Before surgery, reassure your patient and put them at ease. Make sure they take pre operative antibiotics and anti-inflammatory medication. You and your assistant will be fully scrubbed and the patient fully draped. The patient should rinse with chlorhexidine and use it to sterilise the peri-oral tissues. Ensure adequate anaesthesia before surgery - it gets tricky to infiltrate when a flap is raised. Think through your flap design and be confident with your incisions. Obey the basic principles and respect the tissues. Do some research around soft tissue surgery and you'll pick up some great tips. Once the flap is raised inspect and neaten your osteotomy site - removing any sharp edges with a round bur and proceed to mark your starter point. It's a real art maintaining the same drill trajectory so be confident and precise. Use the markers throughout and take an initial PA after your first drill - you can still make corrections at this stage if needed. Using 1200 rpm (this varies) and copious cold saline irrigation follow the drill sequence until you reach the desired width and depth. In less dense bone you can use a lower rpm and vice versa. But respect the bone. Inspect your osteotomy walls with a blunt instrument and all being well you're ready to place. It's about now you'll be thinking about graft materials. They can be fiddly so find a good course. Soft tissue grafting is a whole new kettle of fish so maybe put it in the diary for the future, as you'll need to get good at it. Taking an implant out of its packaging is nerve racking at first. You'll see what I mean when you do it. Just make sure you engage the driver fully before moving and in one clean movement straight into the osteotomy. Start it off by hand then finish with the torque wrench to 35ncm (this varies with manufacturers). We're looking for good 'primary stability' - a self-explanatory term. Take a post op radiograph and hand-tighten the healing abutment. Implants are usually buried when a large volume of particulate is used, or block graft performed. 2-stage surgery is a nice way to develop the gingival tissues for emergence profile - a technique worth learning. Suture with whatever material and technique works best for you. Don't be afraid to take bigger bites if it helps close the wound and ideally they should be tight enough to just approximate the wound edges. If they are too tight they'll just tear through with the post op inflammation and restrict blood flow. Make a personalised set of post op instructions covering all the key areas and give strict advice to leave dentures out initially. I put my mobile number on mine in case of emergencies. Make thorough notes. Include the Lot and batch of the implants used and record even the slightest details - trust me it will help you sleep at night. Also make sure you write up and grade your radiographs. Keep a logbook of all your cases - record patient name, date and procedure then stick an implant sticker next to it. Put another sticker on the consent for continuity. Remove the sutures after 2 weeks and plan the pick up impressions 6 weeks later. If you've done extensive hard tissue grafting its often wise to leave it for at least 3 months. Never forget that implants can fail early dentaltownuk.com \\ SEPTEMBER 2017 17http://www.dentaltownuk.com