Chapter 4- Postoperative management
Tsuyama YasuhikoManager of Dental Surgery, Dentistry, Mitsui Memorial Hospital
In implant treatment, the emphasis is often placed on the installation techniques, but the importance of
postoperative management should not be forgotten. This is of particular significance after the installationof one-piece types, therefore the explanation to the patients and the confirmation of the coherence to the
management from the view point of implant preservation are vital. The understanding of thecomplications that can arise such as bone rejection, and their management, can have a significant effecton the subsequent outcome of the treatment. The stance of the practitioner to inspect the patient
conditions in detail during the postoperative management acts to build a mutual relationship based ontrust with the patient.
The aim with which to conduct postoperative monitoring acting as a surgeon is discussed in this chapter.
I.

Protecting the implantA.

Protecting the one-piece typeThe implant body of one-piece type is left exposed from the gingivae once the operation is completed forthe first time. The prognosis is largely influenced by its preservation techniques. If occlusal force isapplied on the implanted body whether without realizing, a characteristic bone resorption is known toresult, as shown by the radiographic account as shown in Fig. 3-4-1. A bone resorption featured as aninverse triangle towards the cervical region of the implant body is evident here. The implant body has
been noted to fall out in approximately two weeks time once such bone state is created, if not treated(methods for which will be mentioned later in this section). It is therefore of particular importance towarn the patient not to chew with the implanted region, and actually check that they have not been doing
so. From the past experiences, four to eight weeks have been adequate as the consolidation period before
the forces can be reapplied, but it is largely dependent on the degree of primary stability or the occlusal
force of the individual. In conducting the pull-out strength test, the bonding strength was reported to
rapidly increase in the space of eight weeks therefore the consolidation period of eight weeks may beadequate for those surgeons with less experience.

Fig. 3-4-1 Absorbed state of the bone where external force
was exerted straight after implantation

There are cases where the patient applies forces unconsciously, including touching with the tongue;
resting the cheek on palm of the hand; tooth brushing the implant body, and all these can inhibit the
implant from stabilizing. Implant body should be fixed to other structures where these occurrences are
predicted. As an example, the implant, fixed onto the adjacent teeth with the application of Superbond isshown in Fig.3-4-2. Where there is a request for the placement of temporary crown directly after the
installation, a method is present to fix the implant body by fabricating provisional tooth with immediateloading resin (Fig. 3-4-3). This method is particularly effective for regions in which the esthetics isimportant, such as the anterior regions of the maxilla. The placement at this position should be conducted
once establishing centric occlusion and protrusive occlusion as well as sufficient amount of clearance. The
patients must be warned not to chew in this region. Alternatively, as displayed in Fig. 3-4-4, a celluloid
protective mouth-shield can be inserted as a guard to protect the inserted structures. With respect to theanterior teeth, if these provisional structures are fabricated prior to installation, it can be effective inprotecting the implant body as well as achieving an aesthetic recovery (Fig. 3-4-5,6).

Fig. 3-4-2 Fix implant with adjacentFig. 3-4-3 When equipping false tooth rightnatural teeth with Superbond

after implanting, ensure sufficient clearance

Fig. 3-4-4 Cellulose mouthpiece

Fig. 3-4-5, 6 - The fabrication of provisional structures before theimplant installation can be effective in the protection and for an
aesthetic recovery, especially for the anterior teeth region.

B. Protecting the two-piece typeThe insertion of the fixture of the two-piece type results in a fully covered state of the implant body,therefore the preservation measures are often neglected. It is essential not to ignore the fact thatmicro-motion is conveyed through the gingivae to the implant body. This is such an influential factor thatafter bone augmentation procedures such as sinus-lift to the case where there is a deficiency in thevertical height of the bone in conjunction with the installation of two-piece type; or where the two-piecetype implant installation was facilitated by the GBR method, the implant body can be protected from themicro-movement with the placement of titanium plate.
There are artificial dentures, temporary dentures and plaster types to the protection bed. Directtransmission of the micro-movement can be prevented in using any of these types by creating a spacearound the planting cavity. The closed state after the two-piece type insertion to the anterior mandible, in
conjunction with the GBR technique is featured in Fig. 3-4-7. A temporary crown was subsequently placedand fixed with adjacent teeth with Superbond for protection and aesthetic recovery purposes (Fig. 3-4-8).

Fig. 3-4-7-a,b,c Two-piece type implantation to the anterior mandible with GBR techniqueFig. 2-4-8-a,b Placement of a temporary crown
II. Infection control and countermeasure
It is an impossible task to avoid the invasion of the resident floras in the oral cavity or the foreign
microbes into the implant cavity. Therefore the administration of suitable antibiotics is essential for theprevention of infection.
The complete closure of the fixture of the two-piece two-stage type within the cavity creates a highly
favorable environment for the proliferation of the anaerobic bacteria. Therefore first-line antibiotics that
also cover the anaerobic bacteria are often selected. The implant bodies of two-piece one-stage or
one-piece type, on the contrary, are left exposed from the gingivae surface thus are often considered as anopen wound. In clinical practice however, the gingivae flap is stitched up closely around the implant body,therefore these should also be considered as a closed wound. Thus the first-line antibody covering
anaerobes should also be administered for the one-stage types.
Temporary bacteremia has been shown to occur in the procedures such as tooth extraction. Since implant
treatment is also associated with this type of surgery, there are cases where preoperative course ofantibiotics may also be required. The administration of 2 g aminobenzylpenicillin (ABPC, ampicillin) an
hour before the surgery has been recommended by the American Heart Association (AHA) for a number ofunderlying diseases. There are no standard guidelines set in Japan, but following the AHA guideline isrecommended. The body temperature and the systemic condition of the patients must be examined
postoperatively. If the fever-like symptoms persist, there is a possibility of bacterial endocarditis,
therefore consider consulting the medical doctor and administration of antibiotics.
There are no clarified period of administration, and have often been derived from the past clinicalexperiences. Generally, it is administered for the week till the stitch removal. Assess whether a correct
dosage has been administered relative to patient’s body weight, and that the patient has been compliant
with the course prescribed. In the follow-up, in addition to inspect patient compliance with the oral
medication, obtain the time of administration also. If the instruction is to be taken after each meal, it isimportant not to lengthen the time period between dinner and breakfast, and it may be required to ask
the patients to delay their dinner slightly.
The efficacy of the course of antibiotics should be derived from the local examination. Symptoms arising
within five days of implant installation such as redness, swelling or pain, are an indication of
postoperative infection. The antibiotic therefore is ineffective therefore consider changing it to anotheragent. The most effective means would be to identify the causative agent with a bacterial culture test andadminister the antibiotic agent that is specific for it. But since the identification procedure takes a fairamount of time, administer another group, such as changing the agent to macrolides where cephem
antibiotics were being administered previously. It is ineffective to continue with the same antibiotics or of
the same group. If the oral agents are not sufficient, antibiotic infusion may also be required as an
adjunct.
III. Pain management
In the AQB implant installation, it is vital to bury the recrystallized HA coated layer within the bone
structure. Mucoperiosteal flap formation is essential since this confirmation can only be done visuallywith the surgeon’s eyes. The formation of the flap can consequently result in accumulation of blood
effusion in between the flap and the bone, therefore slight swelling and pain are inevitable. The problem
arises where the patients try to manage this pain with ice to the space between the implant body and the
buccal mucosa. Alongside touching the implant body with the tongue, such actions can act as the external
forces, consequently preventing the interaction to be achieved with the bone. The importance of pain
management with considerations to the administration of analgesics is therefore a vital part of the
postoperative therapy.
The first-line analgesic in the clinical practice is the non-steroidal anti-inflammatory drug (NSAIDs).
Prostaglandins which are the stimuli for pain are often contained within the exudates therefore theadministration of NSAIDs, a synthetic inhibitor, act rapidly to deliver effective inhibitory effect. NSAIDs
have been associated to have various side effects therefore its use in some of the conditions, as stated inTable 3-4-1, this should be done with caution. It is contra-indicated in asthmatic patients and in thoseindividuals who are undertaking a course of new quinolone. The second-line agent is acetoaminophen(non-pyrine type), but its action is less effective than NSAIDs.
The manner of administration, whether it is a regular intake or a single internal use, is often determinedby the level of invasiveness of the surgical procedure. For instance, a single intake is sufficient for
installation of one-piece type, but for the formation of extensive mucoperiosteal flap, with concomitant
application of bone graft, or sinus-lift procedures, a regular intake is necessary.
Where the oral drug is insufficient to derive at an optimum effect, a concomitant administration of
suppositories may be effective. As a common side effect of analgesia, gastric discomfort has often resulted,
therefore concomitant use of stomach medicine should be considered. The sense of pain varies largely
among the individuals. Paying attention to patient’s complaints and insuring them of the safety can have
similar effects to the pharmacological analgesic action.

1. Asthmatic patients (Contraindication to aspirin included asthma patients)
2. Concomitant use with new quinolone
3. Gastroduodenal ulcer patients
4. Nephropathy patietns (Dialysis patient)
5. Early pregnancy and late pregnancy
6. For use in infants and elderly
7. Patients who are taking anticoagulants
Table 3-4-1 Precaution for use of NSAIDs
IV. Management of postoperative bleeding and subcutaneous bruising
The source of the bleeding in implant treatment should be determined, whether it is from the bone or thegingivae. The agent that is often used in clinical practice to distinguish between the two is 2% xylocaine
with epinephrine. Administer this agent to the bleeding area with infiltration anesthesia, and applypressure for five minutes with alginate impression agent, as illustrated in Fig 3-4-9. If the bleeding stops
with this process, the source can be identified to be of the gingival origin. This can be treated by simply
stitching up the bleeding area. If the source is from the area surrounding the implant body, the bleeding
can be stopped by stitching to close the gap between the gingivae and the implant body. If the bleed does
not stop, suspect the bleeding or bleeding tendency to be sourced from the bone. This should be managedwith the use of hemostatic plaster as featured in Fig 3-4-10-a, and pressurize the area with this plaster aswell as with the periodontal pack (Fig.3-4-10-b) for two to three days.
In the past clinical practice, in the patients who had been undertaking a course of oral anticoagulants oranti-platelet therapy were temporarily discontinued prior to the implant surgery but in the recent years
the continuous administration of these agents have been recommended. The reasons for this change canbe due to the reports of, firstly, the risk of triggering myocardical infarction or stroke by thediscontinuation of the systemic intake of these agents, and secondly, that local hemostasis is still possible
by conducting a suitable measure, even with the concomitant administration of the drug agents.
The bleeding from the oral cavity is mixed with saliva therefore appear to be more than the actual blood
volume and can trigger anxiety in patients. Such explanation may be relevant for the patient to relax, as
well as effectively managing the hemostasis.
There have been cases of patients presenting with subcutaneous bruising on the face or the neck in thethree to five days following the surgical procedure. This has been observed after an extensive applicationof gingival periosteal flap in procedures such as sinus-lift or bone augmentation, which indicate thetransfer of blood from one location to the other. It is often found at a location away from the where thesurgery was conducted, which can make the patient worried. The presentation of the subcutaneous
bruising around the optical sockets after the sinus-lift procedure to both sides is shown in Fig. 3-4-11-a.
The condition of the patient seven days after the surgery is shown in Fig. 3-4-11-b. The subsidence of thebruise on the face can be observed, but a large subcutaneous bruise has presented on the neck region.
Generally, these types of bruising eventually turn to a yellow color and disappear in the space of roughly
three weeks.

Fig. 3-4-9 Apply infiltration anesthesia and thenapply pressure for approximately five minutes withalginate impression agents.

Fig. 3-4-10-a,b When the bleeding or bleeding
tendency is suspected to be originating from thebone,fabricatehemostasis

plaster(a),andpressurize the area with hemostasis plaster andperiodontal pack (b)Fig 3-4-11-a,b physiological observation after performing sinus-lift procedures on the both sides.
Subcutaneous bleeding bruising has manifested around the orbital sockets and on the corners of themouth.
a. Two days after the sinus-lift procedures conducted on the both sides.
b. Seven days after the sinus-lift procedures conducted on the both sides.
V.

Management of inferior alveolar nerve paralysis and mental nerve paralysis

Both inferior alveolar nerve paralysis and mental nerve paralysis are complications of implant surgery
that should be avoided the most. The treatment outcome resulting in these complications canconsequently damage the relationship with the patient that had been built on trust, and can even lead tofiling for a lawsuit. The complete recuperation from the nerve damages is often complicated but recovery
of its functions is possible up to a certain degree. It is important to swiftly get onto the subsequent
surgical intervention facilitated by the specialist organizations.
A. The cause and clinical conditions
Factors that can be accounted for the cause include: direct injury from the drilling; pressure exerted by
the implant body; or the pressure exerted by the development of hematoma. The most importantamongst these is the damage from the drilling as a complete recovery from this is difficult. A direct injury
to the nerves is often thought to result in abnormal bleeding or significant pain, but these symptoms arerare.
The common clinical symptoms of paralysis are dependent on the extent of injury, and vary from thesense of numbness or tingling in the lower lip or in the skin of the chin. The sensing and the complainingof these symptoms vary among the individuals therefore the region of the numbness, the type, and thedegree of these symptoms should be recorded in the medical records.
B. Clinical evaluation of the injury
In the evaluation of the sensory disturbances, both quantitative analysis and audit of the patient’s
subjective symptoms should be included and be judged as a whole. It is recommended to combine aquantitative and one with high reproducibility in the evaluation of sensory perception. There are staticquantitative sensory testing (QST, Fig.3-4-12), and two-point discrimination testing as the typicalexamples, which are both effective in the evaluation of the degree of recovery over a period of time.
The audit of the subjective symptoms should be recorded over the course of the treatment using checksheet of subjective symptoms, alongside taking photography of the area of the sensory disturbances (Fig.
3-4-13).

Fig. 3-4-12 Quantitative sensory testing with
Semmes-Weinstein monofilaments

Fig. 3-4-13 Photograph featuring the area of neuroparalysis.
After cyst extraction from the tooth root of left mandibularcanine. SW Pressure Aesthesiometer 4.74

C. Treatment of the injury
The therapeutic intervention for the damages has not yet been established, and the reality is that they
are being treated by combining the methods as mentioned below.
1. Pharmacotherapy
The most frequently used are the combination therapy of Vitamin B12 and ATP. With regards to the
combined administration of these drugs and the treatment course have been a subject of debate, but inauthor’s facilities, both these agents are administered for the course of three to six months.
Steroidal agents can be administered as an alternative. The objective of this is to ease the pressure
exerted on the nerves by reducing the swelling inside of the mandibular canal. Administrations of up to
three days have been recommended. The only concern is the side effects of this group such as the gastricdisturbances or menstrual irregularities. Therefore before prescribing the course, a consultation with a
medical doctor who is experienced with the use of steroids would be desirable.
2. Surgical intervention

There are two arguments for the methods to solve the issue that has been created by the implant body.
First, observe for any improvements in the symptoms resulting from the relieving the applied pressure
on the mandibular canal by elevating the implant body by 1 to 2 mm above the canal (Fig. 3-4-14). Thismethod is considered to be most effective for the cases where the probability of the damage is less likely
to be the direct drilling injury, and more likely to be from the pressure exerted by the implant body.
However, in the case of AQB implant, this method is not recommended, as the elevation of the implant
body can consequently expose the recrystallized coating.
Second argument is to “remove the implant as soon as possible”. The objective of this is to relieve thecontinuously applied pressure from the hematoma or the aberrant bone fragments, with the removal of
the implant body.
With regards to the neurectomy procedures, nerve anatomosis or nerve graft can be considered as atherapeutic option but the complete recovery even with these procedures is considered extremely rare.
3. Other therapeutic interventions
Laser surgery and acupuncture have been conducted as a method to accelerate the regeneration process
by increasing blood flow to the area. The patient with inferior alveolar nerve paralysis, undergoing
acupuncture therapy is featured in Fig. 3-4-15. A complete recovery from nerve paralysis that resulted
from implant installation has not yet been experienced with acupuncture therapy. So far, it has only beeneffective for the reduction of the area of paralysis.

Fig. 3-4-14-a,b,c. Elevation of the implant body by 2 mm as a countermeasure for the damage to themandibular canal.
a. Preoperative panoramic radiographb. Preoperative dental radiographc. Postoperative panoramic radiographFig. 3-4-15-a,b Images featuring thepatient undergoing acupuncture for acase of inferior alveolar nerve paralysis.
D. Preventative measures for the injury
The key to preventing any damage caused on the nerves lies in the identification of the exact location of

the mandibular canal before the procedure, as well as its orientations and their variations. Recent
findings indicated that the inferior alveolar neuromuscular bundle to branch into two in the area close to
the distal position of the secondary molars. Therefore the surgical procedures should be conducted withthe awareness of these two branches (Fig. 3-4-16).
Conflicting views exist on the anterior loop of the mandibular canal, but the implant body isrecommended to be installed with the distance of at least 5 mm away from the mental foramen. The
surgical procedures in the area proximate to the mental foramen should be conducted with the upmost
care, especially as any pressure applied or any shifts in the mental nerve can be detrimental to thestructure.
There are several studies conducted with respect to the distance required in between the base of theimplant body and of the mandibular canal, but in clinical practice, this has been said to be largely
dependent on the skills of the surgeon. From the past experiences, the implant should be installed at a
distance 2 mm away from the alveolar canal and 5 mm away from the mental foramen in order to avoid
inducing nerve paralysis.

Fig. 3-4-16 Radiograph illustrating the branching of
the inferior alveolar neurovascular bundle into twoin the vicinity of the distal positions of the second
molars.
VI. Removal of the suture and postoperative follow-up
The timing of the stitch removal differs in the nature of each clinical progress. It is often conducted when
the wound no longer shows any separation clinically, and the suture thread can be seen to be looseningout from the tissues. With regards to the one-piece type, the stitching of the mucosa surrounding theimplant body, it is usually removed roughly a week later. If the suturing has been applied too tightly,
partial necrosis of the gingivae is known to result (Fig. 3-4-17), in which case, the stitches should be
removed earlier, for example five days after the implantation. The type of the suture thread is also
important to be considered. For example, food becomes stuck to the silk thread but this can be avoided
with the use of nylon thread, thus the latter may be more suitable when leaving the threading attached
for more than a week to ensure that stability is achieved.
The thread should be removed after exposing those sections of the string that was incorporated within themucosa above the gingivae surface, and taking measures to prevent its re-insertion back into the tissue
structure.
During the healing period (from the time of installation till the removal of the stitches), the patient
should visit for a check-up, every other day, for the inspection of the operated region, and the cleaning of
the implant body. This should provide the patient with the sense of security. The monitoring the patient
progress should consequently improve the installation techniques of the surgeon. The follow-up after thestitch removal should be conducted once a week.

Fig. 3-4-17 Partial necrosis is known to result fromapplying too much tension on the threading.

VII. Patient consultation
The most effective methods to explain postoperative management to the patient would be to provide themwith the information in a written form (Fig. 3-4-18). The explanations are usually to be given three times.
The first is generally done before the implant treatment, but detailed explanation should be avoided at
this stage and adopt a style to explain gradually with the progress of the treatment. The second is given
before the installation of the implant. The explanation at this stage should be given in detail aided by the
information in the written form. The third explanation is given after the end of the implant surgery. Avoid
giving repetitive information and conduct the consultation with checking the compliancy of the patient to
the things that had been asked of them. When giving explanations to the patients, the practitioners
should be aware that the overload of information at any of the stages can lead to increased sense of fear
and anxiety towards the implant treatment itself.
The explanation document should be itemized to maximize the understanding by the patient and accept
the terms. The examples of the headings should include: postoperative progress and their precautions;medication counseling; instruction for the follow-up; plaque control; and response to emergency.
5. Preoperative preparation<Preparation few days before surgery>Appointment
Make the appointment with consideration to the fact that there
is a possibility of the face becoming swollen for a week after thesurgery.

<On the day of the surgery, Before the surgery>Appointment
Please avoid being late or cancel your appointment as much as
possible since the period for one surgery can take up to ten
different treatments.

Clothes
Physical condition
Please come prepared with clothes that are both relaxing and
Ensure you have been fully rested for 2 to 3 days before theone you would not mind getting dirty.
surgery to be in good condition without fatigue.
Make sure your physical condition is best on the day of surgery. Make-up
It is still possible to perform the surgery even if your condition is
Please do not wear make-up below your nose as the face will needslightly poor, but will be postponed in case of fever.
to be disinfected.
Please remove polish off the nails of the right index and middle
Mandibular range of motion
finger.
Implantation will be difficult with a trismus. Provided that widthof three fingers (the index finger, the second finger and the third Meal
finger) can be inserted vertically it should not be a problem. If you
There are no food intake restrictions, and breakfast is allowed. If
have difficulties opening the mouth widely, please inform youryou have been given preoperative medications, please take themdoctor beforehand.
as directed by the doctor.
Regular medicine
The pharmacological effects of some drugs are unfavorable forsurgical interventions, such as the medicines for arteriosclerosis(e.g. warfarin) that acts to thin the blood and slows down thehemostasis, which needs to be dealt with before the surgery.
With regards to some of the medicines for diabetes mellitus,
antipsychotic agents, nonsteroidal anti-inflammatory drugs andoral contraceptives, there are agents that may be better stopped

Cleaning
Brush your teeth more thoroughly than usual and shave.
<Right before surgery>ToiletPlease come having been to the toilet. The surgical procedures
can take a longer time than it was initially planned.

before surgery. Please notify your doctor of your current treatment
details.
This is particularly important if you are taking medicines forosteoporosis, because these medicines can cause necrosis of thebone after the surgery. Please be sure to inform your doctor about
this. Make sure you undergo surgery once the medications forosteoporosis have been stopped.
<The day before surgery>Pain
The surgery is performed under anesthesia, so it is usually
painless. If the given anesthetic is not effective, anotheranesthetic will be provided. You never need to bear the pain,so please do not afraid to receive the surgery. If you still feel
uneasy, the general anesthetic will be given (￥200, 000 will
be added to your bill).
Fitting with the bone
Some of patients are concerned as to “ What if the implant will
not fix well…”, but if the implant treatment is unsuccessful, thesurgery will be performed again for no additional fee(replantation surgery). All of the current implant systems havebeen proven to have high performance and you can consider the
failure rate, where the implant does not integrate with the bone,
to be less than 5%.
Harm
Titanium is highly biocompatible therefore titanium implant canbecome safely integrated with the bone without causing any
harm to the body.
Stories of unsuccessful treatments in the past
Implants have been applied for the past 20 years, but materials
and forms of implants in the past were vastly different from thosein current use and success rates were low. For example, theimplants made of artificial sapphire had problems withintegrating with the bone and blade implants had issues with its
removal if any complications occurred. The present implants
have been shown with high performance with reduced
possibilities of failure, thus it is possible to remove and install
implants even if complications are to arise.
If you know someone who had a bitter experience with the past
implant systems, know that these are completely different fromthe implants used at present, which have high efficacy and are
rarely problematic.

Hair
If you have long hair, do not tie your hair in a way that would
restrict your head movement.
<During the surgery>Time of surgery
The surgery usually takes 15 – 30 minutes to place one implant.
Some patients think about the surgery throughout the process,but it is better to think about other things to avoid fostering
anxiety. It is possible to listen to music if you have a tendency to
become anxious, so do not hesitate to ask if it may help you torelax.
Taste
The salty taste will persist during operation from thephysiological saline solution.
Touch
The anesthesia can make you feel painless, but not your senseof touch. For example, the anesthetic effect is working, it may
still be possible to sense milling of the bone or cutting into thegum. Individuals who have a fear for such can confuse thissensation with pain, but understand that is not the case.
TongueIf your tongue is large or it is positioned high in relation to theteeth, the tongue can be obstructive to the surgical procedure. It
will be pressed down to help us perform operation, so do not try
to move your tongue.
6. Points of caution for the 7 – 10 days after the operation
Postoperative care
After the operation, it is necessary to avoid applying external
force to the implant for it to integrate with the jawbone more
rapidly. Foods such as rice gruel/porridge are recommended andavoid biting with the implant site for 7 – 10 days after theoperation.
Swelling can occur 3 - 4 days after the surgery, but will disappear
again in 4 – 5 days. It can be cooled with a wet towel placed in arefrigerator, and put this next to the swelling. Do not press theimplant site with force. A course of painkillers, antibiotics andstomach medication will be prescribed, please take them asadvised by the doctor or the pharmacist. Allow at least 3 hours in
between taking the painkillers.
Please gargle after an every meal and before sleeping with theprescribed mouthwash. Your saliva may be mixed with blood forthe first couple of days after the surgery, but gargling too much is
not recommended to help the healing.
Some patients who dislike taking medications stop taking them if
their conditions do not appear serious. Please follow thedirections from your doctor and be sure to take medicine sincethese have been prescribed for a reason such as antibiotics forprotecting the wound from the bacterial invasion.

Fig. 3-4-18-a An example of explanation document 1 (From Yonezawa Dental Clinic in Tokushima
Prefecture)-Bleeding
Postoperative notes of caution are the same as those at the tooth
extraction. Avoid doing things that will increase your heart rateincrease such as having a bath, drinking alcohol or exercisingbecause will cause bleeding. Taking a shower should not be a
problem. Please do not gargle too much. The mechanism of thestop in bleeding is that it first solidifies by forming a jelly-likeplug similarly to a scab. This will be removed if you gargle with

10. Cleaning of implant
With the placement of the superstructure (artificial crown), theplaque becomes more easy to attach to implant. Therefore
plaque control becomes a vital component of the aftercare. You
will be given instructions on how to conduct interdental
brushing, dental flossing, in addition to normal tooth brushing.
11. Cases where any problems occur in implant treatment

too excessively. If this is repeated, with the scab coming off every
time, the wound becomes less likely to heal and bleeding will not
stop. Try not to think about it.
Removal of suture thread
Suture thread will be removed within 7 – 10 days after thesurgery but continue to avoid biting at the implant site and eat
tender foods.
7. Notes until 2 months after placement
1 – 2 months period after the placement is the most crucial.
Please continue to avoid biting at the implant site and do notpress the implant with a tongue or fingers. People have a habitof applying his/her tongue to the position that is of concern, andthis is done unconsciously. However, this will obstructive theintegration of the implant to the bone. It does not mean that the
implant is not compatible with the tongue, but the problem liesin continuing to touch the implant. It does not become an issue
if the tongue merely touches it, but it becomes so when thisdevelops into a habit, and then preventing the implant from
integrating with the bone. Be aware of the tongue habit. In
addition, please eat tender foods as much as possible.
8. Integration/Superstructure (artificial tooth)
The period needed for integration is usually 11/2 – 6 months forthe implant to integrate with the bone. The superstructure(artificial tooth) will be placed once determining that the
integration has occurred, and the implantation has beensuccessful. The patients who have been placed with thesuperstructure immediately after implantation (such as all-in-4
treatment) are recommended to continue with the liquid foodfor a month.
The implant structure is narrower than that of natural teeth
therefore do not expect the outcome to be exactly the same as
before. Since the thinness of the root, food tends to get stuck in
between the spaces therefore we will advise you to utilize theinterdental toothbrush.
Due to the titanium structure of the implant, these are notsubjected to dental caries but the oral hygiene is still essential
to maintain as it can still be affected by periodontal disease. It
becomes difficult to maintain implant if the necessary level oforal hygiene is not retained after the placement of thesuperstructure. The conditions may appear to be stable, but
once you neglect the oral care, you may lose the tooth you justgained. Do not neglect the oral care even if it appears healthy.

At the time of the implant surgery
At the time of implant operation, in spite of the preoperative
examinations, the jaw bone at the site of implantation isinadequate. Please be aware that the operation may be stopped
or bone augmentation procedure will be needed as an additional
procedure (additional fee).
Until 2 months after the surgery
In principle, there should not be any movement with theimplant. Where oppressive pain or movement have been notedwith the implant at 1 – 2 months after implantation, it can beassumed that integration with the bone have not beensuccessful due to osteogeneration in the implant surroundings
have not taken place for a reason or another. In such cases, theprogress will be observed for another 1 – 2 months with theplacement of temporary crown to determine whether thesuperstructure can be attached or whether another procedure,
removal/re-implantation will be necessary. In such cases, thenext surgery should not be prolonged with the expectation thatthe condition will be improved for the sake of future surgeries.
The limit for such observation period is 6 months after the
implantation.
In cases where any problems occur after the end of implant
treatment
Please contact us immediately if the artificial tooth attached tothe implant comes off or is damaged.
In addition, please contact us immediately if any problems
arises with your own natural teeth (for example, a crown comeoff or a tooth is shaky), so that any alterations to the overall
occlusion can be adjusted to avoid putting excessive pressure on
the implant.
12. Implant treatment expense
Implant treatment is not covered by your health insurance
therefore it will be a private treatment and will have to be paidby yourself. We ask that you pay at the time of ① examination,② implant placement surgery and ③ attachment of theartificial tooth.
You will not have to pay if the surgery is stopped because of theshortage of the bone of the placement site or other issues that
arose during the procedure.
If the treatment has been interrupted on your terms, please
understand that the expense up to that point will not be
refunded.

9. Periodical examination after the treatment finishes (recall)
The aftercare is imperative in the implant treatment. Please
visit the clinic for the follow-up. We will call you in for a medical
check-up a week, a month, 3 months and 6 months after thesuperstructure
placement.
At
thissession,theorthopantomography, dental photograph and intraoral
photograph will be taken properly and the doctor will inspect
for presence of bone resorption, conditions of the gingiva, teeth
and implant for any rubor, tumor, retraction, drainage, dolor,
bleeding, tartar, pocket depth, mobility and other abnormal
findings. After this, provided there were no abnormal
symptoms, the follow-up period will be every 6 months. In thissession, the areas and structures other than the site of implant
will also be under inspection, such as the conditions of thedentin, periodontal tissues and occlusion. These will then becompared to the postoperative results.

Fig. 3-4-18-b An example of explanation document 2 (From Yonezawa Dental Clinic in Tokushima
Prefecture)A. Postoperative progress and points of precaution
The treatment course is explained from the installation to the placement of the superstructure by
separating the contents into three: the period in between the installation and the stitch removal; period
in between the stitch removal and the placement of the superstructure; period after the superstructure
placement.
1.

The period in between the installation and the stitch removal

The most important point to bear in mind during this period is to avoid becoming in contact with theimplant body. Avoid chewing with and to occlude with the implanted area is one, but the avoidance of any
application of external factors should not be forgotten. The patient should be told to avoid touching theimplant body with the tongue or rest the side of the cheek on their hand. The suture is removed roughly
within a week, during which time the cleaning of the implant body should be done by a professional. The
instructions for the pharmacotherapy, such as the regular intake of antibiotics, the efficacy of analgesics,
and their side-effects should be given. In addition, their compliancy to the prescribed course should bechecked at each check up, as well as providing instructions in case of night time bleeding and contact
details for emergency.
2.

The period in between the stitch removal and the superstructure placement

Within this period, the patient usually relaxes, having been relieved of postoperative pain, and end up
occluding with the implant body. The instructions not to occlude with the implanted section should begiven repeatedly. This should be provided with detailed reasoning, and inform them that theconsolidation period is roughly eight weeks; then shorten this period in accordance with the analysis of
the state of the bone with the technique that will be discussed later. It is best to avoid lengthening theperiod of consolidation from the time that was given initially. There have been patients that have brushed
the implant body with the tooth brush within this time. The ultra-soft brush must be employed andchecked that no excess pressure is applied. The patient should visit the clinic once a week within thisperiod, after the stitch removal and placement of the crown prosthesis, to check for presence of bone
rejection and plaque control. After the placement of the temporary crown, monitor the state of occlusion
for roughly a month, alongside the final checks of any bone rejections.
3.

The period after the superstructure placement

Explain to the patients of the importance of plaque control and the necessity of regular check-up. The
patient must be able to recognize that the plaque control by the patient themselves can affect the implant
treatment prognosis. Instruct the patient to visit the clinic every six months for regular observation.
Patients should be informed that during these visits, the state of occlusion, plaque control, and X-ray
radiography are assessed. Finally, inform them that there will be letters to remind them to visit the clinic
regularly and to not leave a space of more than a year without visiting.
B. Example of detailed explanation
1.

After the one-piece type installation“In the two months following implant installation, the integration of the implant with the bone occurs
rapidly. If the implant is chewed with, felt with the tongue/ fingers or placing the side of the cheek on thepalm, the force applied on the implant body can prevent this integration becoming achieved. In somecases the implant body has been known to fall out, so it is important to make a conscious effort not to
occlude with the implant on its side.
Be aware that there may be bleeding mixed with the saliva for a few days, and that gurgling excessively
to get rid of this will only exacerbate the bleeding. Please refrain from any extensive exercise, having abath for a long time and alcohol for the rest of the day. Extent of swelling does vary amongst individuals
but it may manifest. The peak of swelling is two to three days time. In treating this with extremely cold,
like ice cold water will only harden the swelled state, therefore it should be applied lightly with a towelwetted with tap water instead.
A course of antibiotics to prevent infection has been prescribed, so please take these as has been
instructed, on time and with the correct dosage. If side-effects of rash or diarrhea presents, let us know.
The analgesics have been prescribed for a course of five days. It starts to work 30 minutes after taking it,so take one as soon as you feel slight pain. Other options such as the use of suppositories will beconsidered if it has not been sufficient, so please do not hesitate to consult us.
Take care when brushing the implant. Please refrain from touching it till the stitches have been removed
and we will be responsible for the cleaning till then. Once the stitches have been removed, you can start
brushing the implant with ultra-soft brush that we have provided without applying any force. The normal
toothbrush will be used once the artificial tooth is placed, but always use the ultra-soft tooth brush till wegive you the instruction.
Visit the clinic regularly, as frequently as possible, till the removal of the stitches. Having removed thestitches, visit the clinic once a week. The temporary tooth is fitted two months later, followed by the final
prosthesis a month after that. Then the treatment will be complete with a few fittings of the final
structure, but please come for a regular follow-up, every six months is the standard. There will be a letter
sent to remind you of the follow-up. We will inspect for the state of hygiene in the area of implant, thestate of occlusion, and with the radiograph.
Consciously take care of the oral hygiene as the oral care plays a huge role in the life-time of the implant.
There have been reports of smoking to have a deteriorating effect on implant. It is best to give up smoking
to achieve successful outcome with the implant”
2.

After the two-piece type installation“The primary surgery has been successful. The implant body has been buried and covered with the gum
so you will not be able to see it. The temporal crown structures or shields will be placed on top of this but
refrain from placing it before the stitches are removed. Chewing even after the shielded has been placed
can exert pressure on the implant body so please avoid chewing at this position. Be aware that it usuallyrequires roughly a period of 2 months for the implant to integrate with the bone, so avoid applying any
pressure before this. If there is pain or swelling with the shield, there are no obligations to force it on, but
visit the clinic as soon as possible.
It is usual to find swelling the day after the surgery. The peak is likely to occur in 2 days time, and willsubside a week later. You may find a simultaneous manifestation of bruising to the face or the neck. This
mark will turn from blue to yellow and completely disappear in three weeks, so it should not be
concerned.
Please refrain from gurgling too much after the procedure, and limit it to four times a day. It can also be acause of bleeding so minimize as much as possible. Blood may be mixed with the saliva in the first few
days after the implant treatment but it is nothing to be concerned with.
Anti-suppurative and analgesia have been prescribed, which should be taken as directed at a regulartime with the correct amount. Inform us in case that the drug does have not been suitable. If theanalgesic is ineffective, do not hesitate to tell us, use of suppositories may be considered.
Try to visit the clinic as frequently as possible till the removal of the stitches. The secondary surgery will
be conducted in two months time depending on the healing process. The secondary surgery will be tomount the abutment, then the placement of the temporary crown on the same day. You will be able tochew from here. You will then be in charge of cleaning your teeth. First, use soft brush and interdental
brush. Please bear in mind that the level of tooth brushing will influence the survival rate of the implant.
There have been reports of smoking having a deteriorating effect on the success of implant treatment
therefore we recommend that you stop smoking.
A month after the placement of the temporary crown, the final prosthesis will be fitted. The treatment
will be completed then but please come for a regular follow-up sessions after that. Every 6 months is thestandard. There will be a letter sent to remind you near the time of the follow-up. We will check for thestate of hygiene in the area of implant, the state of occlusion, and with the radiograph.
With the placement of implant, you should be able to chew in the same way as your own teeth. This will
enable you to chew sticky or hard food that was difficult before. Eat with appreciating the benefit of theimplant. As I mentioned before, the postoperative care is imperative to be able to continue this chewing
sensation, therefore please do not hesitate to ask any questions and inform us of any worries that you
may have at any time.”
VIII.

Points to bear in mind till the placement of the superstructure

A. Response to the bone rejection after the implant installation
1.

Clinical symptoms and characteristics of bone rejection

Rarely, cases present where the symptoms of pain and gingival swelling persists for a longer period oftime than two weeks after the installation of one-piece type, and falling out four weeks later. The implant
body is known to fall out due to bone resorption from contracting infection for a reason. The reason forthis can be owed to a bone rejection to a stimulus. Bone rejection of this type can be classed into threegroups in terms of the disease state to those caused by force, heat or down growth.
Typical manifestation of symptoms:Persisting pain.

Swelling in the gingivae surrounding the implant body.



There is no plosive sound when tapped.

Transparency in the bone structure is featured in the radiograph

Slight movements can be observed

These types of symptoms arise in the two to four weeks following the implant installation. Upon
manifestation of these symptoms the implant body is known to fall out rapidly if a suitable treatment is
not conducted. It is possible to prevent its elimination by fixing the structure strongly with the use ofSuperbond, and administration of antibiotics.

2.

Bone rejection resulting from application of mechanical force

Two factors can be considered as the causes of bone rejection: first, exertion of too much force at the timeof implant insertion; and second, the application of excessive occlusal force. The cause of mechanicalorigin manifests as a characteristic image in the radiograph, typical image of which can be seen in Fig.
3-4-19, the third week after the installation. Here, a resorption cannot be found on the base of the implant,
but a significant bone resorption that is in an inverse triangle can be seen in the area around the implantcervix. The state of the bone thought to be affected by the excessive occlusal force is shown in Fig. 3-4-20.
Here, a similar radiograph image can be seen. If these kinds of images are obtained, suspect themechanical forces as the causative factor.
Installation should be conducted with bearing in mind that the application of too much pressure at thetime of installation can result in pressurized resorption, as a preventative measure. The expansion of theimplant cavity diameter, as the last step, should always be performed with the reamer, and insert the
implant having confirmed the depth of the implant cavity to be 2 mm excess of the length of the implantfrom the HA coated point. To avoid excess occlusal force, the buccolingual width of the superstructure
should not exceed three times the width of the implant body diameter. In the molar region, the occlusion
at point A should be avoided, and ensure anterior disclusion to be achieved.

Fig. 3-4-19 Radiograph of the bone rejection resulting from appliedmechanical force, three weeks after the surgery.

Fig. 3-4-20 Radiograph featuring bone resorption thought to havecaused by excessive occlusal force.

3.

Bone rejection resulting from application of heat

Burning can induce bone rejection. Fig. 3-4-21 features the resorbed state of the bone. The significant
difference with those of the mechanical source is that the bone rejection profile with heat lacks thecharacteristic inverted triangular bone resorption. The bone resorption image is an overall bone resorbed
state. With such findings of the bone, heat should be suspected as the causal factor.
To prevent bone rejection from heat, the following factors have be considered during the installation
procedure.


Always perform the procedures with waterConstruct the cavity with 20 torques and 60 revolutions as the standard practice.

Wash the implant cavity after every step.

Fig.3-4-21 Radiograph of the bone refection resulting from heat4.

DowngrowthThis condition has been known to manifest where the occlusal pressure is applied before the implant has
not had the time to integrate with the bone. The probability of this occurring is increased if occlusalpressure is applied within a month after the installation of one-piece type. The radiograph featuring atypical state of downgrowth is shown in Fig 3-4-22. A slight case of bone resorption can be observed in thecervix region of the implant body. Where this kind of finding can be observed in the radiograph, avoid
applying any occlusal force for two months. The progress of resorption should be monitored over a periodof time.

Fig. 3-4-22 Radiograph featuring a typical downgrowth state of the bone5.

Responding to bone rejection

The key to overcoming this issue is to recognize the symptoms of bone rejection early by bearing in mind
the possibility of bone resorption after every implant installation. To enable this quick response, it isessential to inspect the area closely and with X-ray analysis. It should always be inspected at four stages
as mentioned below:Straight after the installation (to analyze the state of the installation, and to be used as the basis forthe following postoperative observations).



Two weeks after the installation (to recognize the initial signs of bone rejection).



Four weeks after the installation (final check for signs of bone rejection resulting from theinstallation).



Two weeks after the superstructure placement (check for bone rejection resulting from occlusal
forces).

The bone rejection should be treated by a firm fixture of the implant body and administration of
antibiotics. The points for a firm fixation with Superbond are mentioned below:Fix with the Superbond in a way that it covers the implant body (Fig. 2-4-23).



Leave interdental space to help retain an adequate level of oral hygiene.



Two month should be considered as the standard period for consolidation.



Leave sufficient distance between the antagonist teeth, and tell the patient to avoid occlusion on the
consolidating region.



The fixation with the natural teeth should be within limits of physiological movement.

The follow-up after the fixation should be conducted once a week to once two weeks to confirm that there
is no loosening, and the state of the gingivae. The impression material consisting of agar is the mosteffective for use when using Superbond. The agar impression material is applied to coat the surface of thegingivae (Fig. 3-4-24) before adding a layer of Superbond with a brush (Fig.3-4-25). This way, the flowing
off of the Superbond can be prevented. After the Superbond has been set, the agar impression material
can be removed, and then polish the Superbond layer to remove any sharp edges (Fig. 3-4-26).
Alternatively, a method to attach fixing apparatus fabricated with an immediate resin, with Superbond isalso possible (Fig. 3-4-27).
The points of administration of antibiotics with the presentation of bone rejection are mentioned below.
Administer a different group of antibiotics that had been given as a postoperative preventative
measure.



The standard treatment course is a week but consider repeated course of administration where theinflammation of the gingivae is persisting.

Fig. 3-4-23-a,b,c. Fix with Superbond as to cover the implant bodyFig. 3-4-24-a,b. After the installation (a), apply agar impression material to cover the gingivae surface.

Fig. 3-4-25 Apply Superbond

Fig 3-4-26. After the Superbond has been set,with a brushremove the agar impression agent and polishthe layer of Superbond to remove any sharpedges.

Fig. 3-4-27-a,b. An alternative method in which a fixing appliance fabricated with self-curing material is
attached with Superbond.
Lastly, a case encountered that was recovered from bone rejection is presented.
To the case of bone rejection resulting from mechanical force as featured in Fig. 3-4-19, four months
consolidation period was given. The radiograph featuring the condition a year later is shown in Fig.
3-4-28. For the bone rejection to have resulted from thermal damage as shown in Fig. 3-4-21, a period of
two month was given for consolidation. The radiograph of the same area six months later is shown in Fig.
3-4-29.

Fig. 3-4-28 Radiograph taken of theFig. 3-4-29 Radiograph taken of the state astate a year later from the case of boneyear later from the case of bone rejection to

rejection

have resulted from thermal damage as

to

have

resultedfrommechanical force as shown in Fig.3-4-19

shown in Fig. 3-4-21

References
1) Noma Y, Seto K, eds. Standard Oral surgery 3rd ed. Tokyo. Igaku-Shoin Ltd.(in Japanese)
2) Kamijo Y. Illustrated oral anatomy 4 Neurology. Tokyo. Anatome Co.,Ltd. (in Japanese)3) Koga T. Scientific evidence based implant surgery, Basic. Quintessence Publishing Co., Ltd. (inJapanese)
4) Akagawa Y, Matsuura M, Yatani H, Watanabe H. Fundamental concepts and techniques of oral
implant. Ishiyaku Pub, Inc. (in Japanese)5) Takahashi S, Sonoyama N, and others eds. Standard oral surgery 2nd ed. Igaku-Shoin Ltd. (inJapanese)
6) Katsuki T, Uchida Y. Basis of surgery and surgical anatomy for implant/oral surgery. Quintessence
Publishing Co., Ltd. (in Japanese)