We created an immediate implantation surgical guide. This protocol brings together the practical experience of the Refformat surgical team. The guide was developed by the scientific group of the clinic under the leadership of Khyshov Maxim Vladimirovich.

We prepared a manual protocol for young doctors who start their surgical dentistry practice. The guide will tell you in detail about the operation of one-stage implantation. We described the entire process of surgical treatment: from the consultation and algorithm of surgical manipulations to postoperative management of the patient.

Protocol of immediate implantation

Modern methods of dental treatment:

Minimum time spent by the patient in the chair

Modern standard of implantological treatment

1/13.

The painlessness of the surgical stage

Creating optimal conditions for prosthetics

Predictability of the result

Minimal injury the operation

Long-term clinical result and excellent aesthetics

Terms and criteria for immediate implantation

2/13.

Immediately after tooth extraction

Immediate implantation

There is no healing of bone and soft tissues

The prevalence of the type in our practice

There is no healing of bone and soft tissues

Clinical situation during implant placement

About 6-8 weeks

Early implantation after soft tissue healing

Clinical situation during implant placement

Gum healing without bone healing

The prevalence of the type in our practice

We rarely use it. With immature tissues, it is difficult to analyze an X-ray and control the development of the inflammatory process.

About 12-13 weeks

Early implantation with incomplete healing of bone tissue

Clinical situation during implant placement

Gum healing and substantial bone healing

The prevalence of the type in our practice

A popular technique. The bone is more mineralized
compared to the early implantation period. A simplified drilling protocol allows the implant to be installed. We do not use a finishing drill and a tap.

6 months or later

Delayed implantation

Clinical situation during implant placement

Complete healing of tissues in the area of the socket

The prevalence of the type in our practice

We use it rarely, usually with large destructive processes of the jaws, for example, cysts from 2 cm in diameter

Indications and contraindications

3/13.

Coincide with the indications for tooth extraction

Root caries

Root fracture

Chronic periodontitis of hard severity without exacerbation

Chronic granulomatous periodontitis (any periodontitis)

after elimination of acute inflammatory phenomena

Absolute contraindications

Heart attack or stroke

Diseases of the cardiovascular system

Obtaining the conclusion of a cardiologist 6 months after the onset of the disease

Conditions for implantation

We are waiting for 6 months from the onset of the disease

Our recommendations

Diseases of the endocrine system

Our recommendations

Consultation and treatment at the endocrinologist. After stabilization of the condition, control tests and a specialist opinion are necessary

Conditions for implantation

Glucose less than 7 mmol/ml,
glycated hemoglobin less than 7.5 mmol/ml.
Normalization of calcitonin levels

Radiation/ chemotherapy in the anamnesis

Oncological diseases

Our recommendations

If the maxillofacial area is irradiated, implantation is not possible.
In other cases, we wait for 6 months

Conditions for implantation

Obtaining an oncologist’s opinion after 6 months from the onset of the disease

Taking bisphosphonates

Osteoporosis

Our recommendations

Consultation of the attending physician regarding long-term replacement therapy, more than 6 months

Conditions for implantation

— Stop taking bisphosphonates 6 months before implantation
— Conclusion of the attending physician
— Stabilization of biochemical parameters

— Diabetes: glucose over 10, glycated hemoglobin over 8
— Diseases of the thyroid gland

Relative contraindications

Pregnancy

Lactation

Age under 18

Herpetic rashes

We are planning implantation after pregnancy. In case of acute inflammatory pathology, we remove the tooth at any stage of pregnancy.

The antibiotic amoxicillin is compatible with breastfeeding. During lactation, bone resorption prevails over osteogenesis. In our practice, no significant differences were found during implantation.

In the acute stage, we do not perform implantation.

The candidate's age is determined by skeletal maturation, not passport age. The closure of the main growth zones is determined by the X-ray of the hands. We perform implantation after the closure of growth zones.

Acute infectious processes in the oral cavity

Specific diseases

During the period of deterioration of the general condition of the body

Infectious diseases

2-3 days before the operation, we perform oral sanitation and prescribe rational anti-inflammatory and antibiotic therapy.

Implantation is carried out with in consultation with the attending physician.

Implantation is carried out in consultation with the attending physician.

Implantation is performed after stabilization of the condition. With arterial hypertension, it is carried out in consultation with the attending physician, under sedation and under the supervision of an anesthesiologist-resuscitator.

Example: cold, flu, high blood pressure

Rational antibiotic therapy is important.
Example: with viral liver damage, fluoroquinolones are allowed: Levofloxacin, Clinafloxacin, Ofloxacin, – and penicillin group antibiotics: Ampicillin, Ampisid, Ampic, Azlocillin.

Example: syphilis, actinomycosis.

The first days of the women's cycle

Cosmetic injections

The pain threshold and blood coagulation are reduced. We recommend postponing surgical procedures for a few days.

We recommend postponing the operation for 7−10 days, the formation of hematomas is possible.

Initial consultation

4/13.

Find out the patient’s complaints and expectations. It is important to discuss the duration and stages of treatment, and to inform about possible complications.

We collect information about the patient's bad habits and chronic diseases.

An orthopedic surgeon makes a comprehensive treatment plan. The implantologist pl an implantation.

Collection of anamnesis and conversation with the patient

16:45

Сбор анамнеза, обсуждение ожиданий пациента, знакомство

11:06

Данные внешнего осмотра челюстно-лицевой области

02:34

Диагностика патологий ВНЧС, особенности открывания рта

Biotype and condition of soft tissues

The presence of bridles

Dental formula

Examination of the oral cavity

04:53

Осмотр слизистой оболочки полости рта и красной каймы губ

The required amount of oral cavity sanitation before implantation

02:29

Прикус, его патологии, зубная формула

03:05

План лечения, этапность хирургии, ортопедии, терапии

01:06

Заключение

Bone height in the implantation area

Proximity of the maxillary sinus

Proximity of the mandibular nerve

X-ray analysis

The presence of inflammation, cysts, fractures of the tooth

Presence of multiple chambers, sinus septa

Bone height in the implantation area

Proximity of the maxillary sinus

Proximity of the mandibular nerve

Analysis of a 3D Cone Beam Tomography Image

The presence of inflammation, cysts, fractures of the tooth

The presence of several chambers, septa in the sinus

Thickness of the cortical layer

Density of spongy bone (A tool in Viewer)

Resorption of the cortical plate

Thickness of the vestibular bone

Sublingual recess

Discussion of the need for treatment under sedation

Indications for treatment under sedation are

Large volume of surgical intervention

Aggravated allergic anamnesis

Pathologies of the cardiovascular system

Stomatophobia

Necessary analyses

Electrocardiogram (ECG)

Detailed biochemical blood analysis

General blood test

The analysis for hospitalization is an analysis for HIV, syphilis and hepatitis B and C.

Occlusal and side mirror

Soft tissue retractors

ISO 100

Photo protocol

Aperture F22-29

Shutter speed 1/160

You will need:

Camera Settings for Canon:

20:24

Why conduct a photo protocol

Preoperative preparation and planning

5/13.

00:55

How to process a patient

01:13

Aseptics and antiseptics
Hand Preparation

01:27

How to set up the operating table

Operating table instruments

Lowering handpiece 1\20

Step-up handpiece

Scissors

Suture material

Needle holder

Korntsang for processing the face and oral cavity of the patient

Carpules with anesthetic

Farabeuf Hook/Minnesota Retractor

Sterile saliva ejectors with adapter

Curved tweezers

Anatomical tweezers

Universal curette

Curette spoon

Sickle trowel

Periodontal probe

Dental rasp (xyster)

Scalpel and disposable blades 15C, 12D

Metal bowl for collecting autobones

Mirror

Carpool syringe

Forceps

Elevator

Optragate

Sterile gauze wipes

Antiseptic preparation for the treatment of the patient’s hands and face

We also use:

Aqueous solution of chlorhexidine bigluconate 0.2%

Bone-plastic material Bio-Oss or other osteoconductive dispersed material

Implantology Kit

Equipment for the operation

Liston centrifuge, model C 2204. We use it in the 3000 rpm mode, 20 minutes to make a PRF membrane.

Physiodispenser

This centrifuge is a matter of pride of Russian production.

Tooth Extraction Tools

straight forceps

bayonet tongs

S-shaped forceps

Forceps for removing wisdom teeth in the upper jaw

beak forceps

Elevators with a flattened working part 3–4 mm, with a narrow working part for anterior teeth - 1.5–2 mm

It is possible to use luxators, but they are thinner than elevators, so they will not be able to give a full force.

Elevators and Luxators

Immediate Implant Protocol

6/13.

We divide the anesthetic cartridge into 5–7 injections in order to avoid hydraulic fracturing of the underlying tissues.

1–1.5 carpules are injected from the vestibular side according to the type of infiltration anesthesia, 1/3 carpules are injected from the palatal side.

Anesthesia

PRF / Platelet Rich Fibrin is a platelet-rich fibrin clot.

After anesthesia, we take 8 ml of venous blood for the manufacture of PRF, use a 9 ml Vacuette tube with filler. With the action of adrenaline, the membrane is of better quality than when taking blood before anesthesia.

Making a PRF Membrane

according to the personal practice of anesthetists at the Refformat clinic.

The blood is centrifuged at 3000 rpm for 10 minutes.

Atraumatic

Fast

Comfortable for the patient

Criteria for a successful tooth extraction

We use carbide burs for sawing the crown part, this will help avoid unpleasant odors.

Carbide bur for crown fragmentation

Lindemann cutter with extended part

5:1 step-up handpiece

Fragmentation of teeth

Turbine handpiece is not intended for surgery

Required tools:

After separation of the crown part of the tooth, we remove the vestibular wall of the root with a cutter.

We form a cut in such a way as to form a space where a fragment of the tooth root will be moved when the elevator moves.

Fragmentation of single root teeth

We focus on the initial state of the tooth. With the preserved crown part of the tooth, we cut in the projection of the furcation and remove the roots with an elevator.

We form a cavity with a cutter in the cervical zone of the tooth, on the border with the bone, under the working part of the elevator. We make a cut in the projection of the extraction of the root.

Fragmentation of multi-rooted teeth

We determine the trajectory of extracting a fragment of a tooth, depending on the point of application.

We form a site with a triangular bur according to the standard protocol.

When working with pilot drills, the rotation speed is 500–700 rpm.

The use of irrigation avoids overheating of the bone. Osteoblasts are destroyed at 47°C.

Formation of the implant site

We exclude additional trauma to the bone due to continuous reciprocating movements.

The positioning of the drill is carried out in the palatal or lingual wall of the socket or in the bi/trifurcation region, since these zones are more stable. The cortical vestibular plate is thinner and less supplied with blood.

We set the bur in the correct orthopedic position, and do not focus on the contour of the socket.

The depth of drilling is determined relative to the lower bone edge.

Positioning

When forming the bed, we determine the trajectory of the position of the implants using the parallelism pins.

For dense bones, use special drills.

The implant is placed in the center of the ridge, closer to the back wall of the socket. Orientation along the line of fissures.

We evaluate the correct position of the implant after healing of the socket and bone remodeling.

The thickness of the bone around the implant is more than 1 mm.

Implant placement

Bone remodeling after immediate implantation is about 1.5 mm in height.

The implant is installed palatally relative to the projection of the root.

01:10

Formation of the implant site

Formation

Forming cutter for the entire intended length of the implant with a mode of 500–700 rpm.

Basic drilling: 250 rpm, no irrigation for bone collection.

Bed preparation algorithm

At each stage of drilling, we check the position of the implant with a parallelism pin.

Прецизионное сверло Precision Drill (дополнительно)

Пилотное сверло
Drill with tip Tapered, Ø 2,0 мм

Индикатор направления
Direction indicator

Корневидное сверло
Tapered Drill, Ø 3,5 мм

Корневидное сверло Tapered Drill, Ø 4,3 мм

We collect autobone from the turns of the drill when forming the site.

In a metal bowl we mix it with bone-plastic material.

Autologous bone harvesting during bed formation

We wet the bone material with the liquid component of the fibrin clot or saline.

We open the implant from the sterile package above the operating table.

We check the fixation of the implant driver on the implant before inserting it into the oral cavity.

Surgical stage. Implant placement

We use a key ratchet or ratchet for the final positioning of the implant.

We estimate the required level of implant penetration into the bone.

An implant with a conical connection is deepened by 1.5–2.5 mm.

An implant with a flat connection and a polished neck is placed 0.5 mm below the bone level.

Determining the depth of implant insertion into the bone

Deepening of the implant is necessary for the formation of the biological width.

Gingival sulcus.
Epithelial attachment. We form the largest part to the polished neck or abutment, which must be well polished. Epithelial attachment is formed to the polished neck of the implant or to the abutment. The quality of polishing of the abutment and crown neck is important.
Connective tissue attachment to a rough surface.
Biological width.

The concept of biological width

Choosing the optimal position of the implant in the bone

We take into account the anatomical features of the receiving implant site, as far as it is surrounded by a bone.

Lower jaw

Excessive bone compression at a torque of more than 70 N/cm2 is not achieved in the trifurcation zone, since an insignificant part of the implant surface is surrounded by bone.

Upper jaw

<15 H/cm2

Low

20

Stability value

Cover screw

Possible suprastructure

25-30 H/cm2

Short gum former, minimum chewing load

Stability value

Possible suprastructure

Medium

35

<35 H/cm2

It is possible to make a crown (aesthetically significant area). The temporary crown is NOT involved in the bite

Stability value

Possible suprastructure

High

70

<70 H/cm2

Avoid such values, perform bone decompression

H/cm2

Stability value

Possible suprastructure

Soft tissue plasty after implant placement

7/13.

Work in an aesthetically significant area

Thin or medium gum biotype

Criteria for the use of CTG in implantation

High smile line

The presence of pronounced frenulum of the lips, gum recession

Insufficient volume of attached gingiva

Severe defect of the vestibular bone of the socket of the tooth

Donor zone: maxillary tubercle or palate area.

We determine the size of the graft at the sampling stage. We use a periodontal probe.

Features of CTG sampling

After sampling, we move the graft into saline.

Drying of the graft is unacceptable.

We use a sharp scalpel 15C or an ophthalmic one. We form an incision in the submucosal layer, slightly larger than the size of the graft.

We position the graft in the formed pocket.

We fix the graft with one suture.

Preparing the Receiving Site for CTG

We use suture material with a thread thickness of 6–0.

In the space of the socket in front of the implant, we loosely introduce a mixture of autoclave with bone-plastic material

We preliminarily impregnate the bone mixture with the liquid PRF fraction.

After making the bone material, we remove the excess.

Bone grafting

The bone-plastic material is covered from above with a wrung-out PRF membrane to avoid contact with the oral cavity.

Using PRF

Soft tissue plasty

Analysis of the control X-ray

8/13.

In simple cases, we use an orthopantomogram, but take into account the distortion up to 25%.

In most cases, we perform CBCT.

Orthopantomogram

In the photo, we determine the unfixed gum former.

After the operation, we evaluate the position of the implant

Integrity of anatomical structures.

The degree of immersion of the implant into the bone.

The presence of bone tissue on all sides of the implant.

CBCT

What data needs to be checked?

Postoperative management

9/13.

Tight fit to soft tissue, no ischemia

Removal from the bite by 1.5-2mm

Safety precautions for the patient: do not bite, the crown performs an exclusively aesthetic function.

Temporary prosthetics in an aesthetically significant area

Temporary crown parameters:

Recommendations for the patient

On the day of the operation

Amoxiclav 875 mg. 1 tablet 2 times a day for 5 days. Combine with meals.

Omez 1 tablet in the morning 30 minutes before meals, for 5 days.

Ibuprofen 400 mg 1 tab for pain relief.

For the first two days, apply cold once every two hours for 15 minutes in the area of the operation.

From the following day

Dexamethasone 2 tablets 1 time per day. Start taking the drug the next day after surgery and take it for 3 days.

Carry out oral baths 3-4 times a day after meals for 5 seconds.

Conduct oral baths with an aqueous solution of chlorhexidine 0.02% (Perio Aid or Paradontax) from the next day after implantation for 10 days.

Within 10 days, brush the teeth in the area of operation only with a surgical soft toothbrush, starting from the following day.

Refuse active physical activity for 3 days. Do not take a warm bath and do not go to the bath for 2 weeks.

Quit smoking for 2 weeks.

The next day, the curator of the clinic calls the patient and finds out about his well-being.
Inspection and removal of sutures are carried out after 10-14 days.
Inspection with a control radiography is carried out after 5-6 weeks.
Photo protocol and prosthetics.
Control examination and x-ray are carried out 1 time in 6 months during the first year after the end of the treatment. Further control inspection and picturing are carried out every year.

Stages of clinical management of the patient

Complications

10/13.

We install the implant as distally as possible according to the protocol and fix the plug.

We choose the size of the collagen membrane. The membrane will be fixed with pins one tooth further from the defect.

If there are neighboring teeth, we make an intrasulcular incision. It ends behind the adjacent tooth and rises without damaging the papilla. You should be comfortable working, and you should not peel off a large flap.

Fracture of the cortical plate

What to do? Option 1

The socket around the implant is filled with autologous bone. We can take the bone tissue from the tubercle of the upper jaw and pack it in the area of the defect with bone-plastic material. From above we cover it with a membrane and fix with pins.

We suture all the incisions, the membrane itself remains visible in the lumen of the socket.

We install the implant as distally as possible according to the protocol and fix the plug.

The fragment is rotated and fixed with mini-screws.

We fill the socket around the implant with autologous bone with osteoplastic material, and cover it with a PRF membrane from above.

What to do? Option 2

All incisions are sutured without tension, the membrane remains visible in the lumen of the socket.

We plug the base of the socket with a collagen sponge or PRF membrane without strong pressure.

Using a nasal test, we check the tightness of the mucous membrane of the maxillary sinus.

We inform the patient that it is necessary to slightly blow into the nose.

Perforation of the mucous membrane of the maxillary sinus

What to do:

We conserve the socket.

Careful analysis of the 3D image.

Conducting a nasal test — pinch the patient’s nose and ask to blow.

In a doubtful situation, we initially plan to conduct a closed or open sinus lift. Criteria for selecting the necessary operation and the protocol for carrying out can be read in a separate protocol of Refformat.

How to avoid:

When working on the upper jaw in the sinus area, we are deliberately set to perform a sinus lift.

We form a new orthopedically correct site closer to the palatine or lingual wall.

If it hasn’t worked out, we preserve the tooth socket.

Low primary stability

What to do:

We evaluate our capabilities and the initial situation.

We plan to form a site inside the wall of the socket, not next to it.

The implant should be surrounded by bone tissue by at least 1/3 of the diameter and by 2-3 mm in the apical part.

How to avoid:

Socket conservation

11/13.

Two (three) wall defects in the vestibulo-oral direction.

Deep and wide socket, when the diameter of the cyst is greater than the diameter of the proposed implant.

Indications for socket conservation

The rarefaction of bone tissue at the apex of the molar, even with a preserved septum, cannot always be sutured tightly.

If the defect is single-walled, then it is possible to install an implant, and fill the free space with a mixture of autologous bone and xenograft, cover it with a pressed PRF membrane and suture it up.

The patient’s fear, willingness to wait, or financial situation.

Without walls. We place the osteoplastic material mixed with the PRF membrane.

Three-wall defect without cortical plate. Mucosal support is needed to avoid soft tissue collapse. The socket is loosely filled with osteoplastic material mixed with autologous bone.

Operation protocol

Defect with preserved walls. To stabilize the clot, we use only the PRF-membrane, we do not lay either autologous bone or osteoplastic material.

The manipulation protocol depends on the type of defect.

Overview of studies

12/13.

Publications

There are no significant studies on this topic, so we are conducting our own large study on the effectiveness of this protocol.

Russian publications

medical-diss

pubmed

International publications

There is no specific digital data for the dissertation. Even in international studies there is data only on a small sample of installed implants. 116 pieces in total.

pubmed

International publications

In 2008, there were no objective data on implant research. A lot has changed since then. We recommend that you familiarize yourself with the works of Professor M. Esposito

Therefore, we created the Reformat science project, within which we are planning to provide objective data on long-term monitoring of the implants that we have installed.
We are interested in cooperation with young doctors who are full of enthusiasm and desire to contribute to the development of evidence-based surgical dentistry!

Reformat science