Step 1: Clinical Analysis and Examination

Occlusion Check

• Procedure: The patient is asked to occlude their teeth.

• Objective: To check whether there is enough space (7-8mm) from the bone level to the opposing tooth for implant placement.

Gingival Height Measurement

• Anesthesia: Local anesthesia is administered.

• Procedure: A periodontal probe is inserted till the crestal level to check gingival height.

• Gingival Height: Usually 2-4mm. Less than 1mm indicates insufficient keratinized tissue.

Biotype Evaluation

• Assessment: Check whether the gingiva is thin, thick, keratinized, or non-keratinized. Biological width is taken into consideration. In case of implant, biological width is gingival height. Gingiva is not attached to implant like mucosa is attached to tooth structure with PDL fibers. We need keratinized tissue to form a tight collar to adapt with the abutment. (In case it is not available, grafting procedure is done in which a 3-flap graft is taken from the palate, but this is not usually done.) If there is moderately formed keratinized tissue available, implant can be placed. 

• Biological Width: In the case of an implant, biological width is the gingival height.

Countersinking the Implant

• Procedure: Fix the implant below the crestal level.

• Platform Switching: refers to the concept of using a dental implant with an abutment that has a smaller diameter than the diameter of the implant platform. This technique has been found to offer several benefits, primarily related to preserving the bone and soft tissue around the implant site. 

Minimum Height Requirements

• Occlusal Level to Gingival Level: Should be 4-5mm.

• Tissue and Gingival Thickness: Should be 2-3mm.

• Total Height: 7-8mm.

• Abutment Height: Minimum height should be 4mm.

Ridge and Bone Assessment

• Palpation: Check bone resorption by palpating the buccal and lingual surfaces.

• Ridge Mapping: Done on a hard plaster model with a ridge measuring gauge if CBCT is not used. Width is measured on the plaster model at different levels. 

• Local Anesthesia:

• Administer local anesthesia to the patient to ensure comfort during the procedure.

Use of a Ridge Mapping Caliper:

• A ridge mapping caliper or gauge is used to measure the width of the alveolar ridge.

• The caliper is inserted through the soft tissue at predetermined points along the edentulous ridge to measure depth and width of gingiva 

Measurement Points:

• Typically, measurements are taken at several points along the ridge to get an accurate representation of its width and contour. 

• The measurements of gingiva intraorally are subtracted from measurements on the plaster model. This gives width of bone. 

CBCT Scan

• Accuracy: Provides more accurate measurements.

• Lower Jaw: Implant should be kept away from the ID canal by 1-2mm.

• Maxilla: Measure the distance from the sinus to the crest of the bone.

Implant Selection and Placement Planning

• Selected Implant: 4.8 x 8.0 mm.

• Bone Availability: 2mm on both sides of the implant.

• Minimum Width in Molar Region: 4.5mm, ideally 5mm.

• Implant Direction:

  • Mandibular Teeth: Center of the implant should align with the center of the opposing tooth.

  • Maxilla: Palatal cusp should occlude with the central groove of the lower teeth.

• Implant Stability: Checked with bone all around it.

Step 2: Guided Surgery

Model Scanning and Synchronization

• CBCT Software: The model is scanned, and gingiva is visible.

• Guide Design: Model is scanned in CBCT software. Gingiva is also visible in this planning. Its very light but can be demarcated. Model is synchronized. Add picture of the guide. The rest of the teeth are covered. Printing the whole arch makes the guide more stable. This scan is entered into a guide printing software. Angles are counterchecked, guide is designed and sent to a 3D printer. A guide is fabricated. 

Implant Guide Sequence

Implant is gamma-sterilized and the first thing it should touch is the socket bone (nothing else). Implant is delivered with a cover screw which is inserted into the implant and tightened. A flapless surgery was done with a tissue punch through the guide. Tissue punch creates a hole of 5mm by removing gingiva and achieving access to the bone. 

Flapless Surgery

• Tissue Punch: Creates a hole of 5mm, reducing the need for sutures.

• Healing: Gum heals in 7-14 days.

• Guide Used: 3.2 x 12 mm.

• Implant Size: 4.8 x 8 mm.

• Drilling:

  • Use a 12mm drill because the guide offset is 4mm.

  • Establish a height of 8mm in the bone.

  • Sequence: 3.2 x 8mm channel, followed by drills of 3.3mm, 3.8 x 8mm, 4.3 x 8mm, and 4.8 x 8mm.

Bone Density

• Hounsfield Units on CBCT: Indicates bone density.

• Bone Quality:

  • D1 Quality: Usually at the crestal level.

  • D2 and D3 Quality: Mostly present.

  • Maxilla: D3, D4 type is mostly present.

One Drill Down Concept

• Procedure: Drill 1-2mm down than the implant to be placed.

• Neck Drill: Use a 4.8mm neck drill to create a neck channel 4.8mm wide at the top and 4.5mm at the bottom.

Implant Insertion

• Hand Winding: Used for initial insertion.

• Torque Wrench: Feasible torque is 25-35 N.

• Torque Adjustment: To reduce excessive torque, unwind the screw and rewind it.

Step 3: Post-Insertion Procedures

Healing Abutment vs. Cover Screw

• Healing Abutment: Can be placed to avoid second-stage surgery, but not preferred due to hygiene concerns.

• Cover Screw: Preferred to reduce the risk of peri-implantitis.

Step 4: Prosthetic Phase

After 3 Months

• Crestal Incision: Made at the implant site.

• Cover Screw Removal: Flap is opened, cover screw removed.

• Healing Abutment Placement: Left for 7 days to form a collar of keratinized gingiva.

Impression Taking

• Open Tray Impression: Taken and sent to the lab for creating an abutment.

By following these detailed steps, Dr. Shahrukh Lodhi ensures a comprehensive and meticulous approach to dental implant planning and placement, maximizing the chances of a successful outcome.