IMPLANT SURGERY

M A N U A L

S - I M P L A N T S
Surgical Manual – SEMADOS®-S-Implant
Page
Contents
1. Introduction – Concept 5

2. Preparatory Measures 6
2.1. Diagnostic Procedures
2.2. Radiographic and Positioning Template

Surgical Procedures – STAGE I

3. Exposure of the Alveolar Ridge 10

3.1. Anterior Mandible
3.2. Posterior Mandible
3.3. Maxilla
3.4. Additional Procedures

4. Preparation of the Implant Bed 14

4.1. Transfer of the Implant Position
4.2. Preparing the Implant Site
4.3. Verifying the Implant Length
4.4. Pretapping and Countersink Preparation

5. Unpacking of the SEMADOS®-S Implant 19

6. Insertion of the SEMADOS®-S Implant 20

7. Wound Closure 21

8. Postoperative Management

9. Patient Recalls – Healing Period 22

Surgical Procedures – STAGE II

10. Exposure of the Implant and Preparations

for the Restorative Procedures 23

3
SEMADOS®-S implant

Top plug

Premounted insertion tool

Implant

Glass vial

Implant cover screw

Bottom plug

4
1.
Introduction –
Concept

The SEMADOS®-S implant is designed

for submerged endosseous
integration. The implant material is of
pure titanium (grade 4). The
microstructured osteoconductive im-
plant surface, with an average pore
size of 5 microns, is designed for fast
and uneventfull osseointegration.

To achieve successful implant treat-

ment and long term results, the sur-
geon should not only be familiar with
the implant system itself but also apply
an atraumatic surgical technique. The
principles of aseptic surgery should be
observed.

Specific educational programs con-

ducted by experienced lecturers
enable physicians (and assistents /
nurses) to get well acquainted with the
BEGO-SEMADOS® system and can also
reveal the vast spectrum of possible
applications inherent.

It is mandatory that the criteria for the

selection of patients (indications and
contraindications) are strictly ob-
served. The surgeon and dentist have
to ensure adequate operative skills
and sterile conditions for endosseous
implantations as well as for precise
and proper restorations.

5
 2.
Preparatory
Measures

The objective is to place the implants

in a prosthetically favourable position
taking into account the individual
anatomy and bone physiology. In an
ideal position the implant should be
surrounded by at least 1.2 mm of vital
bone and be located in an area of fixed
gingiva.

Mounting of the study casts in a 2.1. Diagnostic Procedures

semi-adjustable articulator
The preoperative diagnostics include a
detailed anamnesis with special regard
to any internal diseases or contraindi-
cations and a thorough clinical exami-
nation. Pathological findings requiring
treatment should be eliminated prior
to implant therapy.

Important parameters to be assessed

are :

width of the attached gingiva at the
prospectiv implant site,

width and shape of the alveolar
processus, and

localisation of sensitive anatomical
structures (e. g. nerves, vessels,
teeth, sinuses) adjacent to the
probable implant position.

Measuring the thickness of the

mucosa / width of the alveolar ridge
as a function of the distance from
the alveolar crest

6
 1.
Einführung –
Konzept

The study casts of both jaws should be

analysed, since this is the only way
to determine the correct position and
inclination of the implants.

A diagnostic set-up will provide a basis The laboratory technician provides

for the fabrication of a template which the diagnostic set-up with acrylic
can be used for diagnostics (radio- teeth simulating the anticipated
graphy) and the transfer of desired result
implant positions to the jaws.

This set-up is used to manufacture

a vaccuum-molded acrylic template

The diagnostic template is trimmed

to be placed in the mouth, radio-
opaque balls of defined diameter or
metallic cylinders can be integrated
for measurement and control of
possible implant sites or angulation

7

The inclination of the implants
should follow the position of the
natural teeth to allow axial loading
of the implants
The buccal and occlusal views of
the template show the tubes/holes
in the template which allow the
insertion of the pilot drill in a
predetermined direction
8
2.
Preparatory
Measures
2.2. Radiographic and
Positioning Template
A panoramic X-ray film is an indis-
pensable diagnostic tool. If necessary
intraoral films, lateral and occlusal
radiographs or computer assisted to-
mography can be added.
Each panoramic X-ray unit is
characterized by different magnifi-
cation factors in variing regions.
A standardized measuring film
permits the selection of the
appropriate implant length and can
also be used for the estimation of
grafting procedures (e. g. right
upper jaw)
If stainless steel balls of known diam-
eter or titanium tubes are incorpo-
When the template is applied, it is
important to make sure that there
1.
rated in the template, the radiographs is adequate interocclusal space Einführung –
also provide information concerning for drill, handpiece and other
the correct position of the desired instruments. If necessary the tubes Konzept
implants. The dimensions and suitable can be left open on the buccal side
implant length can be determined by
multiplication with the enlargement
factor.

It is recommended to select the

implant of maximum length and
diameter.

Measuring balls or holes,

Recommended implant diameters marked with rings, in the
3.25 - (X) - - - - - mandibular template provide
Maxilla

3.75 (+) ++ (+) + + (X) (X)

4.5 ++ (+) ++ ++ ++ + +
information about the
- = not suitable
5.5 (+)
1
-
2
+
3
+
4
+
5
++
6
++
7
(X) = can be used in connection with other im- correct implant po-
Teeth
plants or teeth
3.25 (+) (+) - - - - - sition between the
Mandibula

(+) = suitable, can be used in the case of

3.75 ++ ++ + + + (+) (+)
4.5 + + ++ ++ ++ + +
connection with other implants
+ = suitable
mental foramina
5.5 - - - - - ++ ++ ++ = recommended

Colour coding: The following are colour coded:

We have extended the colour coding to • implants
the entire system and coded all com- • sealing screws
ponents according to the diameter. • impression posts
• model implants
• dentures
Diameter (in mm):
3.25 =
3.75 =
4.50 =
5.50 =

Using the BEGO-SEMADOS®

radio-graphic template the
surgeon can estimate the
possible length and
diameter of the implants
with regard to the
individual magnification.
The scale reaches from
1:1.0 up to 1:1.3

9
3.
Exposure of the
Alveolar Ridge
– STAGE I –

SEMADOS® S implants are designed Before starting, disinfection of the

for submerged healing and should perioral region, application of sterile
thus be inserted flush with the bone drapes around the operative field and
surface. disinfection of the oral cavity is neces-
sary. The incision can be done on top
One-stage treatment with immediate
of the alveolar crest or labial to it, de-
loading is possible when adequate
pending upon site, number of implants
bone conditions are available and the
and desired bone grafting or augmen-
implants get connected with a (e. g.
tation. The papillae of neighbouring
*Dolder®-) bar. Sparse movement of
teeth should be preserved. In all cases
surrounding soft tissues, reliable pri-
adaptation of the wound margins with-
mary stability and utmost care when
out any tension is desirable.
performing impressions is mandatory.
Excessive exposure of the alveolar
bone should be avoided, since dissec-
tion of the periosteum leads to in-
creased transversal bone resorption.
Modelling osteotomies should be per-
formed only with great care, bone
chips harvested here can be useful for
augmentation!

The transfer of the implant position

Cross section of the anterior
mandible before incision
using the template is accomplished by

transmucosal perforation of the
cortical bone with the pilot drill or

marking/preparation after exposing
the alveolar ridge.

Once the mucosa is transsected the

The mucosa and periosteal layers
are dissected stepwise to ensure
later wound closure without any
tension and safe coverage of the
implant(s)
periosteal layer is incised close to the
identified implant site and can be
gently elevated in oral direction. The
flap can be tied back with a temporary
suture, delicate retractors or an pe-
riosteal elevator.

*Dolder®: registered trademark in accordance with Prof. Dr. Eugen Dolder, formerly at Dental Institute of the University of
Zurich.

10
 1.
Einführung –
Konzept

3.1. Anterior Mandible

The mucosal incision is placed at the

lowest point of the vestibulum which is
generally 8 to 10 mm below or lateral If the alveolar ridge is to narrow
of the alveolar crest. Any muscle tissue to provide sufficient bone for an
between the incision and the buccal implant, the crestal part can
surface of the bone can be removed. be reduced in height or must be
The periosteum should be incised augmented to create an appropriate
only in the immediate vicinity of the bony layer
implant site and carefully elevated
lingually. During this procedure the
lower lip should be kept under contin-
uous tension.

Exposure of the mental foramina is

only necessary if the preoperative di-
agnostics failed to mark these exactly
and implant placement is desired in a
more posterior (first premolar) posi-
tion.

It is important to realise that the men-

tal nerve may spread directly under-
neath the mucosa. A rose burr is used to mark the site
for the TriSpade drill
Extended lingual dissection is not nec-
essary and to be avoided to prevent
ecxessive hematomas in the floor of
the mouth and to preserve the pe-
riosteal blood supply. If there are
doubts about the lingual bone contour
careful palpation or probing is advis-
able. Utmost caution is required be-
cause an atypical artery can lie in
A fenestration of the lingual surface
direct contact with the lingual perios-
of the anterior mandible must be
teum.
avoided, since this results in rapid
bone resorption and might cause
severe bleeding from an atypical
artery

11

The line of incision in the lower
jaw must be avoiding the marginal
periodontal tissues of remaining
teeth, lingual extension is possible
with crestal incisions to reduce the
tension of the flap. Care has to be
taken to avoid contact with the
mental nerve either at the foramen
or at the submucosal course
12
3.
Exposure of the
Alveolar Ridge
3.2. Posterior Mandible
Implant placement in the premolar
region requires the preparation of the
mental foramen and, as well as in the
molar region, precise measurement
of the vertical dimension. For single
tooth replacement the incision is
placed on the alveolar ridge, and in
larger edentulous areas, especially if
bone grafting should follow, about
8 mm buccal off the crest. The mar-
ginal periodontal tissues of neigh-
bouring teeth are left intact.
The stepwise preparation of the muco-
periostal flap is performed as de-
scribed above.
 1.
Einführung –
Konzept

3.3. Maxilla

If a larger segment of the maxilla must

be exposed, the incision should be
placed in the buccal fold, because Stepwise dissection of the soft
palatal incisions will compromise the tissues of the maxillary ridge;
vascularisation of that flap. The in- muscles inserting close to the crest
cision has to avoid the papillae of may be resected
natural teeth. If an augmentation is
required the flap can be lengthened
by periosteal advancement to allow
wound closure without any tension.
Muscle tissue inserting at the buccal
surface of the maxilla may be removed
leaving the periosteum intact. There is
no need for exposure of the incisal
canal or the bony palatal vault.
Fenestrations of buccal concavities
The nasal and maxillary sinuses and should be avoided or must be
sometimes considerable buccal con- covered with augmentative material
cavities of the alveolar processus
require special consideration.

3.4. Additional Procedures

If the bone geometry or volume of the

alveolar processus do not present
favourable conditions, because im-
plants would not be surrounded with
sufficient vital bone, augmentative
procedures are necessary. Autogenous
cancellous bone should be preferred
in comparison to allografts or ablative
methods reducing the alveolar height.
Titanium mesh, plates for osteosythe-
sis and/or compression screws can be
used to secure the bone grafts. Addi-
tional application of barrier mem-
branes is possible.
Augmentation procedures must
be based on specific surgical
skills and require an operating
unit with corresponding equip-
ment as well as a well trained
staff!

13

Different alveolar bone quality and
contour require a differentiated
approach and length of the healing
period (as per LEKHOLM)
The drills are used following the
order below:
a) Rose burr for marking the site
b) Pilot drill to determine the
inclination of the implant
(diameter 1.6 mm)
The TriSpade drills, i. e. drills with
three cutting edges, are used to
prepare the implant bed according
to desired length and diameter:
c) TriSpade 2.5 mm
d) TriSpade 2.8 mm (for Ø 3.25 mm
implants) – green
e) TriSpade 3.25 mm
(for Ø 3.75 mm implants) – blue
f) TriSpade 4.0 mm (for Ø 4.5 mm
implants) – red
g) TriSpade 4.7 mm (for Ø 5.5 mm
implants) – turquoise
14
4.
Preparation of the
Implant Bed
To achieve primary stability and fast
osseous integration of an implant, it is
mandatory to precisely create a con-
gruent implant bed.
Thermal damage to the bone has
to be avoided under all circum-
stances.
Drilling at a speed of not more than
800 rpm and adequate, i. e. generous
cooling, peferably with sterile saline
solution, is indispensable.
Burrs with internal cooling have
the advantage to apply the cooling
medium at the cutting edge, which is
the region of maximum friction heat.
The saline solution also removes the
debris and continuously cools the
whole drilled canal.
Internal cooling should be preferred
in all steps of the preparation, all
BEGO-SEMADOS®-TriSpade drills are
designed for internal cooling.
An intermittend (up-and-down-) tech-
nique with moderate pressure can
further reduce the heat damage to the
bone.
 1.
Einführung –
Konzept

4.1. Transfer of the Implant

Positions

The acrylic template is used to transfer

the desired implant positions from the
set-up or plaster cast to the jaws. A
mark can be placed on the mucosal
surface, transmucosally to the bone
surface or after exposure of the bone
after reflecting the mucoperiosteal The pilot drill can be used to mark
flap. the implant position transmucosally

A rose burr is used for sloping sur-

faces, otherwise the pilot drill will
mark the implant site.

4.2. Preparing the Implant Bed

The blade angulation of the TriSpade

drills ensures smooth rotation and in After reflection of the flap the
combination with the coolant, which pilot preparation is performed
emerges close to the cutting edges, under continuous irrigation
promotes the easy clearance of the
removed bone. Intermittent strictly up-
and-down movements during drilling
and moderate pressure help to prevent
thermal damage to the bone.

Tilting of the instruments must be

avoided during the final steps, since
this may cause uncontrolled widening
of the crestal part of the implant bed
and thus impair the primary stability
of the implant.

15

Secured with a piece of thread the
paralleling posts facilitate the
axial alignment of the drill holes
for neighbouring implants
TriSpade drill preparation of the
implant bed. The marks on the drill
correspond to the different implant
lengths
Drillstops attached to the TriSpade
drills prevent drilling deeper than
desired
16
4.
Preparation of the
Implant Bed
The depth of preparation can be mon-
itored by the circular marks on the
TriSpade drills. If a certain predeter-
mined depth may not be exceeded with
the drilling, special drill stops can be
attached. These will safely limit the
maximum depth to 7 mm, 8.5 mm,
10 mm, 11.5 mm and 13 mm on short
drills. If long drills are used the 10/15
stop will limit the depth to 15 mm, the
13/18 stop to 18 mm.
Unless an unfavourable bone contour
dictates otherwise, it is important to
direct the drill hole in an axis oriented
at the opposing alveolar ridge. If a
number of implants is planned it is
recommended to start preparation
with the most posterior implant posi-
tion and continue with the same drill
to the anterior region.
The paralleling posts are helpful for
the correct inclination of subsequent
drill holes and are available for all
diameters of the TriSpade drills.
Depending upon the width of the alve-
olar processus the drill hole can be
widened step by step just by changing
the drills which are available with a
diameter of

2.5 mm,

2.8 mm
(for Ø 3.25 mm implants),

3.25 mm
(for Ø 3.75 mm implants),

4.0 mm
(for Ø 4.5 mm implants), and

4.7 mm
(for Ø 5.5 mm implants).
 1.
Einführung –
Konzept

4.3. Verifying the Implant Length

The depth gauge is used to verify the

depth gained and establish the pos-
sible implant length. The drill hole
should be about 0.5 mm deeper than
the desired length to make sure that
the implant can be inserted flush with
the bone level.

The drill stops are available for all

lengths and diameters. The maxi-
mum depth is written on it

The depth gauge is used to verify the

final depth of the preparation

17

Profuse and continuous
irrigation is imperitve during screw
tap preparation
Pretaping can be carried out for all
implant lengths and diameters.
The basal cortical bone plate should
not be perforated
18
4.
Preparation of the
Implant Bed
4.4. Pretapping and Countersink
Preparation
Implant sites located in dense cortical
bone or in homogenous density class 1
or 2 bone require pretapping. Taps
can be used with the ratchet or with a
slowly rotating handpiece (maximum:
60 rpm, stricly axial, sufficient pres-
sure!).
In tapping the friction of the threads
cause heating, so profuse irrigation
of the area involved is mandatory. As
soon as a decrease in resistance indi-
cates the cancellous bone has been
reached, no further preparation is
necessary. In class 3 or 4 bone density
no pretapping is required. In the
posterior maxilla it is sometimes suffi-
cient to prepare with a drill one step
smaller than actually needed for the
desired implant and only prepare one
third of the hole with the correspond-
ing TriSpade drill or use the counter-
sink only. The self-tapping threads of
the implant will cut in easily and will
provide the essential primary stability.
Because the core diameter of the
implant increases at the neck portion,
in compact bone the drill hole has to
be larger than the other part of the
preparation. This can be done with the
countersink drill. It facilitates the
insertion of the implant and prevents
fractures of the crestal bone.
5.
Unpacking of the
SEMADOS®-S-Implant

The package includes the implant

which is sealed in an sterile double
vial and the instructions for use, which
should be acknowledged and followed
carefully. The label on the packing
indicates the implant diameter and
length as well as the reference and lot
numbers. This is followed by the date
of expiration of sterility and the CE test
mark.

The circulation nurse removes the

vial from the package and opens the
outer vial or secondary packing by
bending the cap. The sterile contents
(primary packing) can be carefully
slid onto a sterile surface (operating /
instrument table) without touching the
opening of the secondary packing or
its contents.

The surgeon, holding the primary

packing in a vertical position, can then
remove the top plug and place the
insertion tool on top of the implant
Unpacking the sterile, primary vial
where the transfer-/insertion post is
premounted. The tool snaps in and
the implant can be safely transferred
to the prepared site attached to the
ratchet or handpiece.

It is imperitive to avoid any contact of

the implant surface with saliva, mu-
cosa, gloves or other instruments dur-
ing the transfer and insertion! The in-
scription ‘in’ should be visible when
the implant is being picked up! Should it become necessary to in-
terupt the insertion, the implant can
either be put back into the glass vial
(primary packing) or left in a small
titanium bowl on the tray.

Again, it is important to avoid any con-

tact with the implant surface!

19
 6.
Insertion of the
SEMADOS® S Implant

The cover screw is picked from the

second (bottom) plug with the
1.25 mm hexagon screwdriver and
after cleaning the internal threads
closes the opening of the implant.
Make sure that it can be easily
unscrewed!

The insertion tool is used to screw

in the implant until it ends up flush
with the bone level. Adequate

cooling!

20
7. 8.
Wound Closure Postoperative
Management

Prior to insertion the implant site
should be irrigated with saline solu-
tion to remove debris and blood clot.
The flap is retracted to prevent contact
with the implant surface and the
neighbourhood of the drilled hole gets
disinfected and dried.
As soon as blood emerges from the
hole the implant is placed in the
opening and instantly screwed in with
either the ratched or a handpiece
rotating extremely slowly. While turn-
ing moderate pressure to advance
the implant and strict control of the
axial direction must be applied. If an
increase of resistance is noted or a
torque of more than 25 Ncm is
needed, coolant should be adminis-
tered to the still extraosseous part of
the implant for at least 10 seconds
after no more than 2 full turns.
After thorough cleaning and disinfec-
moved. tion the operationg field is checked
for debris or sharp bony edges, these
should be removed or smoothened be-
fore suturing.
It is essential to ensure passive wound
closure and use an atraumatic suture
of not more than 4/0 (1.5 metric). The
suturing technique (interrupted, verti-
cal or horizontal mattress- or con-
tinuous stitches) should be selected
according to the individual situation.
The implants should be completely
covered with the mucoperiosteal flap.

Insertion is complete when the im-

plant neck is flush with the bone. Pri-
mary stability is achieved if the implant
cannot be moved unless higher torque
is used or shows the sound of a fixed
tooth when knocking on it. There is
no need to screw in the implant until
it reaches considerable resistance or
the bottom of the drill hole. Adjacent
structure might be damaged or the
threads securing the implant get de-
stroyed which causes loss of stability.

The ratchet can remain on the inser-

tion tool while the screw locking it
into the implant get loosened with
the 1.25 mm hexagon screwdriver. If
a handpiece was used this has to
be taken off first, and then the pre-
mounted insertion tool can be re-

21
 9.
Patient Recalls –
Healing Period

During the healing period the wound

should be checked at regular inter-
vals.

The postoperative care can be divided

into
– the immediate postoperative period
of soft-tissue healing, and
– the time needed for osseointegra-
tion.

Mechanical irritation of the mucosal

wound should be avoided during the
immediate postoperative period. The
surface of the wound can be delicately
cleansed after meals to remove any
plaque. Careful rinsing of the oral
cavity with an antimicrobial solution
(e. g. hexedinechloride) is useful .

Analgesics and/or non-steroidal anti-

phlogistics can be prescribed if neces-
sary, Aspirin® is not indicated, as it
interferes with blood clotting.

The diet during the first 10 days

should be restricted to liquids or thin
soft food. The patinet may wear a
bridge or denture, if it is adequately
relieved to ensure that it afflicts no
trauma or compromizes the micro-
circulation of the implanted area.

Antibiotics are indicated only in ex-

ceptional cases.

22
10.
Exposure of the Implant and Preparations
for the Restaurative Procedures
– STAGE II –

Follow-up checks should be scheduled

on the first day after surgery and then
at intervals of several days depending
upon the individual situation and ex-
tend of surgery performed.

Sutures get removed at 8 to 10 days,

further follow-ups every 3 to 4 weeks.

If the patient wears a removable den-

ture, this can be relined, although
care has to be taken to avoid trauma
or pressure on the periimplantal tis-
sues. If possible, temporary soft lining
should be perferred.

Small dehiscences will usually resolve

without further consequences. In in-
stances of major suture failure cleans-
ing and freshening of the wound mar-
gins and secondary sutures are recom-
mended.

The timing of the second stage surgery

(re-entry – exposure of the integrated
implants) depends upon the primary
bone quality and the progress of
osseointegration which can only partly
be estimated by X-rays (bone apposi-
tion? radiolucency? cleft or direct
bone-implant contact visible?).

Mandibular implants in solid bone

with reliable primary stability can be
exposed and loaded after 2 months.
Implants placed in poor bone quality
or needing grafting procedures may be
loaded after 3 to 4 months time –
always provided that osseous integra-
tion has occurred! In special cases the
period for osseointegration may be
extended to 6 months, but due to bone

23
 SEMADOS®-S-Implants: The patented SEMADOS®-S-Implant
The highly efficient implant System at a glance:
system for all applications:
• Implant material:
• Economical Pure titanium, Grade 4, according to
• Easy-to-understand system ISO 5832
• 100% German quality product
• Clinically tested • Diameter
• Universal in use 3.25 mm, 3.75 mm,
• Meets high aesthetic demands 4.5 mm and 5.5 mm
• Length in mm: 7 / 8.5 / 10
SEMADOS products give dentists and
® 11.5 / 13 / 15 / 18
dental technicians the means to produce • Clearly laid-out surgical tray Narrow, highly
first-class functional and aesthetic soluti- organised to suit each step polished shoulder
ons reliably. of the procedure • Minimisation of marginal
BEGO Implant Systems and SEMADOS®- bone resorption
• Reusable drills with internal
S-Implants represent the state of the art in cooling • Irritation-free mucosal
implantology. apposition
• Functional prosthodontics
with impressive aesthetics • Self-tapping thread
• Thread can be precut if
• Case-specific sets for
the situation demands
clearly structured working

Optimal connection to the prosthesis

• Internal thread permits detachment of
prosthesis SEMADOS®-
• Internal hex (2.5 mm) protects S-Implants:
superstructure elements against torsion
Surface quality
Order No. 82603 · © 2005 by BEGO September 2005 · www.adwork-werbeagentur.de
• Internal taper ensures gap-free seating The implant system
• Pure titanium (Grade
of superstructure elements for your long-term 4) with microstructured,
• Optimal oral hygiene (excellent success! osteoconductive, uncoa-
resistance to microbial leakage) ted surface

Class II b medical device accor-

S - I M P L A N T S ding to Directive 93 /42 / EEC

BEGO Implant Systems GmbH & Co. KG · Technologiepark Universität · Wilhelm-Herbst-Straße 1 · 28359 Bremen
Phone (+49-421) 20 28-246 · Fax (+49-421) 20 28-265 · www.bego-implantology.com · e-mail: info@bego-implantology.com
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