IMPLANT SURGERY

Implant Dentistry

Jaime L. Lozada, DDS

Professor, Restorative Dentistry
Loma Linda University
Loma Linda, California

INTRODUCTION
Implant surgery involves a series of steps (incision, preparation of the osteotomy site
using progressively larger drills, threading the bone, and implant placement) that
systematically results in the placement of a dental implant (figure 1) (video A, B, C).

DENTAL IMPLANT SURGERY CHECKLIST

A well organized protocol includes thorough diagnosis and treatment planning. Proper
planning requires that the practitioners involved in the care of the patient jointly discuss
the various phases of the patients treatment. The restoring dentist and the surgeon (team
approach) must decide on all the details prior to the surgical appointment (reference #1).
The team must decide if the patient is an appropriate candidate for dental implants;
determine where the prosthetic teeth will be located; fabricate a radiographic template;
radiographically verify that bone is present beneath the proposed sites for the prosthetic
teeth; identify the number, type and location(s) of the implant(s) that will be placed;
design the prosthesis; fabricate a surgical template that identifies where the implants
should be located during surgical placement; determine the cost and number of
appointments; and determine whether the implants should be placed using a stress
reduction protocol. While most implants can be placed using local anesthesia, some
patients manage the process better using a stress reduction protocol whereby the surgery
if performed in conjunction with intravenous sedation or oral sedatives (reference #2)
(figure 2). These details must be discussed with the patient along with the benefits of
treatment, alternative treatments, and the risk of complications associated with the
treatment so they can ask questions and understand the plan of treatment, thereafter being
sufficiently knowledgeable that they can sign the informed consent document (a
document that must be signed by the patient before treatment begins).

The following items are often used as a checklist before surgery.

Treatment Plan
Consent Form
Pre/Post Surgical Instructions
Surgical Template
Radiographs
Implants
Graft Materials

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INFORMED CONSENT

The following is a list of items often discussed during the presentation of the informed
consent form to patients undergoing dental implant treatment.

When Should Implants Be Used

There are at least four specific situations in which oral implants can provide the treatment
of choice. They are: (1) certain situations in which a single tooth must be replaced, (2)
the replacement of several teeth where there are insufficient remaining teeth to make a
traditional type of prosthesis that attaches to your remaining teeth, (3) the replacement of
all of the teeth of a jawbone, and (4) the replacement of portions of the jawbone for
functional or cosmetic reasons.

Methods of Replacing Teeth

1) Replacing one tooth: The conventional method of replacing a single missing tooth is
with a fixed partial denture which is cemented to the teeth on either side of the missing
tooth. The simplest and most conservative form of a fixed partial denture is a resin
bonded prosthesis. This involves a minimum reduction of tooth structure, but can only be
used under certain ideal circumstances. A conventional fixed partial denture requires that
the teeth on either side of the space be reduced in size to make room for metal or metal-
and-ceramic crowns which will be cemented onto the prepared teeth. The artificial
replacement tooth is attached to these crowns prior to cementation. When properly made
and cared for, these restorations can last for many years.

When the teeth on either side of a missing tooth have already been structurally weakened
from decay or other causes, then crowns are indicated, and the fixed partial denture is the
treatment of choice. However, when the teeth involved are completely sound and there is
adequate bone remaining in the space formerly occupied by the missing tooth, then an
implant that can stand by itself without placing crowns on the adjacent teeth should be
considered. In this instance, the implant may be the most conservative restoration.

2) The replacement of several teeth in the same general area: When two or three
adjacent teeth are missing, a fixed partial denture may still be the treatment of choice
depending on the amount of bony support of the teeth adjacent to the missing ones. The
more missing teeth there are, the greater the load that is placed on the remaining teeth.
When the load becomes excessive, a fixed partial denture will be less likely to succeed.
In such situations, a removable partial denture will have to be considered to replace the
missing teeth. A removable partial denture can be partially supported by the soft tissue
(gums) and underlying bone and thus take some of the load off the remaining natural
teeth. A removable partial denture has the advantage of being less costly, but also has
several disadvantages. It is considerably more bulky than a fixed partial denture, requires
daily removal for cleaning and may be less stable. For these reasons it is usually more
difficult to learn to wear.

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3) The replacement of all teeth in a jaw: The conventional method of replacing all the
teeth in a dental arch is with a complete denture, but if the jawbone provides insufficient
support, implants may be needed and the jawbone may have to be built up.

A complete denture rests on the soft tissue (gums) and underlying bone and when used in
the upper arch it can spread the chewing loads over the entire roof of the mouth. Forces
that might tend to dislodge the denture are offset by a seal and surface tension which
forms between it and the roof of the mouth. This seal helps to keep the denture in place.
Most people are able to adapt reasonably well to an upper complete denture. However, a
lower complete denture is considerably more difficult to learn to wear. The loads are
concentrated over a smaller area and a seal usually cannot be developed to stabilize the
denture. Also, the movement of the tongue and other muscles tends to place more
dislodging forces on a lower complete denture than on an upper.

Pressure on the soft tissue (gums) and bone under the dentures can cause slow changes in
the underlying bone which result in the dentures losing their fit. For this reason complete
dentures should be professionally examined at regular intervals, and when the tissues
show sufficient change, the dentures should be relined, rebased, or remade, depending on
the specific condition. When improperly fitting dentures continue to be worn, the
pressure is concentrated in small areas and the bone is lost more rapidly. Eventually, so
much bone can be destroyed that a complete denture can no longer be made to fit. When
this occurs, an implant may have to be considered.

When treatment is rendered early enough, an implant can be made to fit the remaining
bone. If the condition is allowed to continue too long, the jawbone may become so thin
that it can fracture from a very minor blow or sometimes just from biting something hard.
When the bone becomes this thin, in addition to placing an implant, it becomes necessary
to build the bone back up again. Sometimes this can be done with bone from a bone bank
or bone substitutes, but often the best results can only be achieved by grafting bone to the
jaw from another part of the body such as the hip. This must be done in a hospital.

Benefits
Dental implants permit missing teeth to be replaced by inserting substitute metal roots
into the jawbone and attaching new teeth to the implants.

A single tooth, multiple teeth, or an entire jaw of teeth can be replaced by using dental
implants. Using the implants to support and retain the replacement teeth has several
benefits. The implants help preserve bone in the areas where teeth are missing. The
replacement teeth are attached to the implants which provides better comfort and
stability. The improved comfort and stability makes people feel better and can help one
to look better. The ability to chew food is often enhanced which can improve ones diet
and expand the type of foods being eaten.

Risks
All surgical procedures have certain risks. Whenever surgery is done on the lower
jawbone, especially toward the back of the mouth, there is a very small risk of damaging

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the nerve which carries sensation from the lower lip to the brain. If this nerve is damaged
there can be a loss of feeling or a change of feeling in the lower lip and chin, which can
vary from tingling, itching, burning, feeling cold, feeling hot, or feeling partially or
completely numb. Of course, such damage is not likely to occur. When it does occur,
the feeling will usually return gradually to its normal state within a few weeks to a few
months. However, if the nerve is severely damaged, the resulting numbness could last
for many years or be a permanent change. Similar damage can occur to the nerve from
the tongue, but this is rare.

Whenever an endosseous implant is placed near an existing tooth it is possible that the
tooth root may be damaged during the preparation of the bone to receive the implant.
While such damage is extremely unlikely, if it were to occur it would in all probability
heal uneventfully, though it is conceivable that a condition might develop which could
result in the loss of the tooth.

Other surgical risks are bleeding, bruising, infections, and swelling.

Most implant procedures can be carried out under local anesthesia. This is the safest
form of anesthesia but it does have certain inherent risks which range from minor local
reactions to severe allergic reactions which can result in death. Such reactions are very
rare. When general anesthesia or sedation are required, risks can range from minor
infections of the veins to death and essentially everything in between. Again, such
occurrences are rare.

Prognosis of Dental Implants

Dental implants are made from exceptionally strong materials and are engineered to
withstand biting forces with a considerable margin of safety. While fracture of an
implant seldom occurs, it is possible. Aside from such mechanical failures, all problems
associated with dental implants relate to breakdown of the tissues surrounding the
implants.

Three conditions can result in the loss of tissue around an implant. These are local
conditions, systemic conditions, and overloading of the implant.

Our overall success rate for the devices we use is 95% at 5 years. This means that 95%
of the implants that have been placed here in the past have lasted for 5 years or longer
and that 5% of the implants have had to be removed in less than 5 years. The overall 15-
year success rate for the implants used at the Loma Linda University Implant Dentistry
Center is over 85%. The average life of the dental implants currently used appears to be
in excess of 20 years.

It is impossible to know ahead of time how long any particular implant will last and the
above numbers cannot in any way be construed as a guarantee.

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 Length of Treatment
From the time of the initial consultation, until the time of implantation will usually
require 6 to 8 weeks. After the implant is surgically placed it is usually allowed to heal
for 4 to 6 months prior to starting the final prosthetic reconstruction. Total treatment
generally takes place over a period of 6 to 24 months.

PRESURGICAL INSTRUCTIONS

After the restoring dentist and surgeon have answered all the questions and the patient
has signed the informed consent, the surgeon provides the patient with presurgical
instructions. The following presurgical instructions are used by the Center for
Prosthodontics and Implant Dentistry at LLUSD (see instructions for local anesthesia)
(see instructions for IV sedation or general anesthesia).

SURGICAL PROTOCOL

The preferred environment for dental implant surgery at Loma Linda University School
of Dentistry is a sterile hospital-type operating room. Most implants are placed in this
environment at LLUSD because it assures the highest surgical standards are followed in
the educational programs.

The patient is draped so a sterile approach to the oral cavity can be used. The surgeon
and assistant are gowned and they follow a protocol that avoids cross-contamination
(figure 3). The sterile environment has not, however, been found to significantly
improve the success rate of dental implants. (reference #3).

TWO-STAGE VERSUS ONE-STAGE IMPLANTATION

Dental implants can be placed with the superior portion of the implant exposed to the oral
cavity (one-stage) after surgery or the entire implant can be submerged below the soft
tissue (two-stage). The information contained in the section relates to two-stage implant
surgery. The subject of one-stage implantation is presented later.

When the implants are placed using a two-stage protocol, the first stage involves placing
the implant in the bone followed by suturing the soft tissue over the implant. The implant
remains covered for several months while the bone healing occurs. The second stage
involves an additional surgical procedure whereby a soft tissue flap is reflected to expose
the implant through the mucosa to the oral cavity and the soft tissue is sutured around the
healing abutment (reference 4).

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INCISION DESIGN

The incision design for most surgeries that involve the placement of a dental implant is
executed at the crest of the edentulous ridge (figure 4). The mucosa and periosteum are
incised to the full thickness and the flaps are usually fully elevated and displaced to
expose the area where the implants will be placed (reference 5) (video clips 2, 8, 16).

Incisions for single implants are sometimes made so they do not include the interdental
papillae (reference 6). They may also be reflected from a location remote to the crest of
the ridge when bone regenerating membrane procedures are used in conjunction with
implant placement (figures 5A, 5B, 5C, 5D).

OSTEOTOMY PREPARATION

After flap reflection, it may be necessary to recontour the alveolar ridge crest (reduce the
ridge height) to remove thin areas of bone so there is sufficient faciolingual thickness of
the ridge, thereby permitting the implant to be contained within bone. It may also be
necessary to reduce the ridge height to provide sufficient interarch space for the
prosthesis.

Osteotomies into which implants will be placed are prepared following the surgical
templates planned implant positions(figure 6)(video clips 3, 4, 16). Prior to use, the
template isimmersed in a new solution of 3% glutaraldehyde for 12 hours and then
thoroughly rinsed. The drills for the osteotomy preparations can be used with internal or
external irrigation for cooling the prepared bone (figure 7). Although no clinical study
has demonstrated superiority of either of the two methods, irrigation must always be used
while preparing a site for a dental implant to control the heat generated (reference 7-9 &
reference 10). Several factors have been identified that affect the heat generated during
implant site preparation (reference 11).

In preparing dental implant osteotomies, the surgeon uses a surgical unit with a contra-
angle and handpiece that produces an 18:1 gear reduction and 1500 revolutions per
minute (figure 8). Three drills are usually required to initiate site preparation (pilot,
guide, and depth drills) for most implant systems. Each drill is marked to identify
various depths to which the sites can be prepared (figure 6). After the site is prepared to
the desired depth and diameter(figures 9A, 9B, 9C, 9D), a countersink drill is used
(figures 10A, 10B)(video clip 4).

THREAD FORMATION

Threads are created in the bone of the osteotomy walls using a bone tap in a contra-angle
handpiece capable of producing a 200:1 gear reduction and 40-50 rpms. At this reduced
speed and with higher torque, the surgeon creates the bone threads necessary to insure
primary stabilization of the dental implant (figure 11). (video clip 5).

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SELF-THREADING IMPLANTS

Self-threading (self-tapping) implants can also be used. They are placed in situations
where softer, poorer quality bone is present, such as the maxilla. After the appropriate
depth and diameter are established, they are placed directly into the bone without prior
thread formations (figures 12A, 12B).

IMPLANT PLACEMENT

The implant is removed from the sterile package (without touching the implant). The
implant comes from the manufacturer attached to a premounted plastic carrier which is
used to manually screw the implant into the prepared site (video clip 6).

When the implant is placed into the osteotomy by hand, it is rotated until resistance to
advance is noted. If the implant does not completely seat using hand pressure and more
force is required, a hand ratchet and ratchet adapter can be attached to the insertion
assembly and the implant placed to its final depth. Alternately, the implant can be placed
to its final depth using a handpiece adapter located in the surgical kit. The plastic carrier
is removed and the insertion assembly attached to the handpiece adapter. The implant is
inserted using the handpiece at 35-50 rpm drill speed (video clips 5, 13).

Initial stability of the implant, immediately after placement, is always confirmed. No

mobility nor rotation of the implant should be present at this stage. If a small amount of
movement is detected, the implants are usually still successful. However, it is imperative
that no pressure be applied to such an implant during healing and the healing time should
be extended by 1-2 months. The clinical judgment and experience of the surgeon is the
determining factor in managing implants that exhibit slight movement after placement.

Removal of Insertion Assembly

After implant placement is complete, the handpiece is disconnected from the insertion
assembly (figure 13A). The insertion assembly screw is unscrewed and removed, and
the insertion assembly is detached from the implant revealing the top of the implant
(figure 13B) (video clips 5, 14, 17).

Healing Screw
The healing screw is removed from the packaging and threaded into the top of the
implant to cover and seal the open internal portion of the implant during bone healing
(figures 14A, 14B)(video clips 5, 17). The threads may be dipped into antibiotic
ointment prior to placing the screw into the implant to minimize the potential for
infection.

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 Suturing
Various techniques are used during closure and suture of the tissue flaps (figures 15, 16,
17, 18A, 18B, 18C)(video clips 6, 18). The most common suturing techniques are
vertical mattress and single interrupted ties (video clip 9). A post operative radiographic
evaluation should be taken at this time to confirm implant placement and proper seating
of the healing screw.

Healing Time
The post-operative bone healing time depends on several factors including quantity and
quality of bone, implant stability, health of the patient, and the clinical judgment and
experience of the surgeon. A general guide for healing time is:

Type I bone (3 to 4 months)

Type II bone (4 to 5 months)
Type III bone (5 to 6 months)
Type IV bone (6 to 8 months)
(These healing times are recommended for non-coated commercially pure
titanium implants).

Time Guidelines for Patient Follow-up Appointment

The most common periods for patient follow up after implant surgery can be outlined as
follows:

Suture removal 10 days after surgery. Placement of a provisional soft liner if

a denture will be worn by the patient. The soft liner should be 3 millimeters
thick to optimize the cushioning and minimize the chances of adverse pressure
being applied to the implants.
Post-operative evaluation of soft tissue health and confirmations of non-
loading of implants 3 weeks after suture removal and every month after
surgery for the entire healing period. The soft liner is evaluated for resiliency
each time and replaced as needed. The useful period of service of a soft liner
can be as short as two weeks or as long as 2 months depending on the oral
environment and how the denture is cleaned.

POSTSURGICAL INSTRUCTIONS

It is important to discuss postsurgical instructions with patients (see post operative care
instructions). Overloading the implants during healing must be avoided. Patients should
not wear any removable prosthesis that overlays the surgical area for 10 days `following
surgery unless the prosthesis can be extensively relieved so there is no chance of placing
pressure upon the tissue and the implants. A liquid or soft diet is usually recommended
for the first two weeks following surgery. The following liquid diet information is used
by the LLUSD Center for Prosthodontics and Implant Dentistry (see liquid diet
instructions).

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INSTRUCTIONS

===============================================================

LOMA LINDA UNIVERSITY

CENTER FOR PROSTHODONTICS & IMPLANT DENTISTRY
PRE-SURGICAL INSTRUCTIONS

For Local Anesthesia

1. Please inform your doctor if you are currently taking any medications or have a history of medical
problems. If you are currently taking medications to control blood pressure or cardiac problems,
please take them as scheduled. If you are a diabetic, please contact your physician for insulin control
before your surgery.

2. You can eat a regular diet prior to your surgery.

3. You can drive yourself, however, some cases do indicate the support of a driver.

4. Have your prescriptions (if applicable) filled ahead of time. It is imperative that you start your post
operative care immediately following surgery.

5. If pre-surgical blood work has been ordered, have it completed 3-5 days prior to surgery. Be sure your
results will be available to our office the day before your surgery. The laboratory service you use can
call our office with the results, or we can call them if you provide us with the name of a person to
contact and their phone number. Laboratory results can be faxed to (909) 824-4803 Attention:
LLUSD/Center for Prosthodontics & Implant Dentistry Department.

6. You will be required to change into a hospital gown removing all attire (MEN & WOMEN except
underwear). We suggest you wear loose fitting clothes (such as sweats) that can be changed into easily
and without much effort.

7. We will be monitoring you throughout your surgery so please:

NO make-up
NO jewelry
NO nail polish or artificial fingernails

8. If you wear dentures, please bring them with you the day of surgery.

If you have any questions in regards to your treatment, please do not hesitate to call (909) 824-4983.

===============================================================

===============================================================

LOMA LINDA UNIVERSITY

CENTER FOR PROSTHODONTICS & IMPLANT DENTISTRY
PRE-SURGICAL INSTRUCTIONS

For IV Sedation or General Anesthesia

9
1. Please inform your doctor if you are currently taking any medications or have a history of medical
problems. If you are currently taking medications to control blood pressure or cardiac problems,
please take them as scheduled with a teaspoon (sip) of water or less. If you are a diabetic, please
contact your physician for insulin control before your surgery.

2. Take NOTHING by mouth (including water) 8 hours prior to your surgery.

3. Someone will need to accompany you to drive you home. They should be prepared to stay here in the
event you are ready to be dismissed sooner than expected.

4. Have your prescriptions (if applicable) filled ahead of time. It is imperative that you start your post-
operative care immediately following surgery.

5. If pre-surgical blood work has been ordered, have it completed 3-5 days prior to surgery. Be sure your
results will be available to our office the day before your surgery. The laboratory service you use can
call our office with the results, or we can call them if you provide us with the name of a person to
contact and their phone number. Laboratory results can be faxed to (909) 824-4803 Attention:
LLUSD/Center for Prosthodontics & Implant Dentistry Department.

6. For IV Sedation you will be required to change into a hospital gown removing all attire (MEN &
WOMEN except underwear). For General Anesthesia all attire will be removed. With IV
Sedation/General Anesthesia your equilibrium can and will be altered. We suggest you wear loose
fitting clothes (such as sweats) that can be changed into easily and without much effort.

7. We will be monitoring you throughout your surgery so please:

NO make-up
NO jewelry
NO nail polish or artificial fingernails

8. If you wear dentures, please bring them with you the day of surgery.

If you have any questions in regards to your treatment, please do not hesitate to call (909) 824-4983.

===============================================================
LOMA LINDA UNIVERSITY
CENTER FOR PROSTHODONTICS & IMPLANT DENTISTRY
POST OPERATIVE CARE INSTRUCTIONS

Keep tongue and fingers away from the areas(s) of surgery. Follow the instructions listed below.

MEDICATION - PAIN MEDICATION should be taken before numbness from the local
anesthesia wears off. DO NOT drive or operate machinery while taking pain medication. ANTIBIOTIC
MEDICATION take as prescribed until completed.

SWELLING The FIRST 6-8 HOURS ONLY, apply COLD PACKS to the affected area of your face in
20 minute intervals (20 minutes on/20 minutes off).
The DAY AFTER surgery, place HOTPACKS to the affected area of your face for 20 minute intervals (20
minutes on/20 minutes off). You will experience some swelling. After the first day, continue only with hot
packs. The day after surgery you may rinse lightly with diluted warm salt water 1 tablespoon per quart of
water. This will help with any soreness or swelling that may occur.
The third day is the peak for swelling after most surgeries. Swelling can last for a period of 5-10 days.

10
BLEEDING DO NOT RINSE OR SPIT the first 24 hours after surgery. It is normal to have slight
bleeding for 2-3 days. Your blood and saliva mixture will have a pink tint. This is considered normal. If
profuse bleeding occurs, apply light pressure to the area with clean cloth or apply a wet tea bag over the
surgery site.

DONTs NO SMOKING, carbonated drinks, alcohol, sipping through a straw, spitting, stooping or
lifting. Any of these actions can cause bleeding and a delay in healing which could affect the outcome of
your treatment.

HYGIENE Brush all teeth EXCEPT those adjacent to the implant area unless specified by your Doctor.
DO NOT brush implant, stretch or pull lip away from surgical site. DO NOT disturb stitches in any way
for up to one (1) week. RINSE WITH PERIDEX MOUTH RINSE.

DIET LIQUID for two (2) weeks. With a liquid diet you should have more frequent nutritional intake to
ensure adequate nourishment (example: breakfast, mid-morning, noon, mid-afternoon, dinner and mid-
evening).

RETURN APPT Two (2) weeks. Please call for an appointment if you do not have one scheduled.

For emergency assistance after hours, please call the Loma Linda University Medical Center Operator at
(909) 558-0800 and ask for the Implant Dentistry On-call Doctor.

Any other postsurgical instructions such as oral hygiene instructions, use of chlorhexidine, times when they
will need to return, adverse outcomes that would require them to call the surgeon, etc.
===============================================================

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LOMA LINDA UNIVERSITY
CENTER FOR PROSTHODONTICS & IMPLANT DENTISTRY
RECOMMENDATIONS FOR LIQUID DIET

1. Carnation Instant Breakfast

2. Cream soups (split pea, cream of tomato) not soups such as cream of mushroom as it has small
pieces which may contaminate the suture area and disturb the surgery site

3. Broth soups
4. Ensure high protein drink (available at grocery stores, Wal-Mart and pharmacies)

5. Vegetable juices, V-8, tomato

6. Fruit juices/nectars

7. Baby food (strained only)

8. Ice cream/sherbets (vanilla, chocolate, lemon) no strawberry or nuts as they may contaminate the
suture area and disturb the surgery site

9. Milkshake
10. Puddings vanilla, chocolate, etc. no tapioca

11. Jello clear only

12. Yogurts clear only

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13. Anything you put in the blender is acceptable. However, it must be pureed until it becomes a liquid.
No small particles should remain as they could end up in the suture line and cause a subsequent
infection.

Most dental implant surgical procedures required a postoperative regiment of antibiotics and analgesics for
3 to 5 days.
===============================================================

REFERENCES

1. Barnett BG, Krump JL. Implant dentistry: the significance of a team approach. J
Prosthet Dent 1987; 58:69-73.

Osseointegrated dental implants have revolutionized the care of patients. Optimal results
are best achieved when the surgeon and restoring dentist have a mutual understanding of
what is possible and how it will be achieved. Coordination of the diagnosis, treatment
planning and maintenance help ensure the highest level of success.

2. Misch C. Contemporary Implant Dentistry Mosby 1999 PP 33-65.

This chapter emphasizes the medical evaluation of patients considering implant therapy.
The first part of the chapter discusses the importance of the patient interview with review
of the medical history questionnaire and the physical examination. The next part of the
chapter reviews laboratory tests. The last part of the chapter relates the medical and
dental implications of the common systemic diseases found in implant patients that have
the most profound impact on implant dentistry. These diseases can be categorized as
mild, moderate or severe. Patients with mild diseases may follow any type of treatment
but a stress reduction protocol is suggested for more extensive/advanced procedures.
Patients with moderate disease usually require more monitoring; and surgical placement
in a hospital is usually required when performing complex procedures. A severe state of
disease generally contraindicates elective implant dentistry.

3. Scharf DR,, Tarnow DP. Success rates of osseointegration for implants placed under
sterile versus clean conditios. J Periodontol 1993;64:954-6.

A retrospective study compared the success rate of osseointegrated implants placed under
sterile versus clean conditions. Sterile surgery was performed in an operating
room using a sterile protocol. Clean surgery occurred in a dental school clinic. 273
implants were placed in 61 patients under sterile conditions with an implant success rate
of 98.9%. A total of 113 implants were placed in 31 patients under clean conditions with
an implant success rate of 98.2%. The implants were evaluated clinically during stage 2
recovery. Implant surgery can be successfully performed using either sterile or clean
conditions.

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4. van Steenberghe D, Naert I. The first two-stage dental implant system and its
clinical application. Periodontol 2000 1998 Jun;17:89-95.

Professor Branemark began his pioneering work in the 1960s and his early data was
focused on the rehabilitation of completely edentulous mandibles. He recognized the
tremendous potential of the bone ingrowth on the metallic surface and began clinical
trials. He followed a strict protocol that included the following factors:

Atraumatic surgery
Surgery under sterile circumstances
Two-stage approach with implant submerged below the tissue during healing to
avoid any mechanical or microbiological challenge
Use of commercially pure titanium threaded implants

These principles were maintained throughout clinical trials beginning in 1965.

5. Cranin AN, Sirakian A, Russell D, Klein M. The role of incision design and location
in the healing processes of alveolar ridges and implant host sites. Int J Oral
Maxillofac Implants 1998 Jul-Aug;13(4):483-91.

The nature and role of a linea alba (thin, scarred dense tissue located at the crest of
edentulous ridge). Angiovist dye was used to outline the microvasculature in this area of
dogs. A zone of avascularity was noted directly beneath each linea alba. Alterations in
underlying bone morphology were noted when noncrestal incisions were made and there
is a thin strip of detached avascular tissue present in the reflected flap. Crestal incisions
produced the most predictable primary healing of the soft tissue. Incisions made at other
locations were judged to be less desirable in dogs since they may negatively affect
primary healing and may cause alveolar bone loss beneath the incision.

6. Eriksson A, Albrektsson T, Grane B, McQueen D. Thermal injury to bone. A vital

microscopic description of heat effects. Int J Oral Surg 1982;1:115-121.

Eriksson RA, Albrektsson T. Temperature threshold levels for heat-induced bone tissue
injury. A vital microscopic study in rabbit. J Prosthet Dent 1983;50:101-107.

Eriksson RA, Albrektsson T. The effect of heat on bone regeneration: Anexperimental

study in rabbit using the bone growth chamber. J Oral Maxillofac Surg 1984;42:705-711.

These studies demonstrated that bone will only withstand a threshold temperature ranging
from 44 degrees C to 47 degrees C for 1 minute without affecting its ability to regenerate.

13
7. Brisman DL. The effect of speed, pressure, and time on bone temperature during the
drilling of implant sites. Int J Oral Maxillofac Implants. 1996 Jan-Feb;11(1):35-7.

The successful osseointegration of endosseous root-form implants requires that minimal

heat be generated in the bone while drilling the implant sites. Little emphasis has been
placed on the effect of the load applied to the drill during osteotomy preparation. While
drilling bovine cortical bone at speeds of 1,800 and 2,400 rpm under loads of 1.2 and 2.4
kg, temperatue and time were measured . A low drilling speed of 1,800 rpm and a
minimal load of 1.2 kg produced the same heat as when the speed was increased to 2,400
rpm and the load of 2.4 kg was used. When either the speed or the load was increased,
there was an increase in bone temperature. An interesting finding was noted: increasing
both the speed and the load produced more efficient cutting with no significant
temperature increase.

8. Tehemar SH. Factors affecting heat generation during implant site preparation: A
review of biologic observations and future considerations. Int J Oral Maxillofac Implants
1999;14:127-136.

The purpose of this paper was to summarize the literature related to heat generation.
There is still considerable speculation regarding the best methodology to be used in
assessing heat production and examining bone changes. The following factors were
discussed as they relate to heat generation: drill pressure; graduated versus one-step
drilling; intermittent versus continuous drilling; drilling speed; time; drill design and flute
geometry; irrigation systems; sharpness; diameter; cortical thickness; degree of site
healing; depth; patient age; and bone density and texture.

This literature review provides a good overview of the effect of these factors. While it is
not possible to present all the literature encompassed by this paper, a summary of the
authors interpretation of the literature is embodied in the following information:

1. Pressure applied to the drill. Until proven otherwise, low drill pressure in the
range of 2 kilograms is proposed.
2. Graduated versus one-step drilling. A graduated series of drills to enlarge the
osteotomy has been recommended in the literature produced by the Scandinavian
osseointegration group.
3. Intermittent versus continuing drilling. Intermittent drilling has been
recommended.
4. Drilling speed. This issue is still being debated.
5. Time. The drilling time is directly proportional to the heat generated.
6. Drill design and flute geometry. With the multitude of systems and
manufacturers currently available, it is unlikely that the different designs and
shapes will be definitively compared.
7. Irrigation systems. This issue requires further study.

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 8. Sharpness of the cutting tool. Visual examination of the drill and evaluation of
the effectiveness of the drill in progressing through bone are suggested as means
to supplement the manufacturers guidelines.
9. Drill diameter. It seems that the amount of bone that will be removed is more
critical than the diameter. The diameter of the initial drill deserves greater
consideration.

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