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Implant Surgery and Assistant Guide
Int J Clin Prev Dent 2022;18(3):96-109
Published online September 30, 2022;  https://doi.org/10.15236/ijcpd.2022.18.3.96
© 2022 International Journal of Clinical Preventive Dentistry.

HEE JA NA

Department of Dental Hygiene, Honam University, Kwangju, Korea
Received August 15, 2022; Revised September 11, 2022; Accepted September 28, 2022.
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
Objective: This study introduces the assistance process of dental hygienists during an implant surgery. The purpose of the study is to promote high-quality implant surgery assistance in order to increase the success rate of implant surgeries.
Methods: The authors introduce the implant surgery procedures during the treatment of patient K, who visited Y Dental Department in City G in January of 2020. Surgical procedures and cautions with a focus on the assistance of dental hygienists during a surgery are listed. The roles of a surgical assistant; patient management during surgery; assistive roles in soft tissue incision, retraction, bond preparation, and implant placement; cases that give special attention to suctioning; and medical assistance including sutures are introduced with pictures and explanations.
Results: Dental hygienists must maintain accuracy, agility, and composure along with the practitioner when providing assistance. In addition, dental hygienists’ medical assistance affects the amount of time required for surgery; occurrence of trauma during surgery, post-surgery edema and pain, and post-surgery infection; and surgery failure rate. The role of a dental hygienist in assisting implant surgeries is essential. A patient-centered assistance is important, and a dental hygienist must maintain the patient’s comfort level and psychological stability through communication with the patient.
Conclusion: Dental hygienists’ medical assistance affects the amount of time required for surgery; occurrence of trauma during surgery, post-surgery edema and pain, and post-surgery infection; and surgery failure rate. Clinical Relevance: Introducing dental hygienist assistance and protocols for implant surgery.
Keywords : implant, surgery, assistant, dental hygienist, implant placement, suction, retraction, bond preparation
Introduction

A dental implant is an artificial tooth root made of metal such as titanium in the alveolar bone of the area where the tooth is lost, and a dental crown or denture is attached to it to replace the function of the tooth. In the past, there were implants that were not inserted into the bone, but these days, only implants inserted into the bone are used in dentistry clinical practice, so implants generally refer to endosteal implants. As the demand for high-quality medical services increases, specialized personnel is subdivided and systematically stationed to maximize the efficiency of treatment and to provide the optimal convenience and high-quality medical services to pa-tients. Dentists and dental hygienists perform four-handed dentistry. Dental hygienists play a role of professionals with expertise, skills, and a mindset of a service provider [1]. In order to cut off the infection path and to prevent infection within a dental office, dental hygienists investigate and confirm the medical history of the patients who visit the dental clinic, observe these patients’ overall health, and take immediate measures when an infectious disease is identified [2]. Dental hygienists, along with dentists, prevent oral diseases, educate on oral care methods, and implement preventive measures against infections. They also serve as oral health educators [3]. Therefore, it is important for dental hygienists as well as dentists to maintain calmness, accuracy, agility, and composure during an implant surgery. Patient-centered assistance is important, and it is essential to communicate with patients to help them maintain a comfortable physical state and psychological stability. A dental hygienist should develop and train oneself on implant surgery assistance. It is important for dental hygienists to develop the ability to effectively communicate and collaborate with the surgical team. Dental hygienists must reassure the patients by explaining all the processes and procedures associated with the surgery and check the anxiety level and physical conditions of the patients. The purpose of retraction is to secure the visibility of the surgical site. The retractor is placed at a right angle to the bone surface and should not press on the soft tissue or slip. The rest of the fingers are placed on the face adjacent to the retraction site to secure a stable rest, and the dental hygienist should not press on or pull the soft tissues of the mental foramen. Dental hygienists must inform the patient to raise their hands if they feel pain or tingling sensations before beginning the bond preparation. They should inform the patient to breathe through the nose as water will continue to flow and be sucked into the suction tip. Contact between the implant and the patient’s blood affects the success rate of the implant surgery. No saline or saliva should touch the implant site until one-third of the abutment is implanted. A special attention to suctioning is needed during bone graft, soft tissue transplantation, removal of crushed bone fragments, and shielding and collagen procedures. Especially during a maxillary sinus graft, the suction should be placed slightly away from the window boundary and strictly kept outside the window. During the suturing process, dental hygienists must retract with the left hand while holding the mirror, and the right hand grabs the suction or tamponade. After the surgery, dental hygienists must encourage the patient to stand up slowly and praise the patient for their composure. After the confirmation of radiation results, they should explain the surgery outcomes for the patient’s understanding. They should wash their hands and disinfect and sterilize equipment required for dental treatment. Dental care providers must acquire and practice knowledge on infection paths and infection control measures in an effort to protect themselves and the patients visiting the clinic from any infections. In the study of Choi et al., [4] periodontal and surgical instruments were sterilized in 100% of all workplaces, 95.1% in university hospitals and general hospitals, and 88.8% in dental hospitals and clinics. From a national dental survey in Korea in 2006, more than 80% of Koreans have symptoms of periodontal disease such as gingival bleeding or calculus deposit in mid-1940s [5]. In 2007, the Korean Ministry of Health and Welfare declared periodontal disease as the main causative chronic disease of teeth loss after age 40 [6]. The roles and duties of dental assistants during an implant procedure affect the amount of time required for surgery; the occurrence of trauma during surgery, post-surgery edema and pain, and post-surgery infection; and surgery failure rate. The purpose of this study is to improve the effectiveness of assistants’ performance to increase the success rate of implant surgeries.

Materials and Methods

This study reports the implant procedures on a 56-year-old patient who visited Y Dental Department in City G in January, 2022. The authors listed the precautions to be taken during the surgery, focusing on the tasks of dental assistants. The research was approved by the Honam University Institutional Review Board (IRB NO 1041223-201912-HR-18). Instruments and materials are as follows: two No. 4 rear surface mirrors, 22 mm (Osung, Korea, 2019); basic pincette tweezers, 151 mm (Osung, Korea, 2019); utility pincette tweezers, 155 mm (Osung, Korea, 2019); periodontal explorer, XP23-WHO (Osung, Korea, 2019); metal suction tip, SNC45 (Osung, Korea, 2019); surgical suction tip, snf25set (Osung, Korea, 2019); probe, BHWHO (Osung, Korea, 2019); retractors, RTP90-1 (Osung, Korea, 2019); blade holder, SHF (Osung, Korea, 2019); #15 blade (Osung, Korea, 2019); periosteal elevator, EP9; surgical curette (Osung, Korea, 2019); Mosquito Hemostat, HTM130 (Osung, Korea, 2019); iris scissors, SCT115 (Osung, Korea, 2019); dean scissors, SCD170 (Osung, Korea, 2019); needle holder, SSA1 (Osung, Korea, 2019); suture set, Black Silk # w8114-0 with corner needle, 13 mm, 3/8 45 cm, coated vicryl (Germany, 2019); saline (Osung, Korea, 2019); gauze (Osung, Korea, 2019); surgical forceps (Osung, Korea, 2019); foil (Osung, Korea, 2019); irrigation syringe (Osung, Korea, 2019); irrigation tip (Osung, Korea, 2019); ampoule (Osung, Korea, 2019); needle (Osung, Korea, 2019); fixture implantation; Lindamann drill, lls21 (Osung, Korea, 2019); implant depth gauze, dg1 (Osung, Korea, 2019); caliper, lpc90 (Osung, Korea, 2019); bone graft; bone spreaders, boc22 (Osung, Korea, 2019); bone expender hand kit, bepd (Osung, Korea, 2019); bone expender engine kit (Osung, Korea, 2019); bone expender hand kit (Osung, Korea, 2019); micro saws 08 (Osung, Korea, 2019); trephine burs 30, 60, and 90 (Osung, Korea, 2019); surgical drill stand, dsta16 (Osung, Korea, 2019); convex osteotomes, bovx28 (Osung, Korea, 2019); block bone clamps 197 (Osung, Korea, 2019); bone collect chisel 1 (Osung, Korea, 2019); bone collector 1 (Osung, Korea, 2019); hexa wrench 7-15n (Osung, Korea, 2019); bone crusher 3 (Osung, Korea, 2019); bone crusher mallet 29 (Osung, Korea, 2019); bone mill (Osung, Korea, 2019); bone syringes 47 (Osung, Korea, 2019); bone well, bwsus1 (Osung, Korea, 2019); bone carrier, bsc3539 (Osung, Korea, 2019); bone packer, gp3340 (Osung, Korea, 2019); membrane forceps, mf01 (Osung, Korea, 2019); sinus ronger 100 (Osung, Korea, 2019); crestal approach kit (Osung, Korea, 2019); lateral approach kit (Osung, Korea, 2019); bone screw (Osung, Korea, 2019); bone tack kit (Osung, Korea, 2019); tissue punches 35c (Osung, Korea, 2019); screw removal kit (Osung, Korea, 2019); implant curettes (Osung, Korea, 2019); PRF & GRF Box (Osung, Korea, 2019); surgical mirror (Osung, Korea, 2019); surgical ruler (Osung, Korea, 2019); ice pack (Osung, Korea, 2019); hexamidine 205 ml, 17163 (Bukwang Pharmaceutical Co. Ltd., Seoul, Korea, 2019). First, cover the patient’s face with a hole towel, apply an anesthetic on the surgical site, and wait for 10 minutes. Sterilize the site with hexamidine for 1 minute. Cover the patient’s face again with a sterilized hole towel and sterilize the outer part of the mouth with alcohol cotton balls. Subsequently, sterilize the oral cavity with potadine, spray it with saline, and administer anesthetics once more. Make an incision on the gingiva of the surgical site. Peel off the gingiva with a periosteal elevator. Perform implant drilling in order and measure the depth with a depth gauge. After placing and tightening the fixture, insert healing. Sew the implant placement site using a suture set. Prepare panoramic photos, ice packs, and precautions for the patient. Insert saline-soaked gauze into the surgical site. After taking the last panorama, inform the patient of the postoperative precautions. Perform surgery in order. The following is the role of an assistant in soft tissue incision:

Figure 1. The suction tip is position-ed in close proximity to the path of the blade to ensure visibility of the incision.

Figure 2. The incision is checked using a periosteal elevator. The suc-tion tip is positioned close to the site of the procedure while the valve is lifted.
Surgical Tray Preparation

The materials needed for the implant are the following: mirror, pincette tweezers, dental explorer, periodontal probe, Minnesota retractors, blade Nos. 12 and 15, blade holder, periosteal elevator, surgical curette, Mosquito Hemostat, iris scissors, dean scissors, needle holder, suture set, saline, gauze, surgical towel, foil, irrigation syringe, irrigation tip, ampoule, needle, Lindemann drill, implant depth gauze, caliper, bone spreader, bone expander hand kit, bone expander engine kit, bone expander hand kit, micro saws, trephine burs, surgical drill stand, convex osteotomes, block bone clamps, bone collect chisel, bone collector, hexa wrench, bone crusher, bone crusher mallet, bone mill, bone syringes, bone well, bone carrier, bone packer, membrane forceps, sinus ronger, crestal approach kit, lateral approach kit, bone screw, bone tack, tissue punches, screw removal kit, implant curettes icgr, surgical mirror, surgical ruler, ice pack, and hexamidine. Arrange them primarily according to the user’s convenience. The needle holder handle should be positioned toward the operator and dean scissors toward the assistant.

Soft Tissue Incision

In cases of soft tissue incisions, the assistant should cautiously secure the field of view with the mirror using the left hand and the suction tip using the right hand at a right angle to the soft tissue surface. The assistant checks with the patient whether there is any discomfort when the incision begins.

Retraction

The purpose of retraction is to secure the view of the surgical site. The retractor is placed at a right angle to the bone surface, neither pressing on soft tissue nor slipping. The rest of the fingers should be securely rested on the face adjacent to the surgical site, and the soft tissue of the mental foramen should not be pressed or pulled. The retractor should be perpendicular to the surface of the bone and slightly away from the foramen. It should not put pressure on the depressor anguli oris or levator anguli oris. The assistant must position the retractor to pass the central part of the lips and apply saline or Vaseline on the mouth or the retractor to prevent the lips from drying. The assistant should position the retractor slightly away and higher from the foramen. The retractor is placed stably at a right angle to the bone surface. When the retractor presses the foramen, nerves are pressured, causing sensory abnormalities. When the retractor presses the lower part of the foramen to open the valve, nerves are stretched and damaged, also causing sensory abnormalities.

Bond Preparation

Before removing the bone, the patient is instructed to slightly raise a hand or to speak if he/she feels pain or tingling. The patient is asked to breathe through the nose as there will be a continuous flow of water, which will be sucked away with suction. If the assistant were to directly spray saline on the site of the procedure, then it is sprayed on the area where the drill meets the bone surface while simultaneously administering an appropriate amount of suction. It is recommended to place the suction tip around 5 mm below the drill.

Figure 3. The retractor is placed perpendicular to the bone surface (correct).

Figure 4. The retractor is on the goal surface and is located in a right angle direction (incorrect).

Figure 5. View of the retractor posi-tioned at a right angle to the bone surface from the occlusal surface (correct).

Figure 6. The retractor rests on the soft tissue valve (incorrect).

Figure 7. The retractor is placed slightly away from and slightly above the foramen. It is stabilized perpen-dicular to the bone surface.

Figure 8. When the retractor pres-ses on the foramen, the resulting pressure to the nerves causes sensory abnormalities.

Figure 9. When the retractor is pushed to the lower part of the foreman to open the flap, nerves are stretched and damaged, causing sensory abnormalities.

Figure 10. The retractor is placed slightly away from and slightly above the foramen. It is stabilized perpendicular to the bone The retractor is placed slightly away and above the foramen.

Figure 11. The retractor is stabilized by placing it perpendicular to the bone surface.
Implant Precautions

It is better for the patient’s blood to first come into contact with the implant. Saline should not be sprayed until a one third of the implantation is completed. The cooling effect should be maintained by suctioning around 5 mm away while spraying the saline solution. The patient must be instructed to open the mouth as wide as possible, and caution must be taken to ensure there is no contact with the implant during the use of a metal tip. Suction should be performed at a proximity while checking the placement depth. During the connection of healing abutments or cover screws, the grooves of the connecting parts should be washed and suctioned with saline to remove any blood. After the implant insertion, the patient must be informed about the progress of the operation and calmly reassured about his/her recovery.

Cases that Require Special Attention during Suction

A rolled gauze is hold with a mosquito and pressure should be applied during bone grafts, soft tissue grafts, crushed bone fragments, collagen shields, and shielding procedures. The suction tip is kept slightly away from the window boundary and it should not enter the window during the maxillary sinus graft.

Figure 12. During tap drill, the patient is instructed to open the mouth wide so that the drill does not touch the opposite side when it is removed in reverse rotation.

Figure 13. It is important not to allow foreign substances near the im-plant and to provide sufficient retraction while inserting the implant.

Figure 14. When the implant is inserted to an extent, saline is sprayed and suctioned with the suction tip placed at an approximate distance of 5 mm from the implant.
Suture

During the suture, the left hand should be used for retraction while holding the mirror, whereas the right hand should be used to hold the suction or tamponade. The mucous membrane or tongue is retracted with the mirror during the suture of a horizontal incision in the alveolar bone area. For the suture of a vertical incision in the buccal cavity, the mirror is placed directly below the incision and it is pulled downward from the incision. When the first and second knots are connected, the hemostasis and blood marks are removed with tamponade or suction, and the suture is checked. The third knot is completed with scissors that are to be used with the right hand, and the knot is rested while securing the view with retraction. The nylon suture is cut for about 1-2 mm from the knot. In case of complaints of discomfort during treatment after surgery, a stopper can be heated with the alcohol lamp to reduce the length of the suture and make it round. After the surgery, the patient is instructed to rise slowly. In addition, the patient should be praised for his/her composure during the operation. After confirming the radiation results, the patient of the surgical conditions must be informed to help him/her understand the surgical results.

Figure 15. The inner groove of the implant connection is washed with saline and suctioned.

Figure 16. When the connection groove is clean, the cover screw is connected.

Figure 17. Bone defects are visible in the buccal cavity.
Results

The arrangement of equipment on the surgical tray should be based on the convenience of the user. The handle of the needle holder should be placed toward the operator and the dean scissors should be placed toward the assistant. The purpose of retraction is to secure the visibility on the surgical site. It is placed at a right angle to the bone surface, and it must be ensured that it does not press on soft tissues or slips. Before beginning the bond preparation, the patient is instructed to raise a hand if he/she feels pain or tingling. Therefore, the patient is informed about the continuous running of water, which will be sucked into the suction tip. The patients should importantly be advised to breathe through the nose. If the assistant needs to spray the saline, then the saline is sprayed on the area where the drill meets the bone surface and appropriate amount of suction must be simultaneously administered. It is desirable to place the suction tip 5 mm below the drill. Assistants should keep in mind that it is preferable for the patient’s blood to come in contact with the implant first rather than saline; therefore, saline should not be sprayed until one third of the implant is inserted. Once saline spray has begun, suction should be performed around 5 mm away from the site to maintain its cooling effect. Cases that require special attention during suction include bone grafts, soft tissue grafts, crushed bone fragments, and collagen shields. A rolled gauze is held with a mosquito, and pressure is applied. During a maxillary sinus graft, the suction should be placed slightly away from the window boundary and never inside the window. A tamponade or suction should be used to remove the hemostasis and blood marks to check the suture when the first and the second knots are connected. The scissors are used from the right hand to complete the third knot, while securing the view with retraction. Thereafter, the site is given a rest. The nylon suture is cut about 1-2 mm from the knot.

Figure 18. A bone transplant was performed using BioOss, a crushed bone type of graft. The suction tip should never be allowed to make contact with the bone graft material.

Figure 19. After a nonabsorbent shield is fixed on the bone graft material, suction should be very carefully performed only on the site around the shield to prevent accidental removal of the crushed bone graft material.

Figure 20. To retrieve donor maxil-lary sinus graft material, a window is built above the buccal cavity, and the maxillary sinus membrane is lifted. The suction tip should never enter the maxillary sinus nor make contact with the window edges.

Figure 21. Mirror in the left hand and tamponade in the right hand.

Figure 22. Mirror in the left hand and suction in the right hand.

Figure 23. When closing, the mirror is placed directly below the vertical incision line and pulled downward to prevent the mucosal part of the flap from overlapping and to straigh-ten the incision in the correct posi-tion.

Figure 24. The position of the flap has changed due to incorrect mirror position and pull direction, and the flap is crumpled and overlapped.

Figure 25. The buccal mucosa and tongue are retracted with the mirror to secure visibility and needle move-ment.

Figure 26. Tying the first knot.

Figure 27. When the first knot is completed, blood is immediately re-moved with the suction or tamponade to check the seal and fit.

Figure 28. Tying the second knot.

Figure 29. Suture strands are sepa-rated and cut one by one, 1-2 mm from the knot so that the end of the nylon suture lies flat.

Figure 30. The front suture is cut short with the tip pointing downward, so it is less likely to cause discomfort. However, the back sutures are long and directed upward, and they may cause discomfort by poking soft tissues in the oral cavity.

Figure 31. The ends of the back suture are shortened and rounded to reduce discomfort.

Figure 32. A stopper is heated with an alcohol lamp and applied to the end of the nylon suture to melt the nylon and make it short and round.

Figure 33. While the third knot is tied, the suction or tamponade from the right hand is set aside, and the scissors are retrieved with the right hand.

Figure 34. The most stable way to hold scissors is to place the thumb and the ring finger just inside the holes of the handle of the scissors and to straighten the index finger and place it on the flat edge of the scissors. The middle finger is used as a finger rest on the teeth or other soft tissues.
Discussion

Infectious diseases rely on the host susceptibility and other factors among patients, operators, and colleagues and their families [7]. Because of the nature of dental treatment where most procedures are performed in a narrow oral cavity, anyone can be exposed to a wide variety of bacteria or viruses present in the blood and saliva of patients. In particular, infections can occur through various paths, such as sharp medical devices, needles, exposed wounds, and aerosol. A room contaminated with various secretions from patients can be a medium of infection [8]. Medical personnel in constant contact with patients should wash hands before and after any interaction with a patient; however, many studies report that dentists and dental hygienists neglect the practice of washing hands [9]. It is recommended that every healthcare practitioner must pay special attention toward hand washing and regularly wash hands. Today, most patients undergoing implant surgery have been treated as a treatment to restore their masticatory function after losing their teeth as the main cause of periodontal disease since they were in their 40s. However, there are reports that tissue around implants causes peri-implantitis, which is caused by plaque, excessive load, or uncontrolled whole-body diseases, which results in many implant failures [10].

Implant procedure has continuously evolved since 1969, when the result of Branemark’s implant operation was first published. Previously, a load was added to the implant if a sufficiently mineralized bone was identified around the implant after a healing period of three to six months following the implant procedure [11]. Conventional loading generally refers to add a load in the maxillary sinus six months after the operation and in the mandible three months after the operation. Implant survival occurs when the implant is not removed due to a failure and remains undamaged without causing any special pain or malfunctioning. It is considered as a successful implant when there is no radiographic image around the implant, no pain during use, and no effect on the surrounding anatomical structures while less than 1.5 mm of the upper alveolar bone is lost within the first year upon the initial use of the implant and less than 0.2 mm per year in the subsequent years [12]. In this study too, we do not spray the saline solution until one third of the implant is inserted as it is better for the blood of the patient to come in contact with the implant before the saline. The cooling effect is maintained by performing suction around 5 mm away from the site when spraying the saline. The patient is asked to open their mouth as wide as possible, and the implant is not touched during the use of a metal tip. The suction is performed at close proximity while checking the placement depth. The connecting groove is cleaned with saline while performing suction during the connection of healing abutments or cover screws to prevent blood from collecting on the site. Assistants’ duties, such as informing the patient of the operation results to help them remain relieved, help in increasing the success rate of implants. We also emphasize that every healthcare provider should pay special attention toward hand washing and regularly practice the same. In the implant surgery, the surgeon’s convenience should be a priority of the assistant. Sterilization and disinfection should be thoroughly performed. During the surgery preparation, dentists’ equipment should be arranged based on the convenience of the surgeon. Above all, assistance should be centered on the patient. The operation procedures should be explained in a calm voice to the patients so that he/she is aware of the progress of the operation and remains physically and psychologically relaxed. Precautions before and after the surgery should be explained to the patient in detail. The symptoms such as bleeding and pain should be checked via telephone after the patient returns home. The purpose of this study is to help the assistants in effectively performing proper assistance to increase the success rate of implant surgeries. We wish to conduct research on implant management in the future.

Conclusion

The medical assistance of dental hygienists greatly affects the time required for a surgery, trauma during surgery, post-surgery edema and pain, post-surgery initial infection, and surgery failure rate.

Conflict of Interest

No potential conflict of interest relevant to this article was reported.

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