The complete implantation technique with Dyna implants consists of two
surgical phases and following prosthetic procedure. All elements should be performed as
atraumatic as possible with use of the proper Dyna instruments. This manual contains
only the description of simple surgical procedures used for placing implants in the
mandible for overdentures. For more advanced procedures (use of membranes, sinus
lifting, tissue management) we recommend participating in special training courses and
reading available literature
Anyone wishing to perform implantations should have proper surgical training
and experience in the field of dentoalveolar surgery. It is highly recommended for
inexperienced dentists, at the beginning, to work under supervision of other qualified
operators. It is also important to remember about requirements for equipment that have
to be fulfilled to place implants in aseptic conditions. The surgery theatre should be
thoroughly disinfected. Patient, unit and instruments should be covered with sterile
sheets. Operator and his assister should wear sterile cloth and gloves.
Sterilization
Only the implants are supplied sterile. Expiry date is clearly marked on
every package and should always be checked before implantation. The Dyna instrument cassette
is supplied non sterile and therefore should be sterilized, in the appropriate manner, before use.
Please notice:
All parts must be removed from their packaging before sterilization. Implants are supplied in a
double peel pouch packaging which means that the implant itself (in a plastic bottle) is covered by
three protective layers of packaging.
Do not sterilize or re-sterilize implants.
Instrumentation
A suitably equipped operation room is prerequisite for complete success of any
implant treatment. It is important to have such an instrumentation that allows for secure handling
of all possible situations. The choice is rather personal and depends on individual preferences as
well as techniques performed. Herewith we give an example of basic surgery instrumentation :
Dental mirror, Dental probe, Cotton pliers , Fine tissue pliers, with teeth and flat,
Scalpel, Bone file, Curette, Needle holder, Dissection scissors, Suture scissors, Lip
retractor, Bone ronguer, Suture material, Straight handpiece and contra-angle for
surgical unit.
Premedicatio
Premedication is necessary only in particular situations. Patients belonging to the
“risk group”, or patients with planned extended operation procedures may be premedicated in an
adequate manner – following all general rules. Premedication with atropine has proved to be
useful for diminishing saliva production and can be used as standard. Anxious patients seem to
be indicated for sedative medication.
Anaesthesia
There are several possible way of anaesthetising the patient before implantation.
- Nerve block
- Local anaesthesia
- General anaesthesia
The choice depends on the particular situation and dentist’s preferences. However, in most of the
cases local infiltration anaesthesia seems to be most recommendable. Addition of constructive
agent reduces bleeding in place of implantation. Moreover, patients can feel some pain when
approaching the mandibular canal
First surgical phase.
When carrying out late implantation (after disinfection and
giving the anaesthesia) the bone is exposed by making an incision along the
alveolar ridge.
The mucosal flaps and periosteum are then reflected.
Now, the shape of the bone can be properly judged, eventual sharp ridges
removed (using a crestotom drill or preferably bone ronguer), and the
definitive location of implantation marked with rose drill (using additionally
e.g. drilling guide).
The minimum buccal-lingual thickness of osseous tissue, required to successfully place an
implant, is 5.0 mm. The anterior ridge crest of the mandible often resorbs to a peak
superiorly, leaving inappropriate ridge morphology for implant placement.
In order to achieve demanded 5.0 mm "flat" base, either the anterior ridge crest peak must
be removed (which effectively lowers the level at which the implants are placed), or a bone
graft must be considered.
Prior to selecting implant sites, the osseous tissues should be evaluated with appropriate
radiographic studies such as panoramic x-rays, tomograms, or CAT scans.
When using particular implants the minimal transversal thickness of the bone after
removing inappropriate structures should be as follows:
With the pilot drill the first drilling is made. Using the drilling guide is here
recommendable. The depth of the preparation should be determined before
operation (see 6.3) but it is possible and advisable to change it if the existing
situation allows for, or demands using a longer or shorter implant.
Thereafter, the Lindemann frees can be used to make the preparation wider
and if required slightly change the angulation.
Enlarging of the site depends on the diameter of the implant to be used. The following
sequence of drilling should be applied for different final preparations::
The grooves on drills allow to prepare the site to the exact depth corresponding with the
implants’ length (markings must be fully covered beneath the bone). All preparations should be
done under excessive cooling (preventing possible thermal trauma) with sterile saline solution that
additionally may be cooled before operation. All preparations should be done in a pump-up-anddown
movement with moderate pressure force. To avoid perforations or further prosthetic
problems it is important to control continuously the direction and the depth of drilling. To do so
we advise using parallel/depth instruments and drilling guides. The dental assistant can also be of
use as she or he see the drill from a different angle.
Once the site has been widened to the desired diameter it is ready
to receive implants. The Dyna parallel and depth instruments are used to
control the preparation. If the instrument fits without any problems one
can be sure that the implant will fit as well (see also product catalogue).
To begin with, however, the site should be carefully cleaned (saline
solution) with any debris and the entrance of the preparation controlled
and adjusted if necessary.
The implant is removed from the sterile packaging and introduced
into the receptor site making certain not to contaminate it. (It may only
have contact with the bone and the blood of the patient.)
The implant should be seated by:
-first inserting it into the site, then bending the inserting handle off, and
Final preparation Max. Rounds per min. Drills sequence
Ø 3.0 mm
Pilot
2000 rpm/min pilot→ (lindemann)→Ø3.0
Ø 3.6 mm pilot →(lindemann)→Ø3.0→ Ø3.6
Ø 4.0 mm pilot →(lindemann)→Ø3.0→ Ø3.6 →Ø4.0
Ø 5.0 mm
All spade drills
800 rpm/min
pilot →(lindemann)→Ø3.0→ Ø3.6 →Ø4.0→ Ø4.7→ Ø5.0
1601-01.04 Dyna Pushin Implant Manual GB 80 / 144
-finally pushing it to “the end” with an instrument (e.g. elevator) or the handle
itself touching only the covering screw.
A properly seated implant should be placed slightly (together with the
covering screw) under the bone level. Implants should not be forced to fit
into the site.
If any obstacle exists (when pushing the implant) the handle should be
bent off, covering screw unscrewed, implant using the implant puller removed
and the site once more controlled and adjusted (widening and cleaning). The
implant should be secured in a sterile place and after the site adjustment
reinserted. Next, the puller is unscrewed and the covering screw screwed
back.
The flap is sutured into place.
Please notice:
1 Never overforce the implant into the site-it may lead to destroying the coating and
further failures. With softer type of bone ( Maxilla ) it is, however, possible to knock, but
very gently, the implants into the prepared site, that can be even slightly narrower than
the real implant diameter*.
2 Always stick to the fixed pattern of drilling:
- sequence of drills,
- intermittent drilling technique,
- avoidance of excessive force during preparation,
- use of sharp drills (maximal 20 times per drill depending on bone quality)
- excessive cooling with chilled saline
- adequate rational speed
*see the Dyna training courses
3 Never touch the implant by hand. Avoid contaminating the implant with substances
other than the blood and bone of the patient. If it happens or if the implant has been in
any other way damaged never place it. (see guarantee)
4 Never and in no way sterilize or re-sterilize the implant yourself neither with or
without the packaging. An implant taken out only of its outer pouch can be stored, but
not more than one month, in a clean and sterile place.
5 Always try to prevent perforating or destroying vital anatomical structures.
6 Always try to place the implants in the most favourable position (possibly parallel to
one another and axial to bite forces). When placing more than two implants for fixed
constructions try not to position them in one straight line, and if this is not possible try to
use different diameters. For the overdentures try placing the implants following the
curvature of the alveolar ridge. Remember about the minimal distance from one another
biological width, type of prosthetic construction. The depth of placing should include
consideration of biological height and possible initial bone resorption – which influences
the papilla formation and the final aesthetic result.
7 Try to suture the flap so the healing occurs per primam intentione. Preferably use non
resorbable sutures (000 or thinner)
9 Always tight the covering screw with the hex screwdriver before suturing the flap!
After care.
After every operation each patient should be told to follow certain rules.
Consequently the patient should:
- cool the operation area with extraoral dry ice compress for several hours
(overcooling should be avoided)
- use a “soft” diet
- in some cases it is preferable that the denture is not worn before final wound
healing.
- if necessary use following medications e.g.
Antibiotics
Anti-inflammatory agents (not based on acetylsalicylates)
Analgetic agents
- rinse mouth with 0.2%chlorhexidine solution (40second rinses) for the
whole healing period
Sutures can be removed after 7-10 days, however, the time may vary depending
on particular clinical cases. The existing prosthesis should be adjusted and relined
so that the implants are not loaded during the integration phase. The integration
time of 3 months for the mandible and 6 months for the maxilla should be seen as an
advisory period rather than a fixed time. Operator is always obliged to check for
successful
Second surgical phase
Once the healing period has elapsed, the area is locally
anaesthetised (infiltration) implants are located and recovered with scalpel
or tissue punch. In most cases it is enough to make small incision(s)
parallel to the ridge.
The colour coded titanium covering screw is unscrewed from the
implant and replaced with the chosen healing screw of the same colour. In
some situations a layer of the bone covering the implant has to be
removed first. It is important then to remove enough bone to screw the
healing abutment tightly to the implant
Please notice:
For Octalock healing abutments use Dyna Sulcus reamer
Dyna Sulcus Reamer
The Dyna Sulcus Reamer is a special instrument designed especially for
shaping the bone around Dyna Octalock® implants and simplifying the
placement of the healing abutments during the second surgical phase.
The Reamer is available as hand sulcus reamer (art.no. 18PD1)
Notice:
Using Dyna Sulcus Reamer is limited to Dyna Octalock® Implants. The use of Dyna Sulcus
Reamer during second surgical phase is strongly recommended.
1. Anaesthetise locally the area
2. Identify and expose the cover screws either with separate incisions or
with one supracrestal incision.
Incision should always be done whenever possible in the attached
mucosa even though this should not be exactly over the implants.
Optionally punch can be used to remove tissue above the cover
screws
3. Unthread the cover screws (hex driver, art.no. 5181S)
4. Head the reamer into the implant. Remove the overgrowing bone
around the implants
PLEASE NOTE:
Take all necessary measures not to damage the implant. Make sure to
replace the reamer when it is worn out
5. Screw the healing abutments into place. If necessary suture the
mucosa between abutments. Check the fit with an x-ray.
The inside of the fixture should also be checked for any debris and if necessary cleaned
(e.g. saline).
The type of healing abutment depends on the type of prosthetic construction to be applied.
To achieve better gingival adaptation suturing the wound may be recommended.
During the healing period (usually 7 – 10 days) the healing abutment enables the gingival margin
to adapt and form properly. To ensure favourable aesthetics and emergence profile we
recommend a longer maturation.
Please notice:
The interdental papilla is very important for determining the final aesthetic result within fixed
constructions. It is therefore possible to extend the healing period by producing the temporary
restoration. The contact points should be designed so that the papilla fills in spaces between the
teeth fully. According to the literature regaining 100% of the papilla’s height is possible only
when the distance between the contact point and the bone is not longer than 5mm. (see tab.
below). Having done the temporary construction it is easy to determine the proper position of the
contact points and design the final restoration.
surgical phases and following prosthetic procedure. All elements should be performed as
atraumatic as possible with use of the proper Dyna instruments. This manual contains
only the description of simple surgical procedures used for placing implants in the
mandible for overdentures. For more advanced procedures (use of membranes, sinus
lifting, tissue management) we recommend participating in special training courses and
reading available literature
Anyone wishing to perform implantations should have proper surgical training
and experience in the field of dentoalveolar surgery. It is highly recommended for
inexperienced dentists, at the beginning, to work under supervision of other qualified
operators. It is also important to remember about requirements for equipment that have
to be fulfilled to place implants in aseptic conditions. The surgery theatre should be
thoroughly disinfected. Patient, unit and instruments should be covered with sterile
sheets. Operator and his assister should wear sterile cloth and gloves.
Sterilization
Only the implants are supplied sterile. Expiry date is clearly marked on
every package and should always be checked before implantation. The Dyna instrument cassette
is supplied non sterile and therefore should be sterilized, in the appropriate manner, before use.
Please notice:
All parts must be removed from their packaging before sterilization. Implants are supplied in a
double peel pouch packaging which means that the implant itself (in a plastic bottle) is covered by
three protective layers of packaging.
Do not sterilize or re-sterilize implants.
Instrumentation
A suitably equipped operation room is prerequisite for complete success of any
implant treatment. It is important to have such an instrumentation that allows for secure handling
of all possible situations. The choice is rather personal and depends on individual preferences as
well as techniques performed. Herewith we give an example of basic surgery instrumentation :
Dental mirror, Dental probe, Cotton pliers , Fine tissue pliers, with teeth and flat,
Scalpel, Bone file, Curette, Needle holder, Dissection scissors, Suture scissors, Lip
retractor, Bone ronguer, Suture material, Straight handpiece and contra-angle for
surgical unit.
Premedicatio
Premedication is necessary only in particular situations. Patients belonging to the
“risk group”, or patients with planned extended operation procedures may be premedicated in an
adequate manner – following all general rules. Premedication with atropine has proved to be
useful for diminishing saliva production and can be used as standard. Anxious patients seem to
be indicated for sedative medication.
Anaesthesia
There are several possible way of anaesthetising the patient before implantation.
- Nerve block
- Local anaesthesia
- General anaesthesia
The choice depends on the particular situation and dentist’s preferences. However, in most of the
cases local infiltration anaesthesia seems to be most recommendable. Addition of constructive
agent reduces bleeding in place of implantation. Moreover, patients can feel some pain when
approaching the mandibular canal
First surgical phase.
When carrying out late implantation (after disinfection and
giving the anaesthesia) the bone is exposed by making an incision along the
alveolar ridge.
The mucosal flaps and periosteum are then reflected.
Now, the shape of the bone can be properly judged, eventual sharp ridges
removed (using a crestotom drill or preferably bone ronguer), and the
definitive location of implantation marked with rose drill (using additionally
e.g. drilling guide).
The minimum buccal-lingual thickness of osseous tissue, required to successfully place an
implant, is 5.0 mm. The anterior ridge crest of the mandible often resorbs to a peak
superiorly, leaving inappropriate ridge morphology for implant placement.
In order to achieve demanded 5.0 mm "flat" base, either the anterior ridge crest peak must
be removed (which effectively lowers the level at which the implants are placed), or a bone
graft must be considered.
Prior to selecting implant sites, the osseous tissues should be evaluated with appropriate
radiographic studies such as panoramic x-rays, tomograms, or CAT scans.
When using particular implants the minimal transversal thickness of the bone after
removing inappropriate structures should be as follows:
With the pilot drill the first drilling is made. Using the drilling guide is here
recommendable. The depth of the preparation should be determined before
operation (see 6.3) but it is possible and advisable to change it if the existing
situation allows for, or demands using a longer or shorter implant.
Thereafter, the Lindemann frees can be used to make the preparation wider
and if required slightly change the angulation.
Enlarging of the site depends on the diameter of the implant to be used. The following
sequence of drilling should be applied for different final preparations::
The grooves on drills allow to prepare the site to the exact depth corresponding with the
implants’ length (markings must be fully covered beneath the bone). All preparations should be
done under excessive cooling (preventing possible thermal trauma) with sterile saline solution that
additionally may be cooled before operation. All preparations should be done in a pump-up-anddown
movement with moderate pressure force. To avoid perforations or further prosthetic
problems it is important to control continuously the direction and the depth of drilling. To do so
we advise using parallel/depth instruments and drilling guides. The dental assistant can also be of
use as she or he see the drill from a different angle.
Once the site has been widened to the desired diameter it is ready
to receive implants. The Dyna parallel and depth instruments are used to
control the preparation. If the instrument fits without any problems one
can be sure that the implant will fit as well (see also product catalogue).
To begin with, however, the site should be carefully cleaned (saline
solution) with any debris and the entrance of the preparation controlled
and adjusted if necessary.
The implant is removed from the sterile packaging and introduced
into the receptor site making certain not to contaminate it. (It may only
have contact with the bone and the blood of the patient.)
The implant should be seated by:-first inserting it into the site, then bending the inserting handle off, and
Final preparation Max. Rounds per min. Drills sequence
Ø 3.0 mm
Pilot
2000 rpm/min pilot→ (lindemann)→Ø3.0
Ø 3.6 mm pilot →(lindemann)→Ø3.0→ Ø3.6
Ø 4.0 mm pilot →(lindemann)→Ø3.0→ Ø3.6 →Ø4.0
Ø 5.0 mm
All spade drills
800 rpm/min
pilot →(lindemann)→Ø3.0→ Ø3.6 →Ø4.0→ Ø4.7→ Ø5.0
1601-01.04 Dyna Pushin Implant Manual GB 80 / 144
-finally pushing it to “the end” with an instrument (e.g. elevator) or the handle
itself touching only the covering screw.
A properly seated implant should be placed slightly (together with the
covering screw) under the bone level. Implants should not be forced to fit
into the site.
If any obstacle exists (when pushing the implant) the handle should be
bent off, covering screw unscrewed, implant using the implant puller removed
and the site once more controlled and adjusted (widening and cleaning). The
implant should be secured in a sterile place and after the site adjustment
reinserted. Next, the puller is unscrewed and the covering screw screwed
back.
The flap is sutured into place.
Please notice:
1 Never overforce the implant into the site-it may lead to destroying the coating and
further failures. With softer type of bone ( Maxilla ) it is, however, possible to knock, but
very gently, the implants into the prepared site, that can be even slightly narrower than
the real implant diameter*.
2 Always stick to the fixed pattern of drilling:
- sequence of drills,
- intermittent drilling technique,
- avoidance of excessive force during preparation,
- use of sharp drills (maximal 20 times per drill depending on bone quality)
- excessive cooling with chilled saline
- adequate rational speed
*see the Dyna training courses
3 Never touch the implant by hand. Avoid contaminating the implant with substances
other than the blood and bone of the patient. If it happens or if the implant has been in
any other way damaged never place it. (see guarantee)
4 Never and in no way sterilize or re-sterilize the implant yourself neither with or
without the packaging. An implant taken out only of its outer pouch can be stored, but
not more than one month, in a clean and sterile place.
5 Always try to prevent perforating or destroying vital anatomical structures.
6 Always try to place the implants in the most favourable position (possibly parallel to
one another and axial to bite forces). When placing more than two implants for fixed
constructions try not to position them in one straight line, and if this is not possible try to
use different diameters. For the overdentures try placing the implants following the
curvature of the alveolar ridge. Remember about the minimal distance from one another
biological width, type of prosthetic construction. The depth of placing should include
consideration of biological height and possible initial bone resorption – which influences
the papilla formation and the final aesthetic result.
7 Try to suture the flap so the healing occurs per primam intentione. Preferably use non
resorbable sutures (000 or thinner)
9 Always tight the covering screw with the hex screwdriver before suturing the flap!
After care.
After every operation each patient should be told to follow certain rules.
Consequently the patient should:
- cool the operation area with extraoral dry ice compress for several hours
(overcooling should be avoided)
- use a “soft” diet
- in some cases it is preferable that the denture is not worn before final wound
healing.
- if necessary use following medications e.g.
Antibiotics
Anti-inflammatory agents (not based on acetylsalicylates)
Analgetic agents
- rinse mouth with 0.2%chlorhexidine solution (40second rinses) for the
whole healing period
Sutures can be removed after 7-10 days, however, the time may vary depending
on particular clinical cases. The existing prosthesis should be adjusted and relined
so that the implants are not loaded during the integration phase. The integration
time of 3 months for the mandible and 6 months for the maxilla should be seen as an
advisory period rather than a fixed time. Operator is always obliged to check for
successful
Second surgical phase
Once the healing period has elapsed, the area is locally
anaesthetised (infiltration) implants are located and recovered with scalpel
or tissue punch. In most cases it is enough to make small incision(s)
parallel to the ridge.
The colour coded titanium covering screw is unscrewed from the
implant and replaced with the chosen healing screw of the same colour. In
some situations a layer of the bone covering the implant has to be
removed first. It is important then to remove enough bone to screw the
healing abutment tightly to the implant
Please notice:
For Octalock healing abutments use Dyna Sulcus reamer
Dyna Sulcus Reamer
The Dyna Sulcus Reamer is a special instrument designed especially for
shaping the bone around Dyna Octalock® implants and simplifying the
placement of the healing abutments during the second surgical phase.
The Reamer is available as hand sulcus reamer (art.no. 18PD1)
Notice:
Using Dyna Sulcus Reamer is limited to Dyna Octalock® Implants. The use of Dyna Sulcus
Reamer during second surgical phase is strongly recommended.
1. Anaesthetise locally the area
2. Identify and expose the cover screws either with separate incisions or
with one supracrestal incision.
Incision should always be done whenever possible in the attached
mucosa even though this should not be exactly over the implants.
Optionally punch can be used to remove tissue above the cover
screws
3. Unthread the cover screws (hex driver, art.no. 5181S)
4. Head the reamer into the implant. Remove the overgrowing bone
around the implants
PLEASE NOTE:
Take all necessary measures not to damage the implant. Make sure to
replace the reamer when it is worn out
5. Screw the healing abutments into place. If necessary suture the
mucosa between abutments. Check the fit with an x-ray.
The inside of the fixture should also be checked for any debris and if necessary cleaned
(e.g. saline).
The type of healing abutment depends on the type of prosthetic construction to be applied.
To achieve better gingival adaptation suturing the wound may be recommended.
During the healing period (usually 7 – 10 days) the healing abutment enables the gingival margin
to adapt and form properly. To ensure favourable aesthetics and emergence profile we
recommend a longer maturation.
Please notice:
The interdental papilla is very important for determining the final aesthetic result within fixed
constructions. It is therefore possible to extend the healing period by producing the temporary
restoration. The contact points should be designed so that the papilla fills in spaces between the
teeth fully. According to the literature regaining 100% of the papilla’s height is possible only
when the distance between the contact point and the bone is not longer than 5mm. (see tab.
below). Having done the temporary construction it is easy to determine the proper position of the
contact points and design the final restoration.
No comments:
Post a Comment