Operative requirements for Stage I Surgery

Although Implant placement under general anesthesia must be done in an operating theatre with complete resources, most implant surgery can be carried out in a well equipped dental surgery. Ideally the surgery should be designed to permit surgical procedures under good aseptic conditions. The following should be available:

•  Good operating light.
•  Good high volume suction.
•  A dental chair which can be adjusted by foot controls or by a third party.
•  A surgical drilling unit which can deliver relatively high speeds (up to 3000 rpm) and low drilling speeds (down to about 10 rpm)

with good control of torque.

•  A custom designed (either external or internal) irrigation system for keeping bone cool during the drilling process.
•  The appropriate surgical instrumentation for the implant system being used and the surgical procedure.
•  Sterile drapes, gowns, gloves, suction tubing etc.
•  The appropriate number and design of implants planned plus an adequate stock to meet unexpected eventualities during surgery.
•  The surgical stent
•  The complete radiographs including tomographsz A trained ('scrubbed') assistant.
•  A third ('circulating') person to act as a runner between the sterile and non- sterile environment.

The need for systemic antibiotic cover should be considered. The original protocols recommended an antibiotic such as amoxicillin 250 mg 8 hourly for 5 to 7 days, unless the patient is allergic where a suitable alternative should be prescribed. Alternative regimes include administration of 3 grams of amoxicillin 1 hour before surgery, or 500 mg every 8 hours for 48 hours.

Anaesthesia and Analgesia
Most implant surgery can be carried out under local anaesthesia, although some patients will require sedation or general anaesthesia. The surgical time will vary greatly between different operators and cases. Short cases, for example under 1 hour for placement of one or two implants do not usually present problems with anaesthesia. Complex cases, with multiple implant placement and which require additional corrective surgeries (sinus-lift, autogenous bone-grafts, etc.) may take 2 or 3 hours. It is essential to use regional block anaesthesia (infra-orbital, palatal,inferior dental) and to supplement this during the procedure.Local infiltrations are also administered as they improve the anaesthesia and more importantly control haemorrhage. Sedation is recommended for operations of long duration eg more than 90 minutes. It is a good idea to give analgesics, such as ibuprofen or paracetamol, immediately prior to surgery.

Sterile Technique
Every effort should be made to conduct implant surgery under sterile operating conditions. Chlorhexidine 0.2% is used as a pre-operative mouthwash and skin preparation circumorally. The patient is draped as for other oral surgical procedures, and drill leads should be autoclaved or covered with sterile tubing. Light handles should be autoclaved or covered with sterile aluminium foil. It is convenient to use sterile disposable suction tubing and stents. The instrument tray and any other surfaces which are to be used are covered in sterile drapes.

Anatomical Considerations
The implant surgeon should be fully conversant with all anatomical structures that they are likely to encounter or that will affect implant placement, including (Palmer, et al 3 ):

• In the maxilla

Air sinuses

Nasopalatine canal

Floor of nose and nasal spine

Palatine and pterygoid vessels

• In the mandible

Sublingual vessels

Mental nerve

Inferior dental nerve

Incisive branch of inferior dental nerve

Genial tubercles

• Teeth

Position, length and angulation of roots adjacent to implant sites

• Available bone

Ridge morphology

Bone density

Cortical

Medullary

Localised deformities

tooth sockets

residual cysts/granuloma.