CHAPTER 9
Surgical Management
9.1 INTRODUCTION
To achieve successful results, both clinically and in terms of patient expectation, the clinical team must demonstrate a clear understanding of the surgical anatomy of the jaws, bone biology, physiology and the nature of the process of repair and regeneration (B).
Dental implant treatment requires invasive surgical procedures that are electively being undertaken to improve the quality of life of the patient. It is therefore essential that prior to surgery, a rigorous and well‐documented risk assessment process is undertaken, and an appropriate perioperative care plan is put in place for each patient (see Table 9.1) (B). Use of surgical checklists for adequate preparation for surgery and to minimise human factors related errors is highly desirable [1] (A).
TABLE 9.1 Prerequisites for satisfactory completion of an implant surgical procedure.
|
|
|
|
|
|
|
There are many different approaches, techniques, materials, devices, drugs and protocols that can be used to treat each individual patient. The choice of which of these is the most appropriate is a complex decision that is made on the basis of the patient‐specific criteria, including their wishes and desires, the experience and skill of the clinician, and the current available evidence (C). Regardless of which techniques or materials are used, the clinician must be able to justify their rationale and choices [2] (B).
The clinician responsible for the surgical stages of implant treatment must be experienced in oral implant surgical procedures, including planning for surgery and managing intra‐ and postoperative complications. The surgical procedure should be performed in a suitable clinical setting using appropriate surgical equipment in accordance with the manufacturers’ recommendations. The surgeon and their assistant(s) must be highly experienced and trained in providing oral implant surgical procedures. When the complexity of surgical plan or patient’s medical history warrants it, onwards referral to a more experienced team should be made (see Figure 9.1) (B).
FIGURE 9.1 Triad of contemporary implant dentistry.
Sources: Buser, D., Chappuis, V., Belser, U.C., and Chen, S. (2017). Implant placement post extraction in aesthetic single tooth sites: when immediate, when early, when late? Periodontology 2000 73(1): 84–102; Linkevicius, T., Apse, P., Grybauskas, S., and Puisys, A. (2009). The influence of soft tissue thickness on crestal bone changes around implants: a 1‐year prospective controlled clinical trial. Int. J. Oral Maxillofac. Implants 24(4): 11–17.
9.2 SURGICAL PREPARATION
Surgical procedures and the placement of implants are invasive and evoke a complex stress response from the patient. It is well recognised that safe and efficient surgical practice requires a thorough preoperative protocol.
Surgical work‐up
| Aspirational | Basic | Conditional |
|---|---|---|
| Full written documentation of the condition(s) for which surgery is needed and a full written treatment plan. (ii) | Assessment of the patient’s overall health status and medical history. (i) | Collect, justify and report on appropriate diagnostic tests. (i) |
| Optimisation of the patient’s medical conditions and drug prescription to reduce the patient’s surgical and anaesthetic perioperative morbidity. (ii) | Undertake a perioperative risk assessment. (i) | Ensure that all primary dental disease is managed appropriately prior to surgery. (ii) |
| Appropriate protocols, procedures and aids are implemented to minimise complications. (ii) | Appropriate radiological investigations have been undertaken, assessed and reported. (i) | |
| Develop and implement a perioperative care plan. (i) | The surgical team is appropriately trained and able to carry out the procedure, including managing medical emergencies and complications. (i) | |
| Ensure excellent communication of the protocol, risks and procedure to the surgical team. (ii) | Ensure the patient is educated about the surgery, anaesthesia, and intraoperative and postoperative pain relief. (i) | |
| Ensure appropriate surgical planning has been undertaken, including the position of the implant fixture(s), and volume of grafting if necessary. (ii) |
The most two important goals of preoperative surgical assessment are to ensure that the procedure is performed as safely as possible and to reduce the patient’s perioperative morbidity [3]. It is important to understand that perioperative risk is multifactorial and is a function of the medical condition of the patient, the procedure and the type of anaesthetic administered.
A history, clinical examination, appropriate investigations and diagnostic work‐up are essential to ensure that the operating team is prepared and that the patient is optimised for surgery (see Figures 9.2 and 9.3) (B).
Surgical set up
| Aspirational | Basic | Conditional |
|---|---|---|
| Ensure the availability and maintenance of the appropriate implant equipment and back‐ups. (i) | ||
| In the event of a complication, inform the patient, ideally in writing, of the treatment plan for managing the adverse event. (ii) | Ensure the appropriate safety equipment and drugs are available, maintained and not time expired. (i) | |
| Ensure the availability of the biomaterials, implants, surgical guides and sundries that are needed for surgery and have a system in place to check this. (ii) | Keep accurate, complete and contemporaneous notes. (i) | |
| Demonstrate good hygiene and aseptic technique, including draping and gowning. (iii) | Ensure the appropriate system for sterilisation of the equipment and instruments, as described by Health Technical Memorandum 0105. (i) | |
| Ensure appropriate personal protective equipment is available and worn. (i) | ||
| Ensure the availability of systems for the safe disposal of sharps and clinical waste. (i) |
Preoperative management
| Aspirational | Basic | Conditional |
|---|---|---|
| Carryout the World Health organization Surgical Safety Check List. | Ensure the patient is fully consented for surgery and understands the benefits, risks and limitations of treatment, anaesthesia and sedation as appropriate. (ii) | Prescribe appropriate drugs for the relief of anxiety. (ii) |
| Carryout a pre‐surgical scale if necessary, and a disinfecting oral rinse. (ii) | Assessment of the patient to ensure nothing has altered since the treatment plan and history taking. (ii) | Prescribe and justify the use of antimicrobial agents as appropriate. (ii) |
FIGURE 9.2 The Pink Esthetic Score criteria assess: a) mesial papilla, b) distal papilla height, c) soft tissue level, and d) soft tissue color, texture, and curvature. The White Esthetic Score criteria evaluate: tooth shape, outline, surface texture, color, and translucency.
FIGURE 9.3 Clinical surgical procedure in sterile environment with necessary surgical instruments and equipment.
9.3 BONE AND SOFT TISSUE MANAGEMENT
Stay updated, free dental videos. Join our Telegram channel
VIDEdental - Online dental courses
