| Rapid Search Terms | |
| Surgical Technique | Flap Management |
| Lekholm and Zarb Bone classification | Implant Stability |
| Sutures | Antibiotics |
Introduction to Dental Implantology Seminar Course
First stage: Surgical techniques Surgical Principles, Flap management, sutures, antibiotics, implant stability
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.
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.
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.
Oh T, et al. Effect of flapless implant surgery on soft tissue profile: A randomized controlled clinical trial. J Periodontol 2006; 77:874-882
Park JC, Hwang JW, Lee JS, et al. Development of the implant surgical technique and assessment rating system. J Periodontal Implant Sci. 2012 Feb;42(1):25-9.
Valderrama P, et al. Evaluation of two different resonance frequency devices to detect implant stability: a clinical trial. J Periodontol 2007 78:262-272.
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.
Silverstein LH. Essential principles of dental suturing for the implant surgeon. Dent Implantol Update. 2005; 16:1-7.
Silverstein LH, Kurtzman GM, Shatz PC. Suturing for Optimal Soft Tissue Management. 2009. J Oral Implant 35 (2): 82-90
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.
Ahmad N, Saad N. Effects of antibiotics on dental implants: a review. J Clin Med Res. 2012 Feb;4(1):1-6.
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.
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
Surgical Principles I- “Basic Implant Surgery”
“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
M:
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.
Critique: small sample
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
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°C saline: 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.
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
Title: “Development of the implant surgical technique and assessment rating system”
P: The aim of this study is to develop and establish an objective assessment tool for teaching and evaluating the surgical competence for dental implant placement by residents.
M: Articles published in peer-reviewed English journals were selected using several scientific databases and subsequently reviewed regarding surgical competence and assessment tools. Particularly, medical journals reporting rating and evaluation protocols for various types of medical surgeries were thoroughly analyzed. Based on these studies, an implant surgical technique assessment and rating system (iSTAR) has been developed. Also, a specialized dental typodont was developed for the valid and reliable assessment of surgery.
R: The iSTAR consists of two parts including surgical information and task-specific checklists. Specialized simulation model was subsequently produced and can be used in combination with iSTAR.
C: The assessment and rating system provided may serve as a reference guide for teaching staffs to evaluate the residents’ implant surgical techniques.
Critique: Well-designed model that could be used to help train residents for implant placement.
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
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
Title: “Essential principles of dental suturing for the implant surgeon”
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 pHrapid 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
Needles
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
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**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
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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 in nontensile 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 preference.
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.
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.
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.
Designed By Steven J. Spindler, DDS LLC
