1. Surgical Principles- I. Basic Implant Surgery

Rapid Search Terms

First stage: Surgical techniques Surgical Principles, Flap management, sutures, antibiotics, implant stability


Book Chapters to read.

  • Misch. Density of Bone: Effect on Surgical Approach and Healing. pp 645-667. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.
  • Misch. Posterior Single Tooth Replacement: Surgical Guidelines (CH 30). pp 668-683. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.
  • Misch. Root form Surgery in the Edentulous Anterior and Posterior Mandible: Implant Insertion (CH 31). pp 684-719. Contemporary Implant Dentistry, Misch, C.E., 3rd Edition, 2008, Mosby Year Book.
  • Klokkevold, Han, Park. Standard Implant Surgical Procedures. (CH 71). pp 663- Carranza’s Clinical Periodontology; Newman, Takei et al., 2012, 11th edition, Elsevier.


Basic Implant surgical principles

The effect of heat on bone

  1. Eriksson RA, Albrektsson T. The effect of heat on bone regeneration: an experimental study in the rabbit using the bone growth chamber. J Oral Maxillofac Surg. 1984 Nov;42(11):705-11.
  2. Sener BC, Dergin G, Gursoy B, Kelesoglu E, Slih I. Effects of irrigation temperature on heat control in vitro at different drilling depths. Clin Oral Implants Res. 2009 Mar;20(3):294-8.

Basic Implant Flap Design

  1. Plonka AB, Sheridan RA, Wang HL. Flap designs for flap advancement during implant therapy: a systematic review. Implant Dent. 2017 Feb;26(1):145-152.
  2. Lemos CAA et al. Comparison between flapless and open-flap implant placement: a systematic review and meta-analysis. Int J Oral Maxillofac Surg. 2018 Apr 20 epub ahead of print.
  3. Naeini EN et al. Long-term clinical outcome of single implants inserted flaplessly or converntionally. Clin Implant Dent Relat Res. 2018 Oct;20(15):829-837.
  4. Oh T, et al. Effect of flapless implant surgery on soft tissue profile: A randomized controlled clinical trial. J Periodontol 2006; 77:874-882


Initial Implant stability: 1-versus 2-stage Implant Placement

  1. Esposito M, Grusovin MG, et al. Interventions for replacing missing teeth: 1- versus 2-stage implant placement. Cochrane Database Syst Rev. 2009 Jul 8;(3):CD006698
  2. Siadat H, et al. Does implant staging choice affect crestal bone loss? J Oral Maxillofac Surg. 2012 Feb;70(2):307-13.
  3. Manzano-Moreno FJ. Factors Affecting Dental Implant Stability Measured Using the Ostell Mentor Device: A Systematic Review. Implant Dent 2015 Oct;24(5):565-77. Accessed via OVID.
  4. Valderrama P, et al. Evaluation of two different resonance frequency devices to detect implant stability: a clinical trial. J Periodontol 2007 78:262-272.
  5. Barewal RM, Oates TW, Meredith N, Cochran DL. Resonance frequency measurement of implant stability in vivo on implants with a sandblasted and acid-etched surface. Int J Oral Maxillofac Implants. 2003 Sep-Oct;18(5):641-51.

Implant Suturing

  1. Silverstein LH. Essential principles of dental suturing for the implant surgeon. Dent Implantol Update. 2005; 16:1-7.
  2. Silverstein LH, Kurtzman GM, Shatz PC. Suturing for Optimal Soft Tissue Management. 2009. J Oral Implant 35 (2): 82-90
  3. Khiste SV, Ranganath V, Nichani AS. Evaluation of tensile strength of surgical synthetic absorbable suture materials: an in vitro study. J Periodontal Implant Sci. 2013 Jun;43(3):130-5.


  1. Ahmad N, Saad N. Effects of antibiotics on dental implants: a review. J Clin Med Res. 2012 Feb;4(1):1-6.
  2. Esposito M, Grusovin MG, Worthington HV. Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications. Cochrane Database Syst Rev. 2013 Jul 31;7:CD004152.
  3. Tan WC, et al. Effect of systemic antibiotics on clinical and patient-reported outcomes of implant therapy – a multicenter randomized controlled clinical trial. Clin Oral Implants Res. 2014
  4. Deeb GR, et al. Antibiotic Prescribing Habits of Oral and Maxillofacial Surgeons in Conjunction with Routine Dental Implant Placement. J Oral Maxillofac Surg. 2015 Oct;73(10):1926-31.
  5. Salomó-Coll O, et al. Do Penicillin-Allergic Patients Present a Higher Rate of Implant Failure? Int J Oral Maxillofac Implants. 2018 Nov/Dec;33(6):1390-1395.


Surgical Principles I- Basic Implant Surgery”

The effect of Heat on bone:

Eriksson 1984

“The effect of heat on bone regeneration: an experimental study in the rabbit using the bone growth chamber”

P:to evaluate the effect of increased temperature on initial osteogenesis in implants into bone by using the newly developed bone growth chamber, which permits numerical quantification of the rate of growth of ingrowth bone after a defined thermal injury


  • n=30 healthy rabbits were anesthetized, bone growth chamber was inserted in the tibial metaphysis of the animal.
  • When the implant is inserted into bone, bone tissue will grow through the canal which permits a numerical estimation of ingrowing bone regeneration.
  • Thermal injury was induced via a voltage-regulated heating element screwed onto the threaded implant.
  • The animals were divided into 3 groups, (A) 50C for 1 min, (B) 47C for 1 min, (C) 44C for 1 min.
  • After a healing period of 4 weeks, the bone chamber was removed with a trephine.
  • The implant was taken apart and the ingrown tissue was collected for computerized microradiographic evaluation and histologic examination.

R:Group (A) and (B), 50C and 47C for 1 min, caused significantly reduced bone formation in the implants while no significant effects were observed at group (C) after heating to 44C for 1 min.

BL:Heating to 44C for 1 min caused no statistically significant observable disturbances of tissue regeneration.

Changes: none

Clinically:The reaction of bone tissue to heat is an important surgical problem during drilling and cutting. Copious irrigation, and short lag time between drills is critical to cool the tissue down in order to avoid impaired bone regeneration

Sener 2009

Title: “Effects of irrigation temperature on heat control in vitro at different drilling depths”

P: To measure the bone temperature at various drilling depths and investigate the effect of the irrigation solution temperature on heat generation.

M&M: Fresh frozen edentulous segments of bovine mandibles were sectioned into 12 X ???? 6 cm pieces and divided into three groups: drilling without irrigation, and drilling with irrigation using saline at either 25 or 10°C.

The temperature was measure at 3, 7, and 12 mm depth using Thermoresistors (placed at 0.5 mm from the drilling cavity walls).

R:The maximum temperatures recorded:

-Without irrigation: 50.9, 47.4, and 38.1°C at depths of 3,7, and 12 mm, respectively.

-With irrigation using saline at 25 and 10°C: the maximum temperatures at a depth of 12 mm were 37.4 and 36.3°C, respectively.

-With irrigation using both 25 and 10°Csaline: were below body temperature.

C: This in vitro study showed that more heat was generated in the superficial part of the drilling cavity than at the bottom. Therefore, external irrigation at room temperature can provide sufficient cooling during drilling. Lower temperature saline was more effective in cooling the bone, and irrigation of the site should be continued between the drilling steps.

Flap Management

Topic: Flap Design

Authors: Plonka AB, Sheridan RA, Wang HL

Title: Flap designs for flap advancement during implant therapy: a systematic review.

Source: Implant Dent. 2017 Feb;26(1):145-152.

DOI: 10.1097/ID.0000000000000510

Type: systematic review

Keywords: dental implant; guided bone regeneration; alveolar ridge augmentation; flap design; passive tension flap

Background: Successful GBR relies on 4 properties: PASS, primary wound closure, angiogenesis, stability, and space maintenance. Flap design and releasing techniques can facilitate primary closure, thereby eliminating wound tension, preventing loss of blood supply that can lead to tissue necrosis. Membrane exposure is the most common complication of GBR and can have a negative effect on the regenerative potential of the graft.

Purpose: to group flap reflection techniques for varying degrees of augmentation procedures with the goal of promoting passive primary wound closure to maximize GBR success.

Methods: Literature search completed using PubMed. Flap designs were grouped by their ability to achieve flap extension.

Results: Flap design based on need for flap advancement:

Mild flap (1-3 mm)

-Esthetic buccal flap: immediate implants in esthetic zone due to buccal plate defect likely to result in implant fenestration. Reflection of full thickness flap with horizontal incision in keratinized tissue 3mm apical to free gingival margin followed by 2 vertical releasing incisions extending past mucogingival junction.

-mucogingival pouch flap: also used for grafting buccal dehiscences or fenestration defect at implant placement. Papilla preservation incisions and MGJ incisions for “soft tissue camouflage”. May be useful in areas with thin tissue due to not splitting the flap to achieve primary closure.

-periosteal pocket flap: proposed for horizontal augmentation of knife-edge ridges indicated for staged GBR then implant placement. Splitting buccal flap into mucosal and periosteal components to increase flap elasticity. Mesial and distal vertical releasing incisions provide additional extension.

-lateral incision technique: another staged approach of GBR and implant placement. Lateral incision performed from palatal/ lingual aspect to create a split and full-thickness combined flap. Combined flap design to reduce soft tissue complications as compared with crestal incisions

Moderate flap advancement (4-6mm)

-buccal pedicle flap: to use with ePTFE membranes and later converts to absorbable cellulose membranes. Used at socket preservation or immediate implant placement to allow for soft tissue coverage without discrepancy in MGJ, loss of vestibule, limited KT which can all result from overextension of flap. Buccal keratinized gingival from adjacent tooth used as donor for soft tissue coverage over the membrane through a pedicle or free gingiva graft approach.

-vascularized periosteal membrane: used for primary closure over grafted sockets after flapless extractions. Absorbable membrane may or may not be used. Full -thickness buccal and palatal flaps raised and the additional flap extension is achieved by internally splitting the palatal flap in half from apical aspect to form pedicle and unfolding it over the graft site.

-lingual pedicle: like the vascularized periosteal membrane, this also involves rotated split-thickness connective tissue pedicle from palate.

-palatal advanced flap: similar to lateral pedicle soft tissue graft, rotation of L-shaped split thickness pedicle from palate.

-coronally positioned palatal sliding flap: creating split-thickness planes of palatal tissue from a full-thickness flap to allow for sliding and rotation.

Major flap advancement (7mm and greater)

-Hockey stick flap: full thickness buccal flap has hockey-stick shaped apical extension of vertical incision. Lingual flap extension atleast 3 teeth and involves raising mylohyoid muscle.

-remote flap: modification of hockey-stick with extension of flap in edentulous areas 5mm beyond the graft site.

-double flap: midcrestal horizontal incision with single vertical incision at mesial aspect to preserve blood supply.

-multilayer approach: principles of plastic and microsurgery to obtain double partial thickness buccal flap along with coronally positioned palatal sliding flap.

Discussion: Complications have been reported up to 25% of the horizontal and 45.5% of vertical bone augmentation procedures. Primary issue associated is early exposure of membrane. Surgical complications include damage to vascular and neurologic structures. Mandible: lingual and sublingual artery. Maxilla: greater palatine neurovascular bundle. This review provides strategies that have been proposed since the advent of GBR to increase flap mobility, extension, and length for passive primary closure. Vertical releasing and cutbacks with periosteal scoring provide flap extension to cover a variety of bone graft volumes. Dissection of split-thickness flaps and harvesting of pedicle grafts may augment soft tissue quantity.


Topic: flap vs flapless implant placement

Author: Lemos CAA et al

Title: Comparison between flapless and open-flap implant placement: a systematic review and meta-analysis

Source: Int J Oral Maxillofac Surg 2018

DOI: 10.1016/j.ijom.2018.04.002

Type: systematic review

Keywords: flapless, full thickness, surgical approach, dental implant, systematic review

Purpose: systematic review that compares the clinical performance of flapless implant placement and implant placement with elevation of the mucoperiosteal flaps


  • Focused question: In patients in need of dental implants (P) treated with a flapless approach (I) compared to open-flap implant placement (C) how did survival, marginal bone loss and complications (O) differ
  • Inclusions: randomized controlled trials (RCT), prospective studies. With ≥10 patients that compare the two surgical techniques (flapless and flapped)) in the same study, minimum follow-up of 6 months.
  • Exclusions: in vitro studies, animal studies, case reports, studies with data repeated in other included articles, studies that evaluated only one surgical approach.
  • Two independent reviewers performed a comprehensive search of the PubMed/MEDLINE, Scopus and Cochrane Library databases for publications until December 2017.
  • 559 references identified, among which 24 (13 RCTs and 11 prospective studies) were included in the qualitative and quantitative analyses.
  • 1025 patients (mean age 51.38) who received 1873 dental implants (898 flapped and 975 flapless) included.
  • Mean follow up duration was 21.62 months.
  • Various implant systems used with lengths of 8-18mm, diameters of 3.5-5mm
  • Single crowns were the most common prostheses
  • 15 studies evaluated both arches, 6 evaluated maxillary arch only and 3 evaluated mandibular arch.


  • NSSD between flapless and open-flap surgical techniques in terms of implant survival rates, marginal bone loss, or complication rates
  • 34 (1.92%) of 1770 analyzed implants failed, among which 21 (2.29%) were flapless and 13 (1.53%) were open flap.
  • There was no difference for marginal bone loss comparing open-flap and flapless surgical techniques but there was a high heterogeneity.
  • Complication rates were similar between the two surgical techniques. Complications occurred in 31 (8.03%) of 386 flapless implants and in 29 (7.55%) of 384 open flap implants. Biological factors such as peri-implantitis were the most commonly reported complications.


  • Implant survival rate, marginal bone levels, and complications of flapless surgery were similar to those of open-flap surgery over a mean follow-up period of 21.62 months


Topic: flap v. flapless

Author:Naeini EN, Dierens M, Atashkadeh M, DeBruyn H

Title: Long-term clinical outcome of single implants inserted flaplessly or conventionally

Source: Clin Implant Dent Relat Res 2018; 20(15): 829-837

Type: clinical prospective

Keywords: flapless surgery, long-term, peri-implantitis, single implant, TiUnite surface

Purpose: to evaluate long-term (6-9yrs) survival, marginal bone levels, peri-implant health, and complications of single implants placed either flapless or with a conventional flap.


  • 36 Patients from a previous implant study were recruited for follow-up at 6-9 years.
    • requirements were insertion of implants >7mm in length and 3.3-5mm diameter in healed bone with extractions at least 3months prior.
    • only thick biotypes were used forflapless
  • For the flapless technique, bone sounding was done to determine the ridge dimensions
    • A round pilot drill was used to create a punch.
  • For the flap technique, afull-thickness flap was laid and then implant insertion followed
  • Under-preparation of osteotomies in both groups was performed to ensure primary stability.
  • Implants were placedequi-crestal in the flap group and 3mm sub-mucosal in the flapless group.


  • 15 implants were placed using a flap and 22 were placed flapless.
  • All implants wereBranemark TiUnite external hex.
    • Implants were restored with both screw-retained and cement-retained
  • The average bone loss after 6-9 years was 0.49mm for the flap group and – 0.89mm for the flapless group
    • SSD favoring bone gain around flapless implants.
  • 3% of implants were a success (<2mm bone loss) and 100% survival.
  • PD and BOP, NSSD between the flap and flapless groups
    • average PD 3.4mm
  • No implant was diagnosed with peri-implantitisbut peri-implant mucositis was seen in 70%
  • 24% had at least 1 complication over the6-9 year
    • NSSD between flap and flapless procedures.
    • Cement-retained crowns had more complications thanscrew-retained crowns.


  • flapless implants showed comparable results to flap implants after 6-9 years.
  • high quantity of bone and thick gingival tissues that do not need augmentation are necessary for flapless technique

Oh 2006

Title: “Effect of flapless implant surgery on soft tissue profile: A randomized controlled clinical trial”

P:To examine the soft tissue profile changes of single-tooth implants in the premaxillary region after flapless implant surgery, comparing immediate loading (IL) to delayed loading (DL).

M&M:Randomized parallel-arm controlled clinical trial, 24 patients with single-tooth replacement in the premaxillay region were randomly assigned into two groups (12 IL, 12 DL). The IL group had loaded implants with a temporary crown in occlusal contact immediately after placement and a permanent crown was placed 10-14 days later. The DL group had implant placed with a healing abutment and loaded after 4 months. Custom surgical stents were made for each patient, the tissue was ink-marked using this stent and a 4-mm tissue punch was performed at this site. No flaps were raised. All procedures were performed by two periodontists. The restorative portion was performed by two experienced prosthodontists. Clinical parameters were measured at baseline (implant loading), 2, 4, and 6 months by a single blinded examiner.

R:Mean age was 45 y/o and no significant difference between the two groups. 14 Women and 10 men. Six implants were placed in the maxillary incisor region and the remaining in the maxillary premolar region. At the time of placement there was NSD between groups in bone quality and soft tissue thickness. 3 failures were observed in the IL group. Overall implant survival was 87.5% (100% for DL and 75% for IL). Soft tissue profile remained stable up to 6 months with no significant difference between the two groups for both papillary index (PPI) and marginal levels of soft tissue (mBI). The DL group remained constant while the IL group had a significant increase in PPI in the first two months. There also were no clinical differences found in other clinical parameters (PD, bleeding, plaque, and width of KG).

BL:Creeping attachment might occur within 2 months after immediate loading. A flapless approach for single-tooth implants can provide esthetic soft tissue results for IL or DL. Longer clinical trials with larger sample size are recommended to verify these results

Implant Stability

Topic: Implant Placement

Author: Esposito M, Grusovin MG, et al.

Title: Interventions for replacing missing teeth: 1- versus 2-stage implant placement.

Source: Cochrane Database Syst Rev. 2009 Jul 8;(3):CD006698

DOI: 10.1002/14651858.CD006698.pub2

Type: Discussion

Keywords: immunology, pathogenesis, hypersensitivity, inflammation

Purpose: To evaluate whether a 1-stage implant placement procedure is as effective as a 2- stage procedure.


  • Electronic search was conducted Cochrane Oral Health Group’s Trials Register, CENTRAL, MEDLINE and EMBASE. Authors of all identified trials, an Internet discussion group and 55 dental implant manufacturers were contacted to find unpublished randomizedcontrolled trials (RCTs)
  • 1 stage vs 2 stage implant placement needed to be with the same type of implantsand followed up for at least 6 months after loading.
  • Outcome Measures:
    • Implant failure was defined as implant mobility and removal of implants dictated by progressive marginal bone loss or infection.
    • Examined radiographic bone loss, complications, soft tissue recession, prosthesis failure, and implant failure.


  • 5 RCT’s included 761 implants in 239 patients. 375 1 stage and 386 2 stage
  • Astra TiO2, IMZ titanium plasma sprayed, Branemarkturned surface, Strauman SLA tapered effect implants.
  • Load free healing period was 3 to 4 months for mandibular implantsand 6 months for maxillary implants.
  • 23 implants failed in 1 patientin the 1-stage group. 9 implants failed in 8 patients in the 2-stage group
  • Meta-analysisperformed and no difference was found between the two groups related to prosthesis failure or implant failure.

Discussion: The number of patients included in the trials was too small to draw definitive conclusions. The 1-stage approach might be preferable in partially edentulous patients since it avoids one surgical intervention and shortens treatment times, while a 2-stage submerged approach could be indicated when an implant has not obtained an optimal primary stability or when barriers are used for guided tissue regeneration

Topic: Crestal bone

Author: Siadat H, et al

Title: Does implant staging choice affect crestal bone loss?

Source: J Oral Maxillofac Surg. 2012 Feb;70(2):307-13.

DOI: 10.1016/j.joms.2011.09.006

Type: Randomized Clinical Trial

Keywords: Crestal bone, single-stage, 2-stage protocol

Purpose: To compare implants placed using a single-stage protocol, compared with those using a 2-stage protocol, have an increased risk of crestal bone loss.


  • Inclusion criteria were
    • age older than 21 years, good oral hygiene, 3 adjacent teeth missing in the posterior mandible, a sufficient amount of bone (10 mm) in the recipient sites, occlusal loading with the antagonistic natural teeth, and type II or III bone,
  • 1 implant was inserted using the 1-stage procedure and 1 was placed using the 2-stage approach
  • Implant position (posterior or anterior) were randomized for single or 2 stage protocol
  • Crestal bone loss measured using radiographs after implant insertion, FPD delivery (3 months post-surgery) and after 6 and 12 months of loading
  • Noble 10mm and 4.3mm diameter used
  • Surgery
    • All patients received OHI and must have plaque score less than 20%
    • Crestal incision and mucoperiosteal flap reflected
    • Single stage: implant was placed, and a healing abutment was immediately connected.
    • 2-stage: implant was inserted, and a cover screw was then placed. Wound closure over the 2-stage implant was achieved using horizontal mattress and interrupted sutures
      • 10 weeks after placement, implant uncovered, and healing abutment placed
    • Patients received antibiotic and anti-inflam meds 1 hour after implant placement.
    • Sutures removed 7 days post-op
    • CHX prescribed
    • RPD with 2mm spacer fabricated for patient
    • 3 months after implant placement, FPD fabricated with Gold metal and ceramic were cemented using temporary cement (Tempbond)


  • 11 subjects: 3 women and 8 men (age 21-57)
  • 34 implants placed (17: 1- stage and 17 :2-stage)
  • Three months after implant insertion
    • 2-stage approach caused significantly more crestal bone loss than the 1-stage approach
  • After 6 months of functional loading
    • 1-stage and 2-stage implants showed similar bone levels
  • At 1 year of loading, both continued to show similar crestal bone loss


The present results suggest that the crestal bone loss around implants does not depend on whether the implant is placed using a 1-stage or 2-stage approach. The initial increase crestal bone loss of 2-stage may be due to indirect loading of mucosa


Topic: Implant Stability

Author: Manzano-Moreno FJ.

Title: Factors Affecting Dental Implant Stability Measured Using the Ostell Mentor Device: A Systematic Review

Source: Implant Dent 2015 Oct;24(5):565-77


Type: Systematic review

Keywords: dental implants; stability; resonance frequency analysis; systematic review

Background: The Ostell mentor device uses resonance frequency analysis (RFA) to measure implant mobility and stiffness, yielding the results as implant stability quotients (ISQs), which range between 1 (lowest stability) and 100 (highest).

Purpose: The aim of this systematic review was to explore all factors that might influence dental implant stability as measured with the Ostell Mentor device.


  • Search conducted to include all randomized clinical trials and clinical trials related to factors potentially influencing the stability of dental implants as measured with Ostell Mentordevice
  • 39 articles included inreview
  • Inclusion criteria = publication in English; RCT or clinical trial; study in humans; andthe utilization of Ostell Mentor device to measure dental implant
  • Exclusion criteria = failure to address the PICO question; utilization of device other than Ostell Mentor to measure implant stability; experimental study design; systematicreview or meta-analysis; nonavailability of the full text; publication other than English


Dental Implant Design

  • Langfound NSSD in primary stability between cylindrical vs tapered design (55.8 vs 56.7) when implants placed immediately
  • Hofound higher ISQ values for Branemark vs Nobelactive until 2 months; then NSSD
  • Gultekincompared bone loss and stability for implants with internal conical connection vs platform switch, initially ISQ higher in platform switch; NSSD after 3 months
  • Dursumcompared standard platform to platform switch, ISQ higher in standard at baseline and 6 months
  • Nienkempercompared implant length, higher baseline ISQ for 9mm versus 11mm; NSSD at 4 weeks
  • Schatzlecompared sandblasted/acid etch titanium surface to standard SLA, sandblast/acid etch SSD higher ISQ at 12 weeks
  • Karabudacompared sandblasted/acid etch titanium surface to standard SLA, found SSD higher ISQ at loading stage in sandblast/acid etch
  • Oatescompared sandblasted/acid etch titanium surface to standard SLA, found NSSD ISQ at 6 weeks
  • Geckilicompared stability of titanium dioxide grit-blasted dental implants with and without fluoride, early decrease in ISQ values observed in those without fluoride
  • Abtahishowed bisphosphonate eluting fibrinogen coating improves the fixation of dental implants, greater ISQ for coated vs uncoated baseline to 6 months

Surgical Techniques

  • Turkyilmazcompared ISQ using thinner drills, SSD ISQ increase in implants placed in maxillary posterior region
  • Blaszczyszynfound NSSD in primary stability between implants in beds prepared with conventional burs versus ultrasonic devices
  • Garcia-Moralesfound NSSD primary or secondary stability in implants treated with low-level laser versus nonirradiated implants
  • Markovicfound SSD higher ISQ using later bone condensing versus conventional bone drilling technique
  • Shayestehfound SSD higher ISQ for beds prepped by osteotomes vs conventional burs
  • Tallaricofound NSSD in ISQ between 1 vs 2 stage Nobel implants in premolar/molar area CBCT Bone Density and RFA values
  • Merhebfound SS linear relationship between ISQ and CBCT bone density voxel values at placement and loading
  • Songreported SS correlation between voxel values and ISQ values
  • Turkyilmazfound SS correlation between mean voxel values and ISQ values at implant placement.
  • AksoySS correlation between mean voxel values and ISQ values
  • Fuster-TorresSS relationship between mean voxel values and ISQ values

Methods Used to Measure Dental Implant Stability

  • RabelNSSD between the mean insertion torque and the mean ISQ value immediately post implantation or at 3 months with either self-tapping or non– self-tapping implants
  • Ohand Kim SS negative correlation between ISQ and Periotest values and concluded that both appear useful to predict primary implant stability and determine loading

Loading Time on ISQ values

  • JacksonSS lower ISQ values in immediately loaded versus conventionally loaded orthodontic palatal implants at 8 weeks
  • GüncüNSSD in mean ISQ values over a 12- month follow-up between ILand CL implants in mandibular sites
  • CannizzaroNSSD in ISQ values between IL and early loaded implants
  • LeeNSSD in mean ISQ values at placement or 8-month post-surgery between implants loaded with a hybrid prosthesis with a conventional rigid bar splinting the implants and those loaded with a semirigid cantilever extension system with titanium bars placed in the 2 distal abutment cylinder

Augmentation Techniques

  • CannizzaroNSSD at implant placement or at 3 months or 1-year post-loading in the ISQ values of early loaded implants between those in maxillary sinus augmented with a lateral approach using 50% particulated autogenous bone/50% Bio-Oss and those in crestally augmented sinus using autogenous bone
  • BorgesNSSD in ISQ values between implants placed with and without intraoral autogenous bone graft at implant placement or at 6 months
  • Al-KhaldiNSSD in mean ISQ values between dental implants placed in grafted versus nongrafted anterior maxilla at implant placement or at abutment
  • DegidiNSSD in ISQ values between 80 implants placed in grafted or nongrafted


  1. Primary implant stability can be influenced by themacrodesign of dental implants, and roughness- enhancing surface treatments can increase ISQ values in later osseointegration phases, improving secondary implant
  2. Primary implant stability is lesser with lower bone density and may be enhanced by theutilization of thinner drills (underpreparation) or osteotomes when the bone density is
  3. There is a significant direct correlation between CBCT-measured voxel values (gray scale)and RFA ISQ values, indicating that CBCT bone density data are useful for managing implant treatments.
  4. Authors have concluded that ISQ values are not influenced by the loading protocol althoughtheir findings should be interpreted with caution given the differences in study eligibility criteria between the groups receiving immediate and conventional
  5. No study has detected significant differences in dental implant stability as a function ofbone augmentation

Valderrama 2007

Title: “Evaluation of two different resonance frequency devices to detect implant stability: a clinical trial”

P:Evaluate the ability of electronic and magnetic RFA devices to detect changes in stability during early healing following implant placement and to determine whether implant stability quotient values obtained correlates between these devices

M&M:34 non-submerged titanium implants studies in 17 patients (14 females, 3 males) average age 52y/o, each patient received 2 implants, either in the maxillary posterior (4) or mandibular posterior (30), all cylindrical screw-type diameter of 4.1mm, 8mm to 10mm in length. Stability was measured at placement and weekly until week 6 at which implants received provisional restoration and at 12 weeks when final restoration was seated. ISQ data was collected 3x per visit and values were averaged.

R:ISQ at placement using electric device was 61.9, increased to 63.2 at 12 weeks. With the magnetic device, ISQ was 70.6 at placement, 75.9 at 12 weeks. Both methods indicated a pattern of decreased mean stability from week 1 to 3 post placement, small fluctuation in ISQ from week 3 to 6 and significantly increased mean stability from week 6 to 12. From placement to 12 weeks, both electronic and magnetic correlated significantly

BL:implant stability changes can be monitored by both magnetic and electronic devices with both methods confirming the initial decrease in implant stability that occurs following placement and the eventual increase in stability during the first 6 weeks of functional loading

Barewal 2003

Title: “Resonance frequency measurement of implant stability in vivo on implants with a sandblasted and acid-etched surface”

P: To determine the changes in stability as a reflection of early healing around single-stage, roughened-surface implants in humans utilizing resonance frequency analysis (RFA). RFA makes use of a transducer, attached to an implant, which is excited over a range of sound frequencies with subsequent response analysis.

Hypothesis: The first hypothesis was that RFA can be used clinically to detect changes in implant stability during the early healing period for nonsubmerged, roughened-surface implants. The second hypothesis was that RF values show varying stability patterns based on the bone type surrounding the implant and the implant location.

M&M: Twenty patients had 1 to 4 implants placed in the posterior maxilla or mandible. Bone type was classified into 1 of 4 groups according to the Lekholm and Zarb index (1985). RFA was used for direct measurement of implant stability on the day of implant placement and consecutively once per week for 6 weeks and at weeks 8 and 10. Each visit involved questioning the patient with regard to pain level, removal of the cover screw, and placement of the transducer via hand tightening.

R: Twenty-seven ITI SLA implants placed in the premolar and molar regions of the maxilla and mandible were evaluated. Early failure occurred with 1 implant related to parafunction. The remaining 26 implants were distributed as follows: 29.6% in Type 1 bone, 37% in Type 2 or 3 bone, and 33.3% in Type 4 bone. The lowest mean stability measurement was at 3 weeks for all bone types. The percentage decrease in stability from baseline to 3 weeks was highest for Type 4 bone (8.6%), as was the percentage increase in stability from 3 to 10 weeks (26.9%). A Bonferroni adjusted Student t test comparison of bone groups at each time point revealed highly significant differences between implant stability in Types 1 and 4 bone at 3 weeks (P = .004) and a moderately significant difference between Types 2, 3, and 4 bone (P = .08) at 3 weeks. Implant stability did not change significantly during the 10-week period in Type 1 bone (P .10). With the same test, by 5 weeks, no bone groups showed any difference in implant RFA measurements (P = 1.0).

D: This study demonstrated the lowest values for implant stability at 3 weeks after placement for all bone types. This effect was statistically significant and most pronounced in Type 4 bone. Improved biomechanical characteristics (high % bone to implant contact) of the roughened-surface implant and implant length (length impacts RF value) could affect the stability patterns during the early healing period.

C: There was no significant difference in the pattern of stability changes among different bone types after 5 weeks of healing.

Lekholm and Zarb Bone classification (1985):

Type 1- Oak wood: Hard and dense, less blood supply, takes about 5 months to integrate with implants

Type 2- Pine wood: Not as hard as Type 1, takes about 4 months to integrate with implants

Type 3- Balsa wood: Not as dense as Type 2, takes time to fill in so takes about 6 months to integrate with implants

Type 4- Styrofoam, least dense, takes about 8 months to integrate with implants


Silverstein 2003

Title: “Essential principles of dental suturing for the implant surgeon”

Silverstein 2009

Title: “Suturing for Optimal Soft Tissue Management”

This article was a review of suture materials as well as suture techniques.

Suture Thread

  • Desired qualities: appropriate tensile strength, tissue biocompatibility, ease of tying, allowance of minimal knot slippage
  • Select specific suture thread and diameters based on thickness of tissue and whether tension-free mobile tissues are present.
  • When tissues won’t regain preoperative strength, or the surgical flaps aren’t tension free: use a suture that retains long term strength for up to 14 days and resorbs in 3-4 weeks (PGA)
  • In tissues that heal rapidly: select a resorbable suture that will lose its tensile strength at same rate as the tissue gains strength

2 Mechanisms of Absorption result in degradation of absorbable sutures

  • Sutures of biological origin (Plain and Chromic Gut) are digested by intraoral enzymes
    • Affected by low pHrapid breakdown
  • Sutures from synthetic polymers (PGA) are broken down by hydrolysis in tissue fluids
    • Unaffected by low pH
  • 5-0 thread diameter: most often used to secure soft tissue grafts
  • 4-0 thread diameter: used to secure most other periodontal flaps
  • 3-0 thread diameter: in implant dentistry, used to secure flaps when a mattress suture is placed. And then a 4-0 thread is used closer to flap edges to coapt the tension-free flap edges

Natural or Synthetic Non-resorbable Materials

  • Silk=multifilament”wicks” or pulls bacteria and fluid into wounds
  • Polyester=multifilament, high tensile strength, less knot security
  • E-PTFE=monofilament, high tensile strength, good knot security, more expensive


  • Most common suture needles in dentistry=3/8 and 1/2 circle needs
  • 1/2 circle needle used in more restricted areas
  • Always use a reverse cutting suture
  • Prevents the suture from tearing through the papillae or surgical flap edges
  • Has a smooth inside concave curvature (unlike conventional sutures)
  • The 3/8 reverse cutting needle with a 3-0 or 4-0 thread diameter
  • The 1/2 reverse cutting needle with a 5-0 or 6-0 thread diameter
  • Knots
  • Slip (Granny) Surgical knots=silk, e-PTFE, Chromic gut, plain gut
  • Surgeon’s Knot=PGA and other non-absorbable synthetic sutures
  • Suturing Techniques

Interrupted Suture Technique

**Interrupted sutures should be used only with tension-free mobile flaps and should have needle penetration 3mm from wound edges

  • Mattress Technique
    • Used in areas where tension-free flap closure cannot be accomplished
    • Generally used to resist muscle pull, evert the wound edges, and adapt the tissue flaps to underlying structures.
    • Usually use a 3/8 reverse cutting needle (3-0 or 4-0)
    • Mattress sutures are typically left in for 14-21 days
    • Many variations
    • The needle penetration through the flap should be about 8mm away from the flap edge, or just coronal to the MCG, ALWAYS IN KG

Khiste 2013

Title: “Evaluation of tensile strength of surgical synthetic absorbable suture materials: an in vitro study”

P:To evaluate the tensile strength of surgical synthetic absorbable sutures over 14 days under simulated oral conditions. Tensile strength (TS): time it takes for suture material to lose 70-80% of initial strength. Dependent on rate of resorption.

M:PGA (polyglycolic acid), PG910 (polyglactin), and PGC (poly(glycolide-co-e-caprolactone)) used in 4-0 and 5-0 gauges. 210 total samples (35 each material and gauge tested) Suture samples: Sutures were tied with surgeon’s knot around flexible rubber tubing for consistent loop size and slid off. Oral simulation: Artificial saliva and sterile human serum used to mimic oral environment. pH was kept between 7.4 and 8.1. and temp at 37C.Tensile strength: Tensile strength was measured using Universal UltraTest machine by stretching each suture to failure and recording max load in Newtons (N). Sutures were tested before immersion, at 1 hour, 1, 3, 7, 10, and 14 days. Sutures were innontensile state in oral environment simulation solution.

R: All sutures intact at 14 days and able to be tested. At baseline (preimmersion), the 4-0 sutures had a significantly higher TS than the 5-0 sutures for all three materials until day 10. All materials in all gauges had negligible TS at day 14. All materials/gauges maintained their TS at 1 hour and 24 hours immersion. 4-0 guage: PGA had max TS at base line, day 7, and day 10. All had negligible TS at day 10. 5-0 gauge: PGC had max TS at baseline but all 3 were similar until day 10 and all had negligible TS at day 14.

D:14 day evaluation period was based on clinic relevance and usual time of suture removal. PGA had the highest TS at baseline and maintained strength for 3 days. PG sutures had the least TS but maintained it until days 7 and 10. PGC had the second greatest TS at baseline and maintained it until day 7. All sutures had negligible TS at day 14. 4-0 sutures were stronger and had greater TS than 5-0 sutures for all materials, with PGA (which has been shown to have better handling than silk and catgut) showing the highest TS at day 10, making it a good candidate if TS would be required after 10 days.

C/BL:The results of this study indicate that synthetic absorbable sutures can be used in surgery, although suture selection should be based on the demands of the healing would and the surgeon’s



Ahmad 2012

Title: “Effects of antibiotics on dental implants: a review”

P:The purpose of this study is to review the current literature and information on dental implants and antibiotics prophylaxis. The authors’ objectives are to identify whether or not antibiotics are beneficial to implants, and the circumstances in which pre- and/or postoperative antibiotic regimes should be prescribed.

M&M: A systematic review of literature was accomplished using the electronic databases, PubMed, Medpilot, and Medline. The search terms used were, antibiotic, prophylaxis combined with dental implant, implant failure, osseointegration and oral implant. Studies that met the inclusion criteria were in English, made between 1955 to January 2009 and were retrospective or retrospective that evaluated the effect of pre-operative, post-operative or no antibiotics on the failure rate of dental implants. The inclusion criteria also required that studies be with no loading and must provide the antibiotics regimen used, proper timeline of the implant procedure, follow ups within the first 5 months and the study sample only include low risk patients. An unsuccessful dental implant was characterized by any implant which failed within the first 3 months. Only six studies met the inclusion criteria.

R: The results revealed that there is no significant difference between the success rate of implants with and without use of antibiotics. The overall success rate of implants placed with an antibiotic regimen was 96.5%, while those placed without an antibiotic regimen was 92%.

C: The use of antibiotics pre or/and postoperatively does not significantly affect the success rate of dental implants. The authors recommend that chlorhexidine digluconate (CHX) can be used as an adjunct to implant placement to reduce the risk of infection. They also recommend that guidelines on antibiotics prophylaxis established by American Dental Association (ADA), American Heart Association (AHA), and American Association of Orthopedic Surgeons (AAOS) should be used. In addition, for low risk patients undergoing implant placement, a thorough physiologic, anatomic, and scientific evaluation must precede prescription of antibiotics.

Esposito 2013

Title: “Interventions for replacing missing teeth: antibiotics at dental implant placement to prevent complications (Review)”

P:The purpose of this article is to evaluate the beneficial or harmful effects of systemic prophylactic antibiotics at dental implant placement versus no antibiotic or placebo administration and if antibiotics are beneficial, to determine which type, dosage and duration is most effective.

M&M: Randomized controlled clinical trials with a follow up of at least 3 months. The type of participants included any group of people who were undergoing dental implant placement. The types of interventions included: 1) Administration of prophylactic antibiotics versus no antibiotics/placebo 2) Administration of different antibiotics 3) Administration of different doses or different durations of the same antibiotic. The type of outcome measures were divided into Primary Outcomes: 1) Implant failure which was considered as implant mobility and removal of stable implants dictated by bone loss or infection 2) Prosthesis that could not be placed or prosthesis failure if secondary to implant failures. Secondary Outcomes: Postoperative infections, adverse events. Detailed search strategies were developed: Cochrane Oral Health Group’s Trials Register, Cochrane Central Register of Controlled Trials, MEDLINE via OVID and EMBASE via OVID. There were no restrictions on language or date of publication.

R: Six randomized controlled trials suggest that short term antibiotics, 2 g or 3 g of amoxicillin administered one hour prior to implant placement, or 1 g of amoxicillin one hour prior to implant placement and 500 mg four times a day, for two days postoperatively, significantly decreases early implant failure. Only two minor adverse events were reported, one in the antibiotic group and one in the placebo group, which means that an antibiotic regimen may not have a significant negative impact on the participant’s well-being.

C:The six trials included suggest that administration of antibiotics significantly reduces early failure of dental implants. Using 2 or 3 gr. of amoxicillin orally, one hour preoperatively, significantly reduces failure of dental implants.

Tan 2014

Title: “Effect of systemic antibiotics on clinical and patient-reported outcomes of implant therapy – a multicenter randomized controlled clinical trial”

P: To determine the effect of various systemic antibiotic prophylaxis regimes on patient- reported outcomes and postsurgical complications in patients undergoing conventional implant installation.

M&M: Material and methods: Three hundred and twenty-nine healthy adults in need of conventional implant installation were randomly assigned to one of four groups: (i) preoperatively 2 g of amoxycillin 1 h before surgery (positive control, PC), (ii) postoperatively 2 g of amoxicillin immediately following surgery (test 1, T1), (iii) preoperatively 2 g of amoxicillin 1 h before and 500 mg tid on days 2 and 3 after surgery (test 2, T2), (iv) preoperatively 2 g of placebo 1 h before surgery (negative control, NC). Subjects were examined clinically by blinded examiners over 8 weeks after implant installation. In addition, Visual Analogue Scales (VAS) for pain, swelling, bruising and bleeding were obtained over 14 days. ANOVA was performed for the VAS. Chi-square tests were applied for postsurgical complications.

R: All VAS scores were low for all groups and decreased over time (P < 0.001). There were no significant differences for the VAS scores between the various groups at any time point (P > 0.05). There was only a significant difference in flap closure at week 4, where NC had 5% of the subjects not achieving complete wound closure compared to 0% for the three other groups (P = 0.01), with no other significant differences for any postsurgical complications (P > 0.05).

C: For healthy, non-smokers, or light smokers (<20 cigarettes/day receiving single implant therapy in pristine bone – antibiotics will not improve PATIENT REPORTED experience with respect to swelling, pain, and bleeding post-operatively. However, the NC group that got placebo, more people in this group reported taking analgesics for each of the 14 days questioned compared to other groups. No evidence exists to the superiority of any particular Abx regimen, should the decision to use one be made.


Topic: antibiotics

Author: Deeb GR, et al

Title: Antibiotic Prescribing Habits of Oral and Maxillofacial Surgeons in Conjunction with Routine Dental Implant Placement

Source: J Oral Maxillofac Surg. 2015 Oct;73(10):1926-31.

Type: review

Keywords: dental implants, antibiotics, prophylaxis, oral surgery

Purpose: To determine the current antibiotic prescribing habits of oral and maxillofacial surgeons in during routine dental implant placement to determine whether any consensus has been reached among such practitioners.

Methods: An electronic survey was sent to members of th ACOMS. Questions were tailored to ask about whether antiobiotics were regularly administered either pre or post-op and what antibiotic, dosage and regimen they were using.

Results: A total of 217 members responded to the survey. Results are summarized in the table below:

Question: Frequency:
Prescribed abx pre-op 51.6%
Prescribed abx post-op 71.4%
Both pre and post-op 34%
Most common pre-op abx Amoxicillin 2 gr given 1 hr before, 32%
Most common post-op abx Amoxicillin 500 mg tid for 5 days, 53%

Conclusion: The study found no consensus among oral and maxillofacial surgeons regarding the use of antibiotics in association with routine dental implant placement, the type of regimen to use, or whether such use is even effective in preventing early implant loss. Furthermore, most of the antibiotic regimens being used are not in accordance with the recommendations current in the published data.


Topic: Antibiotics and Impalnts

Author: Salomo et al.

Title: Comparison of restoratively projected and surgically acceptable virtual implant position for mandibular overdentures.

Source: Do Penicillin-Allergic Patients Present a Higher Rate of Implant Failure?

Type: cross-sectional

Purpose: To determinate if patients allergic to penicillin present a higher incidence of dental implant failure compared with nonallergic patients


  • Prior to implant placement surgery, all patients underwent periodontal examination; in cases of a Plaque Index > 20%, the patient received root scale and polishing. If periodontal disease persisted, implant surgery was postponed until achieving periodontal health.
  • Prophylactic antibiotic therapy was prescribed, a single dose of 2 g of amoxicillin taken orally 1 hour before surgery for non–penicillin-allergic patients and 600 mg of clindamycin taken orally 1 hour before implant surgery for penicillin-allergic patients.
  • Antibiotics were prescribed to prevent early implant failure and post- operative infection: amoxicillin 750 mg three times a day for 7 days. In the cases of penicillin allergy, 300 mg clindamycin were administered every 6 hours for 7 days
  • Failures were classified as: (1) early failures, occur- ring before abutment connection; or (2) late failure, after abutment connection. Implant failure was de- fined as the removal of the implant for any reason.


  • 1210 patients were analyzed with a mean age of 61 for men and 58 for women. 1133 patients reported no PCN allergy and 77 presented with an allergy.
  • Patients in both groups were comparable regard- ing age, sex, general health status, periodontal health, number of implants, implant brand, surgical approach, type of restoration, and distribution of implants in the jaws,
  • Implant failure was 8% in the non-allergic group and 24.68% in the PCN allergic group (SSN).
  • In penicillin-allergic patients (at the patient level), 21.05% of the failures were classified as late implant failure and 78.95% as early implant failure.
  • 2,747 implants were included in the study; 133 failed in non–penicillin-allergic patients (5.17%), and 33 failed in penicillin-allergic patients (18.86%)
  • The main reason for implant failure in PCN allergic patients was early and due to lack of osteointegration.

Conclusion: Penicillin-allergic patients treated with clindamycin were almost four times more likely to suffer dental implant failure, compared with non–penicillin-allergic patients. However, other variables such as implant brand, implant location, and the surgeon’s skills should be taken into consideration.