Surgical implant protocol 2-step

Treatment planning
  • Verify perio status xray and probe
  • Review diagnostic aids CBCT xrays etc
  • ID key anatomy IAN, mental n, sinus, lingual concavity)
  • Review medical history and meds
  • Review treatment plan
  • Check patient consent signed
  • Check patient has copy treatment plan

Intra operative

  • Review medical history
  • Vital signs if sedation
  • Protect airway when appropriate
  • Review xrays or scans if space issues
  • Ask assistant verify drill position
  • Parallel pin PA
  • Final PA to verify implant position and seating of abutment or screw

Post operative

  • Ab if bone graft
  • CHX
  • Leave with photo-copy consent
  • PA prior restorative phase
  • Schedule follow up visits
  • Written post op instructions
  • Telephone patient after procedure gauge recovery

Prep work

Wipe down entire area with Lysol
2.  Wash hands and use CHX scrub and then place non-sterile gloves.  Set up room according to protocol.  Make sure Kodak is up for patient and on screen in front of patient.  Entire room except light covers can be done with non-sterile gloves.
Patient is seated and is handed medical history form to review.
Confirm AB and have patient take 600mg ibuprofen
ASK patient if they can take ibuprofen and say that it is to decrease post surgical inflammation and pain.
After that is reviewed then the implant consent form is reviewed with doctor and patient signs.
Assistant can dry mucosa with air/water syringe and place topical.
Profound topical placed on dry mucosa
Assistant takes BP then record BP
First step anesthetic by doctor
Give them CHX .12% rinse for 1 minute
Del. rest of 1 carp B and L 4% art. w/ 1:100k epi followed by 1 carp 2% lido. w/ 1:100k epi
Get patient numb as usual, except you never do lower blocks
Place the patient drape and offer them light blocking glasses
Betadine facial scrub (if wanted)
Mouth prop (bite block) and sterilegauze
Surgery
Midcrestal incision with #15, 15c, or 12  blade with two beveled vertical releasing incisions and reflection of tissue just like we do for surgical extractions
Scalpel from this day forward will be called #15, #15c, or #12.  Never use word scalpel or blade again
12 used for lower first molars, sulcus
15 for lower anteriors
15c for lower first molars, midcrestal incisons, upper premolars
Important to remove all tissue from area, we will scrape area with curette and spoons
Careful lingual flap blunt dissection (watch genoid area)
Assistant holds flap closest to them and surgical suction
Implant size is pre-selected, but may change to something bigger if bone is too soft
Osteotomy through hard cortical bone with locator drill first
First drill is the 2.3/2.0 and when it is 1/3 to 2/3 we stop
Place paralleling pin and check for angle and take PA
Finish drilling with 2.3 to length and then go to next size up
2.8 and so on until correct size is reached.
Undersize in maxilla
Just like endo start with small instrument and go to bigger
Save bone shards in sterile dish (maybe)
Once osteotomy (bone hole) is right size then drive in implant

  1. With hand wrench (end with a flat side to buccal)
  2. With motor start at 35 Ncm then increase

Measure and record final torque

Placement implant and then healing cap
or cover screw
Suture
1-2 horizontal mattress 5-0 PGA
sutures on midcrestal or use PTFE
2-3 interrupted 5-0 PGA on releasing
incisions
Suture with PGA suture, lasts 21 days,
also crazy glue over it (don’t do often)
Anesthetic for the road (.5%
bupivicaine)
Motor needs cold sterile saline (Put 2
bags in frig today)
Because uses saline (salt) must clean
more
Post op instructions
Soft food
Peridex
Continue AB if complicated
3x3x3 rule and pain meds if needed
Post op instruction sheet day of
surgery
2 follow-ups
4-7 days ensure no pain and suture is
still sealed
4 months to uncover
2-6 weeks to take impression (OD 2
non-esthetic 4 esthetic 6)
Xrays with 5mm beads
CBCT scans
Day of 800mg ibuprofen 1 hour pre
Day of either (controversial):
Amox 2 grams 1 hour pre-op then 500mg
6 hours later
Clinda 600mg 1 hour pre-op then 300mg
6 hours later
Most unsterile area we have in the
office at any given time is our patient’s mouth.  So while we try for a sterile field we are
nowhere close to sterile
Implant surgical kit with many sterile
parts to help us
Sterile gloves for us
Sterile saline comes out of hand piece
We will use CHX rinse pre and suture
area closed
Betadine facial scrub
2 suctions-one for saliva and one for
surgical area
Lots of gauze best way to keep a mouth
“clean”
Locator drill-vey sharp 1200RPM
Remaining drills at 600RPM
Insert implant at 11 RPM at 30Ncm then
40Ncm then anything under 70Ncm
Insert implant to bone level or
slightly under
Hex (flat side) to buccal
Implant will be placed
A cover screw will be placed
(different than a healing cap)
Cover screw is flat on implant
Tissue will be sutured over the top of
implant and allowed to heal using PGA at first then maybe PTFE later
3-4 months later an incision will be
made and the implant will be uncovered and a healing cap placed
Healing cap heals 4-8 weeks
Analgesics, CHG, AB 5 days
Amoxicillin 500mg TId two days prior and 5 days after or Z-Packs
starting 2 days before
Medrol dose pack starting day of surgery
Pilot 1300rpm rest 600rpm
.5-1mm sucrestal or at bone posterior
Index fixture mount flat side to buccal
2-1.5mm to tooth or 1mm in non-esthetic area won’t have
papilla
 3mm from implant 4mm
for centrals
BL 2-3mm from height of contour
1-1.5mm bone left
Excess bone in dish
C-A 2-3mm from bucco gingival margin for anteriors a little
more go may go below bone level
.5 carp .5% bupivacaine after
Implant at 11rpm  30
ncm no then go 40 no then hand stay under 70ncm
Get a pre evaluation form with things like tissue thickness/biotype,
papilla height/knife edge, and smile line, small incisal contacts
Kit
Hemostat suture, scissors, anesthetic syringe, explorer with
perio probe, mirror, cotton plier, perio elevator Molt #9, Minnesota retractor,
Stainless steel bowlx3, tissue forceps, round scalpel holder, straight and back
action chisel, spoon, endoplugger, gauze
LA
Double mental nerve block and local infiltration
Angle changes with years of resorption from lingual to
labial
Place drill on lingual and copy angle Buccal and Lingual
infiltration only
Post mand
No block
Place drill on lingual and copy angle
M-D angle is matched to root mesial to area
maxilla
Anterior and/or palatal block and buccal infiltration
Anterior-drill on buccal and copy angle
Posterior-drill angle through palatal cusp
M-D angle is matched to root mesial to area
3mm implant to implant
4mm central to central
1.5-2mm from tooth
2-3mm from cervical facial height of contour
2-3mm gingival margin, slightly more in anterior—usually
just flush bone
Pre op PA
Impression of area and check keratinized tissue
Acrylic guide
Measure Tooth to tooth width and vertical
Want 8mm vertical of do screw retained crown
MD 7-9mm PM with a 3 or 4mm implant
MD >12mm use two implants
Take AB 1 hour pre? And 600mg ibuprofen when first arrive.
1 minute Peridex right before and right after.  Then take home bottle
If bone apical of adjacent tooth and ginigva then place
implant and add a tall healing abutment and then advance flap and submerge
healing abutment, gaining several millimeters
For deficient papilla area this also will work.
Place initial incision in place to gain as much attached
tissue as possible, usually to lingual

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