General Necessities for Surgery

Before we discuss the actual surgical technique of dental implant placement, it would be appropriate to recapitulate the basic principles of surgery. The two principal requirements are adequate visibility and assistance. Adequate visibility depends on three things: adequate access, adequate light, and a surgical field free of excess blood and other fluids. Adequate access requires

1. patients ability to open their mouths wide,

2. surgically created exposure,

3. Retraction of tissues away from the operative field, and

4. Creation of surgical flaps.

Adequate light is another obvious necessity for surgery. A surgical field free of fluids is also necessary for adequate visibility. High-volume suctioning with a small tip can remove blood and other fluids from the field quickly. A properly trained assistant provides invaluable help during oral surgery. The assistant should be sufficiently familiar with the procedures being performed to anticipate the surgeon's needs.

General Principles for Incisions
The general principles for placing incisions so as to create surgical flaps remain the same regardless of the reason for creating them. These are (as listed by Peterson 2 ):

1. A sharp blade of the proper size should be used, usually a # 15 blade on a # 3 BP Handle.

2. A firm, continuous stroke should be used when incising.

3. The surgeon should carefully avoid cutting vital structures when incising.

4. Incisions through epithelial surfaces that the surgeon plans to reapproximate should be made with the blade held perpendicular to the epithelial surface.

5. Incisions in the oral cavity should be properly placed. It is more desirable to incise through attached gingiva and over healthy bone than through unattached gingiva and over unhealthy bone.

General Principles for Flap Design

Surgical flaps are made to gain surgical access to an area or to move tissue from one place to another. The requirements of flap design are (as listed by Peterson 2 ):Prevention of flap necrosis

Flap necrosis can be prevented if the surgeon attends to four basic principles.

Basic requirements of Flap. The Base (y) should be greater than the apex (x),
while the length (z) of the flap should not be more than twice the base.

1. First, the apex of a flap should never be wider than the base, unless a major artery is present in the base. (Fig. )

2. In general the length of a flap should be no more than twice the width of the base.

3. An axial blood supply should be included in the base of the flap.

4. The base of the flaps should not be excessively twisted or stretched, because either of these maneuvers may compromise the supplying vessels.

Prevention of flap dehiscence
Flap margin dehiscence (separation) is prevented by approximating the edges of the flap over healthy bone by handling the edges of the flap gently, and by not placing the flap under tension. Dehiscence exposes underlying bone producing pain and bone loss.

Prevention of flap tearing
Tearing of a flap is a common complication of the inexperienced surgeon who attempts to perform a procedure using a flap that provides insufficient access.Since a properly repaired long incision heals just as quickly as a short one, it is preferable to create a flap at the onset of surgery that is large enough to avoid either tearing it or interrupting surgery to modify it.