorable topography for implant placement, especially when
larger diameter implants are being placed.

Screwretained restoration
The osteotomy should be in the center of the edentulous space in the
mesial distal dimension. Depending on the final restorations modus of fixation
and whether the restoration is for a anterior or posterior tooth, the buccal
lingual position of the osteotomy varies. Anterior screw retained restorations
require a screw access hole through the cingulum and the osteotomy therefore
has to be more lingual with no labial inclination. Cementable anterior
restorations are more forgiving in regards to the labial-lingual position
of the osteotomy. The osteotomy for cementable anterior implant restorations
should be in the center of the proposed final restoration and a slight
labial inclination.

Cementable restoration
Posterior screw retained restorations dictate a dead
center lingual-buccal position, directly underneath the central fossa of the
future final restoration with no inclination buccaly or lingualy. As with
anterior cementable implant restorations, posterior cementable restorations
are more forgiving in regards to the buccal-lingual osteotomy position and
inclination.

Safety zones
The bone is scored with a round drill through the guide or free hand, followed by the
pilot drill according to the drill
protocol to establish the correct osteotomy depth and angulation.
Copious amounts of pre cooled, sterile saline solution should be used to
irrigate the drills and bone. Successively larger diameter drills are used to
widen the osteotomy in accordance with manufacturer guidelines in regards
to bone quality and implant diameter to achieve the most ideal osteotomy
dimensions. The final osteotomy should have a zone of safety of 1.5mm to 2mm
to any vital structures (adjacent roots, mandibular canal). If implants are
to be placed next to each other 3mm of space should exist from one implant
to the next.

Tap drill
Depending on the bone quality and structure, the bone is pre tapped only at the
cortical crest or the complete depth of the osteotomy. D3 and D4 type bone
will in most instances not require pre tapping. Instead the implant is allowed
to tap itself in to the softer bone at the time of implant insertion in to the
under sized osteotomy. Once the osteotomy is finalized the implant is picked
up with a high torque surgical motor and driven in to the osteotomy site with
a low speed (30rpm) and clock wise setting. Avoid contaminating the implant
body by touching or placing the implant on the instrument tray before insertion.

Feature indicator
The polished collar of the implant should be above or flush with the crest of the
bone, depending on manufacturer recommendation. Disconnect the surgical motor from the implant and evaluate the implant position. The anti rotational
feature of the implant should be positioned in relation to the angulation
of the implant. The implant carrier or fixture mount of the implant has in
most cases markings indicating the anti rotational feature position.
For instance, if the implant is inclined toward the buccal, the indicator
should be on the buccal as well. If the inclination is towards the mesial,
the marker needs to be on the mesial too. Utilize a hand ratchet to
finalize proper implant position and remove the implant carrier.

Two stage surgery
Closing the tissue can be done as a one stage or two stage procedure.
Minor bone graft procedures may be performed before suturing the implant site.
A two stage surgery requires suturing the tissue flap over the installed
implant at the initial implant placement and a second surgery after the
initial healing period to uncover the implant. The two stage protocol involves
installation of a low profile cover screw (included with most implants)
before closing the tissue over the implant and changing the cover screw
with a trans mucosal healing abutment (often a separately purchased item) at
the second stage uncovery. This approach requires additional time to let the
tissue heal and mature around the trans mucosal healing abutment.

One stage surgery
A one stage surgery entails
suturing the tissue around the trans mucosal healing abutment at
the time the implant is placed, eliminating a second surgery to uncover the
implant. The trans mucosal healing abutment is installed instead of the cover
screw and the tissue sutured around the healing abutment, allowing the tissue
to heal and mature around the trans mucosal healing abutment. A reduced treatment time frame, less
trauma and scarring in addition to reduced treatment cost make this option
a popular treatment choice.