Dr. Amit M. Gaikwad, Dr. Jyoti B. Nadgere, Dr. Janani V. Iyer, Dr. Anuradha Mohite
Professor and Head of Department,
Department of Prosthodontics and Crown & Bridge, MGM dental college and hospital, Navi Mumbai
Every step-in implant surgery is critical for its success, predictability and for long term results. Improper handling of soft tissue either during placement of implants or second stage procedure (SSP), affects the final esthetic outcome in implant restoration. SSP is the procedure of uncovering the implant with a cover screw and seating the healing abutment with desired collar height to form the soft tissue architecture around the implant for a better outcome. SSP aims to preserve the width of attached gingiva and preserve or regenerate the interdental papilla.3 SSP in two stage implant system is performed by excision or incision technique, depending upon the clinical situation. 6 Flapless approach for SSP is minimal invasive surgical procedure to minimize the crestal bone loss, soft tissue inflammation and overall healing period. A straightforward technique is introduced to fabricate an inexpensive tooth stabilized surgical template for minimal invasive SSP.
Citations: Gaikwad A, Nadgere J, Iyer J, Mohite A.Minimal invasive second stage surgery using thermoplastic sheet. J Prosthodont Dent Mater 2021;2(2):78-80.
Every step-in implant surgery is critical for its success, predictability and for long term results.1 Improper handling of soft tissue either during placement of implants or second stage procedure (SSP), affects the final esthetic outcome in implant restoration. SSP is the procedure of uncovering the implant with cover screw and seating the healing abutment with desired collar height to form the soft tissue architecture around the implant for a better outcome.2 SSP aims to preserve the width of attached gingiva and preserve or regenerate the interdental papilla.3 SSP in two stage implant system is performed by excision or incision technique, depending upon the clinical situation.4 Proper management of SSP results into an implant- supported restoration with symmetric contours and stabilize the issue conditions.
However clinician often overlook this procedure and considered non-essential step in implant surgery which affects the peri-implant tissue around implant restoration. Further, raising the full thickness flap to gain access to the cover screw results in ischemia and crestal bone loss around implant.6 Flapless approach for SSP is minimal invasive surgical procedure to minimize the crestal bone loss, soft tissue inflammation and overall healing period.
A surgical template is a guide used to assist in the proper surgical placement and angulation of dental implants.8 However, a surgical guide not only facilitates implant placement but can also be used for other purposes, including diagnosis, treatment planning, and even second-stage surgery. Hammaker et al described a technique to simplify the second-stage surgery of multiple implants with the same surgical template used for implant placement and a minimally invasive surgical approach. A straightforward technique is introduced to fabricate an inexpensive tooth stabilized surgical template for minimal invasive SSP.
A 30 years old male patient reported with missing mandibular left first molar. Comprehensive treatment planning included a complete oral examination (Fig. 1A) diagnostic wax up for the missing tooth and radiographic examination by cone beam computed tomography (CBCT). The following technique demonstrate flapless approach to uncover the cover screw with inexpensive tooth stabilize surgical template:
1. After local anaesthesia at the site, make a crestal incision on the edentulous ridge and crevicular incision along the adjacent teeth. (Fig. 1B)
2. Raise full-thickness mucoperiosteal flap, prepare implant osteotomy with surgical and prosthetic planning guide and insert implant in this example-4mm x 11.5mm (Xspeed [AO]; Megagen). (Fig. 1C)
3. Attach the open tray impression coping (Impression coping pick up [AO]; Megagen) to the implant body and verify its fit with radiograph (Fig. 2A). Apply petroleum jelly to the occlusal surface of adjacent teeth and add composite resin (Filtek Z350; 3M) open tray impression coping, extending it to the occlusal surface of adjacent teeth. (Fig. 2B)
4. Remove the open tray impression coping and attach it to the laboratory analogue (Implant analogue [AO]; Megagen) Primary wound closure is achieved with 3-0 silk sutures and 3/8th reverse cutting needle. (Fig. 2C)
5. Recall patient for 48 hours of short follow up and then 2weeks follow up for suture removal. After approximately 3-4 months of healing (Fig. 3) evaluate osseointegration by resonance frequency analysis (RFA) and make irreversible hydrocolloid (Tropicalgin; Zermack). Pour the impression in type 3 gypsum (Ultrarock; Kalabhai) (Fig. 4A)
6. Place the impression coping and composite resin jig and mark the position on edentulous area of working cast. Scrape the marked area on working cast (Fig. 4B) to provide space for impression coping and implant analogue assembly. Seat the assembly in created space of working cast (Fig. 4C) and make sure the extension of composite resin seat on the occlusal surface of adjacent teeth. Fill the remaining space with type 3 gypsum.
7. Remove the impression coping and place a long collar height healing abutment (Healing abutment [AO]; Megagen) on implant analogue. (Fig. 4D) Duplicate the working cast with irreversible hydrocolloid impression and pour it in type 3 gypsum. Press 1mm thickness of thermoplastic sheet (Easy vac; 3A Medes) (Fig. 5A) on vacuum form machine.
8. Drill hole (Fig. 5B) through the thermoplastic sheet in the elevated portion of healing abutment. Intraorally seat the surgical template. Make sure the surgical template is fully seated.
9. Choose appropriate tissue punch based on the diameter of the platform of implant to be exposed. Place the tissue punch through hole and verify the position with intra oral radiograph (Fig. 6A).
10. After verification firmly hold the tooth stablize surgical template and make a tissue punch. (Fig. 6B). Remove the tooth stablize surgical template and make sure the cover screw is completely exposed to view the implant completely.
11. Measure the collar height with periodontal probe, select and seat the healing abutment. Verify fit of the healing abutment with intra oral radiograph (Fig. 6C) and give torque of 15 Ncm. Patient is recalled for follow up (Fig. 7A and B) after 10 days for evaluation.
The suggested technique is flapless approach to exposed the cover screw with a surgical template for placement of healing abutment after the healing period. Advantages of this technique is it prevents ischemia, minimize the soft tissue inflammation, crestal bone loss and reduces the healing time period. Selection of patient is essential criteria to achieve healthy peri-implant tissue around implants with the suggested technique. Tooth stabilize surgical template is indicated in clinical situation with adequate width of attached gingiva and presence of tooth on either side of edentulous area.
Stability and proper seating of surgical template is essential for achieving accurate placement for healing abutment. Presence of tooth distal to edentulous ridge provides better stability for intra oral placement of surgical template. Stabilization of this template is difficult to achieve in distal extension situation due to the changes and resiliency of soft tissue. Impression for working cast is made after 3 months of healing period. This is essential as in multiple implant situation as soft tissue changes over 3months affects the fit of the surgical template.
Impression coping and composite resin jig helps to position the implant analogue on the working cast. Clinician can even used this position of the implant analogue to fabricate interim restoration before SSP. The benefits of fabricating an indirect interim restoration before SSP results into better development of emergency profile and preservation of peri- implant tissue.12 Authors also recommend, autopolymerizing resin and light cure acrylic resin material for fabrication of jig.13 Limitation of the suggested technique include situation with inadequate width of attached gingiva, absence of tooth distal to edentulous area and fully edentulous arches with no posterior stop.
The technique described for fabrication of tooth stabilize surgical template is a flapless approach for SSP. Properly fabricated tooth stablize surgical template for SSP reduces crestal bone loss and lead to healthy peri-implant keratinized soft tissue. However, long term clinical studies are essential to validate this concept.
1. Suchetha A, Phadke PV, Sapna N, Rajeshwari H R. Optimising esthetics in second stage dental implant surgery: Periodontist's ingenuity. J Dent Implant 2014;4:170-5.
2. Hertel RC, Blijdrop PA, Kaik W, Baker DL. Stage II surgical techniques in endosseous implantation. Int J Oral Maxillofac Implants 1994;9:273-8.
3. Bassetti RG, Stahli A, Bassetti MA, Sculean A. Soft tissue augmentation procedures at second stage surgery: A systematic review. Clin Oral Investig 2016;20:1369-87.
4. Hertel R, Blijdorp P, Kalk W, Baker D. Stage 2 surgical techniques in endosseous implantation. Int J Oral Maxillofac Implants 1994;9:273-8.
5. Bernhart T, Haas R, Mailath G, Watzek G. A minimally invasive second-stage procedure for single-tooth implants. J Prosthet Dent. 1998;79(2):217-9.
6. Anumala D, Haritha M, Sailaja S, Prasuna E, Sravanthi G, Reddy NR. Effect of Flap and Flapless Implant Surgical Techniques on Soft and Hard Tissue Profile in Single-Stage Dental Implants. J Orofac Sci 2019;11:11- 5.
7. Sunitha RV, Sapthagiri E. Flapless implant surgery: A 2-year follow-up study of 40 implants. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:237-43.
8. The glossary of prosthodontic terms. Ninth edition. J Prosthet Dent 2017;117(5S):e1-105
9. Ramasamy M, Giri, Raja R, Subramonian, Karthik, Narendrakumar R. Implant surgical guides: From the past to the present. J Pharm Bioallied Sci 2013;5:98-102.
10. Garcia-Hammaker S, George FM. Use of a surgical template for minimally invasive second-stage surgery: A dental technique. J Prosthet Dent. 2019;121:37-40.
11. Orentlicher G, Abboud M. Guided surgery for implant therapy. Oral Max- illofac Surg Clin North Am 2011;23:239-56.
12. Kan JYK, Rungcharassaeng K, Deflorian M, Weinstein T, Wang HL, Testori T. Immediate implant placement and provisionalization of maxillary anterior single implants. Periodontol 2000. 2018;77:197-12.
13. Alqahtani F, Goodacre C. A Novel Verification Jig Technique of Using a Composite Resin Material for Implant Supported Prosthesis. Austin J Dent. 2014;1(2):1008.